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Dr. Bonara: A 30-year-old woman was admitted to our emergency department (ED). In the past history, she had prolonged estrogen-progestinic treatment. In April 1999, she was admitted to the Infectious Diseases Department at the Polyclinic in Messina for acute pericarditis (the episode resolved quickly, and the patient was discharged without any therapy). At the end of February 2009, she had a sore throat and fever unresponsive to nonsteroidal anti-inflammatory drugs (NSAIDS) and amoxicillin. On March 7, the patient came to the ED for the persistence of fever, and the onset of diffuse myalgias and sternal pain. The electrocardiogram showed sinus tachycardia, widespread ST elevation (Fig. 1); chemistries: troponin I 15.81 ng/mL (\0.15), AST 111 U/L, ALT 32 U/L, CK 449 U/L, CRP 35 mg/dL, Hb 11.8 g/dL, Ht 30%, MCV 86 fL, WBCs 21,120/lL ? neutrophils 91%. The echocardiogram showed no alterations of the left ventricle (normal size, wall thickness and segmental contraction), EF 55%, mild mitral regurgitation, no pericardial effusion; chest X-ray: normal. Dr. Rietti (cardiologist): Clinical presentation, blood tests, and electrocardiogram were suggestive for myopericarditis; the patient was then hospitalized at the Department of Cardiology. During the hospitalization there was evidence of a pericardial effusion (measured by ultrasound: 8 mm in short axis view in diastole, Fig. 2) with dyskinesia of the interventricular septum and hypokinesia of the right ventricle, and the occurrence of a pleural effusion (first left and then bilateral); the presence of intermittent fever was confirmed. Blood tests showed marked neutrophilic leukocytosis (WBCs 20,000/lL, neutrophils 75%) and increased acute-phase proteins (CRP 35 mg/dL). Marked proteinuria (1.66 g/dL) with hypoalbuminemia was also detected (albumin 1.4 g/dL). All investigations of infective and autoimmunity diseases were negative. The patient was treated with acetylsalicylic acid (2 g daily). On March 12, a nephrological consultation was requested because of persistent proteinuria and cylindruria.

To analyze the clinical characteristics and genetic background associated with the presence of hand arthropathy, as determined by radiological findings, in Italian patients with hereditary hemochromatosis (HHC).In 88 consecutive unselected patients with phenotypically expressed HHC, joint involvement was systematically evaluated in plain radiographs of hands, wrists, lumbar spine, pelvis, and knees. Risk factors considered were age, sex, body mass index, alcohol abuse, organ involvement at other sites, and indices of iron overload, including ferritin, transferrin saturation, and iron removed to reach depletion. HFE genotype was also considered. The independent role of risk factors was tested by logistic regression analysis.Thirty-two subjects (36%) showed signs of metacarpophalangeal (MCP) arthropathy. Intercarpal, radiocarpal, and chondrocalcinosis were less frequent and occurred in association with MCP arthropathy. At multivariate analysis MCP arthropathy was independently associated with older age [odds ratio (OR) 1.20, 95% confidence interval (CI) 1.1-1.33/yr; p = 0.0001], higher ferritin levels at diagnosis (OR 4.17, 95% CI 1.60-13.9 for values1000 ng/ml; p = 0.008), the presence of the C282Y +/+ and C282Y/H63D HFE genotypes (OR 2.69, 95% CI 1.09-7.87; p = 0.04), and higher percentage transferrin saturation (OR 1.05, 95% CI 1-1.1; p = 0.05). The severity of arthropathy was independently associated with older age (p = 0.03) and higher ferritin values (p = 0.05).MCP arthropathy together with a typical pattern of joint involvement is observed in one-third of unselected patients with HHC, and is influenced by the duration and degree of the iron overload.