Dear Editor, Temporal myositis (TM) is an inflammatory disease of the temporal muscle. It is a rare disorder of the masticatory muscle with only a few cases reported, presenting with asymmetrical swelling and local pain of the involved area, occasionally associated with fever and trismus [1]. We report a TM case associated with cancer. A 63-year-old woman was admitted to the hospital due to a chronic symmetric polyarthritis of the hands, wrists and feet. Her past medical history was unremarkable. A diagnosis of seropositive RA was made and she was treated with methotrexate, which was ineffective. Then a switch was made to adalimumab and etanercept, with clinical remission achieved. Seven years later she presented with an acute painful swelling of the left temporal region. No further changes were found on physical examination. Laboratory tests disclosed a normal complete blood count and erythrocyte sedimentation rate (26 mm/h). Temporal muscle ultrasound showed an increased hypoechogenicity and a non-specific oedema in the left temporal muscle. MRI revealed a homogeneous thickness (1.7 cm) of the left temporal muscle, with no cysts or necrotic areas, hypersignal on T2-weighted sequence and enhancement following administration of gadolinium (Fig. 1). A temporal muscle biopsy showed a lymphocytic inflammatory infiltrate, with no signs of vasculitis, suggestive of left temporal inflammatory myositis. Six months later, a homolateral cervical adenomegaly was detected and a core biopsy was performed, revealing a diffuse large B cell lymphoma. A PET scan excluded involvement of other lymphoid organs. Etanercept was stopped and treatment with rituximab, cyclophosphamide, doxorubicin and vincristine was started, with improvement of left temporal pain and swelling, as well as clinical remission of the lymphoma. After 6 years of follow-up with rituximab, the patient remains in clinical remission and asymptomatic.
Infective endocarditis has a wide range of clinical manifestations, making the diagnosis complex. Musculoskeletal symptoms whose prevalence is not negligible are often underestimated. This clinical case is about a 44-year-old female patient with previous aortic and mitral valvuloplasty for rheumatic fever valve disease referred to the outpatient Rheumatology department for the migratory onset of pain and swelling of the left lateral malleolus, right wrist, right first finger and left fifth distal phalanx associated with painful punctate lesions of the digital pulps and lateral edge of the feet and migratory and painful erythematous papules lasting for three months. The susceptibility for IE combined with the finding of spleen infarcts, Osler's nodes and a microorganism from HACEK group on blood cultures supported the diagnosis of subacute infectious endocarditis. Other diagnoses were ruled out. The patient was treated with intravenous antibiotic therapy with complete resolution. This case aims to illustrate the difficulty in diagnosing subacute infective endocarditis, the importance of multidisciplinary work and to briefly review the musculoskeletal manifestations of infective endocarditis described in the literature.
Eosinophilic vasculitis is a rare condition due to vascular damage and infiltration of eosinophils into tissues. Antineutrophil cytoplasmic antibody (ANCA), like perinuclear ANCA (p-ANCA), is common in the context of systemic vasculitis, but its association with illicit drug use is unusual. This case report showcases a distinctive scenario featuring a positive pANCA, prompting a meticulous examination of the interplay between vasculitic manifestations and drug abuse.
To determine the prevalence of hypogonadotropic hypogonadism (HH) among patients with non-functioning pituitary adenomas (NFPA) and the post-surgery outcome on pituitary gonadotropins secretion (PGS); to determine the prevalence of erectile dysfunction (ED) on male patients with NFPA, to evaluate the impact of testosterone replacement therapy (TRT) in those with HH. Retrospective evaluation of gonadal function in 109 NFPA patients (45 males), with a mean age of 51.8 years, diagnosed on the last 10 years. ED questionnaire applied to 34 male patients. Male patients with NFPA were significantly older (males 58.1±15.8 vs. females 47.4±16.94; p=0.001). Most patients had macroadenomas (67%; p=0.001) and only a minority were incidentalomas (19%; p<0.001). Prevalence of HH was 40% (60% on males, 25% on females; p<0.001). Surgery was performed in 54% of all patients (71% of males, 42% of females; p<0.003). After intervention, 14% became HH, 69% maintained previous function and 17% improved. On the questionnaire, 76% reported having ED, 54% of which had HH and 21% were under TRT. Of the patients under TRT, 79% still had ED. Median age of patients with ED was significantly higher [with ED 65 vs. without 49 years; p=0.012). There was no BMI difference between patients with or without TRT (28.0 vs. 27.4 Kg/m2). NFPA was more frequent in older rather than younger patients. Males were older, had more HH and surgery. There was no significant improvement of pituitary function with surgery (17%) and 13% became iatrogenic HH. TRT had a low efficacy to improve ED in these patients.
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