Lithium
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Systemic enthesitis and scalp psoriasis: case report A 54-year-old man developed systemic enthesitis and scalp psoriasis during treatment with lithium for bipolar disorder. The man presented to the rheumatology outpatient clinic at the age of 62 years with a one-month history of dull pain in his left distal lower leg. He also had pain in the right leg for a few weeks. Anamneses revealed that, he started experiencing pain after an angiological evaluation of both lower legs because of varicosis. Initially, he had responded well to the treatment with ibuprofen. However, he required additional treatment with a morphine patch. Eleven years before the presentation, he was diagnosed with bipolar disorder and was receiving regular laboratory-controlled therapy with lithium [route and dosage not stated]. He remained symptom-free under lithium therapy. However, eight-year before the current presentation (at the age of 54-year), he developed scalp psoriasis. Hence, the man was successfully treated with unspecified dermatological treatment. At the current presentation, his clinical examination showed painful soft tissue swelling over the left ankle with no redness in mild lower leg varicosis on both sides. An ultrasound examination raised a suspicion of calcified periosteal haematoma. His fingers revealed moderate polyosteoarthritis without dactylitis, and abdominal skin showed individual psoriasis efflorescence. Laboratory test results showed a reduction of blood cells in the first hour, and the CRP level was 15 mg/L. His renal function and electrolyte levels were normal, and ANA titre was weakly positive with negative double-stranded DNA. A CT scan showed solid cortical bone, but less noticeable periosteum ossifications. The whole body bone scan showed high pathological activity deposits in the left distal fibulae than the right distal fibulae. Also, strong eccentric tracer deposits were observed in the thoracic vertebrae 8 and 9. The radiological findings were consistent with systemic enthesitis. The plain radiographs of his left fibula showed bubble-forming and hairy ossifications at the distal metaphyseal bone surface without any interruption of the cortical. His right-sided fibula also had similar lesions to a lesser degree. Bone scintigraphy showed hot spots at both distal fibulae with a different activity. Also, high activity at the 8 and 9 thoracic vertebra was observed, which caused hyperostotic spurs. Based on these findings and his history, a diagnosis of systemic enthesitis in psoriasis was made. An open biopsy was performed, which ruled out the possibility of ossifying periostitis and tumour. Histological examination showed fibrously enlarged periosteum with the uneven metaplastic bone formation with lamellar bone focal maturation and isolated cartilage matrix. A low perivascular lymphocytic infiltration was also observed. Additionally, the surrounding skeletal muscle was present with the inclusion of stuck muscle fibers in the fibrous tissue. Immunohistochemical analysis showed negative results for MDM2 res
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