PReS 2016 Abstract Submission
Bone in rheumatic diseases
PReS-ABS-1595
CHRONIC RECURRENT MULTIFOCAL OSTEITIS AND COXIELLA BURNETI INFECTION MIMICKING ADULT-ONSET STILL'S DISEASE
Laura O. Damian* 1, Dan Cosma2, Amanda radulescu3, Dan Vasilescu4, Liliana Rogojan5, Calin Lazar6, Simona Rednic7, Mihaela Lupse3
1Rheumatology, Emergency Clinical County Hospital Cluj, 2Pediatric Surgery, 3Infectious Diseases, 4Radiology, University of Medicine and Pharmacy Cluj, 5Pathology, Emergency Clinical County Hospital Cluj, 61st Pediatric, 7Rheumatology, University of Medicine and Pharmacy Cluj, Cluj-Napoca, Romania
Introduction: The infectious etiology of chronic recurrent multifocal osteitis (CRMO) is controversial. Coxiella burneti, the agent of Q fever, may result in a chronic granulomatous osteomyelitis with a relapsing, multifocal course, but also in reactive osteitis.
Objectives: To present a difficult diagnosis of osteitis case in an adult patient.
Methods: A 52-yrs lady, general practitioner working in the countryside, presented for prolonged fever with daily spikes, joint pain affecting the wrists and shoulders and discrete evanescent rash on the trunk. She was intaken in the Infectious Diseases department and extensively investigated, with negative results. Echocardiography identified no valvular disease or vegetations.
Results: Laboratory showed leukocytosis (12,000 WBC/mcL) with neutrophilia (79%), high CRP (9.6 mg/dL, normal <0.6 mg/dL) liver enzymes and ferritin (760, normal 11-307 mcg/L), and mild thrombocytopenia (124 x103 Plt, normal 150-400 x103). She was diagnosed with adult-onset Still’s disease and received colchicine and low-dose prednisone. The fever subsided, but she started to complain of hip pain, and a right hip bone cyst was seen on pelvic radiographs. The alkaline phosphatase, parathormon, vitamin D and quantiferon for tuberculosis yielded normal results. A blood test for Coxiella burneti was positive suggesting convalescence after acute Q fever (IgG phase II > 256, with phase I IgM and IgG <128). She received doxycycline and hydroxychloroquine, with general improvement. However, after three months she presented with a dull, persistent shoulder pain. Radiography showed an irregular localised condensing bone lesion on the right humerus, with a sclerotic rim. Bone biopsy revealed non-specific inflammation, with negative cultures. A whole-body MRI showed 3 cm- osteocondensating lesions (T1 and T2 hyposignal) on the right humerus and on the right femur respectively, with no contrast uptake. Coxiella serology was rather compatible to a subsided acute Q fever than to a chronic Q fever (phase II IgM and IgG <32, with IgG phase I <64, IgM phase I <32). A thorough history revealed that her maternal grandmother had been repeatedly treated with antibiotics for osteomyelitis. Sulphasalazine was added to antibiotic therapy, with good results
Conclusion: In predisposed individuals Coxiella may trigger CRMO. Q fever can mimic many diseases, including adult-onset Still’s disease, and mild thrombocytopenia can be a clue to the diagnosis.
Disclosure of Interest: None Declared