Simultaneous bilateral posterior interosseous nerve palsy caused by rheumatoid synovitis of the elbows
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CASE REPORT
Simultaneous bilateral posterior interosseous nerve palsy caused by rheumatoid synovitis of the elbows Masashi Naito • Ichiro Nakamura • Katsumi Ito
Received: 28 November 2012 / Accepted: 8 February 2013 Ó Japan College of Rheumatology 2013
Abstract A 60-year-old woman with rheumatoid arthritis (RA) developed bilateral posterior interosseous nerve palsy. Her left side recovered after conservative treatment. However, her right side, which had been affected previously, did not recover and required surgery. Although conservative therapy, including administration of biologic agents, should be conducted for tight control of RA activity, we recommend surgical treatment when there is recurrence of the disease.
literature to date (Table 1). There is a previous report on the bilateral involvement of posterior interosseous nerve palsy in a patient with RA, but its onset on both sides was not simultaneous in this case [6]. Here, we report a case of RA showing simultaneous development of bilateral interosseous nerve palsy.
Keywords Bilateral Posterior interosseous nerve palsy Rheumatoid arthritis Simultaneous Synovitis
A 58-year-old Japanese woman developed a fever with a temperature of 39 °C and became unable to extend her right fingers in February 2007. The patient had developed RA in 1992 when she was 44 years old and had been treated at our hospital since 1993. She had mutilans type RA and was at Steinbrocker stage 4 and class 2. She had been treated with non-steroidal anti-inflammatory drugs (lornoxicam, 8 mg/day), steroids (triamcinolone, 2 mg/ day; prednisolone, 2.5 mg/day), and disease-modifying anti-rheumatic drugs (methotrexate, 6 mg/week; cyclosporine, 100 mg/day). The patient had no sensory loss. A laboratory test showed leucocytosis [white blood cell (WBC) count, 10,800/mm3] and an elevated serum level of C-reactive protein (CRP, 12.2 mg/dl). Rheumatoid factor (RF, 162 IU/ml) and anti-cyclic citrullinated peptide antibodies (1630 U/ml) were present. Her right elbow was swollen and was suspected to have rheumatoid synovitis. Magnetic resonance imaging (MRI) revealed proliferated synovium, which was bulging anteriorly and surrounding the neck of the radius (Fig. 1). We considered that the synovium had compressed the posterior interosseous nerve running along the anterior aspect of the elbow joint. Therefore, we injected 10 mg of triamcinolone into her right elbow joint to alleviate the synovitis. Seven days after the injection, she
Introduction Many kinds of lesions around the elbow joint can cause posterior interosseous nerve palsy, including rheumatoid synovitis of the elbow joint [1–14]. Nineteen cases of posterior interosseous nerve palsy secondary to rheumatoid arthritis (RA) in 18 patients have been reported in the
M. Naito (&) Department of Systems BioMedicine, Graduate School and Faculty of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan e-mail: [email protected] I. Nakamura K. Ito Department of Rheumatology, Yugawara Kosei-Nen
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