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Introduction: There are conflicting findings on the link between liver fibrosis and cumulative methotrexate dosages. We aimed to determine the frequency of liver fibrosis in rheumatoid arthritis patients treated with methotrexate and to identify its associated factors., Methods: We conducted a cross-sectional study over 9 months (April-December 2021), including rheumatoid arthritis patients treated with methotrexate. Demographic and clinical data were collected. Liver stiffness was assessed by FibroScan. Fibrosis and significant liver fibrosis were defined as liver stiffness higher than 6 and 7.2 kPa, respectively. Liver tests, albuminemia, lipid profile, and blood glycemia were measured. Metabolic syndrome was also evaluated. Statistical analyses were performed using SPSS., Results: We included 21 men and 47 women. The mean age was 51.60 ± 1.82 years. The mean disease duration was 8.29 ± 6.48 years. The mean weekly intake of methotrexate was 13.76 ± 3.91 mg. The mean methotrexate duration was 4.67 ± 4.24 years. The mean cumulative dose was 3508.87 ± 3390.48 mg. Hypoalbuminemia and metabolic syndrome were found in 34% and 25% of cases. We noted increased alkaline phosphatase levels in four cases. The mean liver stiffness was 4.50 ± 1.53 kPa. Nine patients had liver fibrosis, and four had significant fibrosis. Associated factors with liver fibrosis were as follows: age ≥ 60 years (OR:22.703; 95% CI [1.238-416.487]; p = 0.035), cumulated dose of methotrexate ≥ 3 g (OR: 76.501; 95% CI [2.383-2456.070]; p = 0.014), metabolic syndrome (OR: 42.743; 95% CI [1.728-1057.273]; p = 0.022), elevated alkaline phosphatase levels (OR: 28.252; 95% CI [1.306-611.007]; p = 0.033), and hypoalbuminemia (OR: 59.302; 95% CI [2.361-1489.718]; p = 0.013)., Conclusion: Cumulating more than 3 g of methotrexate was associated with liver fibrosis in rheumatoid arthritis patients. Having a metabolic syndrome, higher age, hypoalbuminemia, and elevated alkaline phosphatase levels were also likely to be independently associated with liver fibrosis. Key points • Rheumatoid arthritis patients require monitoring hepatic fibrosis when the cumulated dose of methotrexate is above 3 g. • Metabolic syndrome is a risk factor for liver fibrosis, suggesting that its management is necessary to prevent this complication. • Hypoalbuminemia and elevated alkaline phosphatase levels (twice the upper limit) in rheumatoid arthritis patients treated with methotrexate were associated with liver fibrosis., (© 2023. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Purpose: Foot entheses involvement is a common manifestation of spondyloarthritis. The superiority of ultrasonography examination in foot entheses damages detection has been reported. We aimed to compare the ultrasonography findings of foot entheses between spondyloarthritis patients. and healthy controls and to identify factors associated with enthesitic heel involvement., Methods: We conducted a cross-sectional study including 37 patients with axial spondyloarthritis (G1) and 37 healthy subjects matched by age and gender (G0). The following pro-inflammatory cytokines were measured: Interleukin (IL-)1, IL-6, IL-17, and IL-23. A blind ultrasonography of foot entheses was performed to examine calcaneal tendon (CT) and plantar fascia (PF)., Results: The mean age was 44.62 ± 12.31 years. Non-steroidal anti-inflammatory drugs were taken in 92% of patients. Clinical heel enthesopathy was noted in 10 patients (27%) of G1. No participant has enthesitic pain in G0. Ultrasonography changes in CT and PF were more frequent in G1 than G0 (p = 0.001 and p = 10 -3 , respectively). In the PF, tendon thickening was significantly higher in G1 than G0 (p = 0.03). Power Doppler in both enthesitic sites was exclusively observed in G1 (p = 10 -3 ). Regarding associated factors, CT enthesophytes were less frequent in patients taking non-steroidal anti-inflammatory drugs continuously or having regular physical activity. PF structural damages were associated with higher erythrocyte sedimentation rate (p = 0.02), higher IL-23 level (p = 0.01), and higher disease activity (p = 0.04)., Conclusion: Ultrasonography lesions of heel entheses were frequent in spondyloarthritis. Disease activity and inflammatory markers were higher in patients with heel enthesitis. Non-steroidal anti-inflammatory drugs intake and regular physical activity may prevent enthesophytes' occurrence., (© 2022. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Osteoarticular manifestations such as arthritis and bone pain are scarce among adults with acute lymphoblastic leukemia (ALL). We present a systematic review of osteoarticular first clinical manifestation related to ALL in adults, and we report a case of an adult patient with a B-cell ALL revealed by refractory pygalgia and arthritis. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the MEDLINE database, including case reports and case series describing osteoarticular manifestations revealing ALL in adults. There were 29 patients with osteoarticular manifestations, revealing ALL (including our case). The mean age was 34.00 ± 13.29 years. Osteoarticular manifestations were peripheral articular signs (7 cases), axial manifestations (17 cases), and osteolytic lesions (21 cases). Vertebral fractures were reported in 4 cases. MRI was performed in 15 cases, showing heterogeneous signal changes in the vertebra, skull, and sacroiliac bones. It showed avascular necrosis of the femoral head in one case. PET scan, performed in 7 cases, showed diffuse or localized FDG uptakes in the bone marrow. Hypercalcemia was noted in 9 cases. The treatment was based on chemotherapy (23 patients) and radiotherapy (4 cases). During the follow-up, remission was noted in 14 cases, death in 9 cases, and was not available in 6 patients. Our review showed that axial manifestations, joint swelling, bone pain, and hypercalcemia could be the first and only symptoms of ALL in adults, making the diagnosis of ALL difficult to recognize, leading to a diagnosis delay. Key Points • Acute lymphoblastic leukemia in adults revealed by osteoarticular manifestations can be misdiagnosed as rheumatic diseases. • Axial manifestations, joint swelling, bone pain, and hypercalcemia could be the first and only symptoms of acute lymphoblastic leukemia in adults. • Complete blood count and calcium blood test should be performed as first-line investigations in adults with axial or peripheral articular symptoms. • Physicians should be aware of this clinical presentation to avoid diagnosis delay and improve prognosis., (© 2022. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Peliosis hepatis is characterized by hepatic sinusoidal dilatation and multiple blood-filled cystic cavities within the liver parenchyma. It can be due to infectious diseases, immunological disorders, neoplasia, and the use of various kinds of drugs. We presented the case of a nonsmoker 55-year-old man who complained about a 5-month history of arthritis. Medical history was consistent with psoriasis and hypertension. He denied any drug use or alcohol consumption. Physical examination showed extended psoriatic lesions. He had arthritis of the knees, ankles, wrists, and elbows. His body mass index was 22 kg/m 2 . Laboratory findings revealed an increased serum gamma-glutamyl transferase level (1014 UI/L, normal value (N) 11-55) and total alkaline phosphatase (278 U/L, N 30-171). Hepatitis A, B, and C serologic test results were negative. Anti-nuclear antibodies, anti-Ro/SSA, anti-GP210, anti-SP100, anti-SLA, anti-LKM1, anti-M2, anti-LC1, and anti-PML were also negative. Histopathological examination of a liver biopsy specimen revealed peliosis hepatis.The pelvic radiograph showed bilateral ankylosis of sacroiliac joints. Hand and foot radiographs showed periosteal bone apposition. The diagnosis of psoriatic arthritis associated with peliosis hepatis was made. The patient received infliximab (5 mg/kg) with a significant improvement after 3 months of follow-up. Peliosis hepatis should be considered as a possible etiology of liver enzyme abnormalities in patients with psoriatic arthritis. We highlighted the effectiveness and safety of the TNF inhibitors in the treatment of peliosis hepatis associated with psoriatic arthritis. Key Points • Peliosis hepatis should be considered as a possible etiology of liver enzyme disturbance in patients with psoriatic arthritis. • Special caution should be advised in the management of psoriatic arthritis associated with peliosis hepatis to avoid the worsening of liver function. • Infliximab is suggested as a possible treatment of peliosis hepatis associated with psoriatic arthritis., (© 2021. International League of Associations for Rheumatology (ILAR).)

Multiple endocrine neoplasia type 1 is a rare autosomal inherited syndrome that affects a variety of endocrine tissues such as the parathyroid, endocrine pancreas, and anterior pituitary. Osseous complications are often misdiagnosed. We presented a case of a 46-year-old woman with pathological fractures of the lower limb. She had a history of type 1 diabetes and galactorrhea. Laboratory examinations showed hypercalcemia and an increased level of parathyroid hormone related to hyperparathyroidism. Serum chromogranin A level was increased at 9369 ng/mL (N < 102). A somatostatin receptor scintigraphy (octreoscan) revealed pathological uptake in the gastric wall, later cave adenopathy, and liver. The diagnosis of multiple endocrine neoplasia type 1 was made based on radiological and histological findings. The patient underwent a subtotal parathyroidectomy associated with somatostatin analog treatment leading to significant improvement. A literature review was conducted by searching PubMed using these following terms: multiple endocrine neoplasia type 1, hyperparathyroidism, fracture, menin, osteoporosis. We emphasized bone involvement related to multiple endocrine neoplasia type 1 syndrome. This diagnosis should be considered when pathological fractures occur in young patients with a history of endocrine disorder. We highlighted the importance of imaging features in making the diagnosis of multiple endocrine neoplasia type 1. Early management of this disease is necessary. Treatment including parathyroidectomy and somatostatin analogs leads to bone preservation and functional improvement.

Epidural myeloid sarcoma revealing chronic myeloid leukemia is scarce. Herein, we describe a patient that presented with back pain and bilateral sciatica secondary to root compression due to epidural deposition of leukemic cells. The magnetic resonance imaging showed epidural masses, causing a slight restriction of the spinal canal with bilateral L5 root compression. Laboratory examinations showed hyperleukocytosis (white blood cell count: 83 × 109/L, absolute neutrophil count: 60 × 109/L). The bone marrow cytology and immunophenotypic findings confirmed the diagnosis of myeloid leukemia. The diagnosis of spinal myeloid sarcoma revealing chronic myeloid leukemia during the blast phase was established. The patient underwent induction chemotherapy. Then, bone marrow cytology revealed less than 3% of blasts, which correspond to cytological remission. Three months later, MRI showed complete disappearance of the epidural masses. A literature review was conducted by searching PubMed using these terms: "Leukemia, Myeloid" AND "Spine" AND "Sarcoma, Myeloid". We emphasize clinical and radiological findings of spinal myeloid sarcoma. This diagnosis should be considered when the MRI reveals epidural mass lesion. The early management of this disease is necessary, and the treatment of myeloid sarcoma is not codified. Our case highlighted that chemotherapy treatment could be sufficient to lead to the disappearance of myeloid sarcoma and the remission of leukemia.