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tion was observed in 10 % of patients in group I and 24.3 % of patients in group II. Injury of 8—10 joints, however, prevailed in group I of patients (36.7 % of patients) compare to group II (27.3 %). 30 % of patients in group I showed commitment to constant treatment and 65 % — group II. At the same time, the treatment only during disease aggravation support 60 % of patients in group I and 25 % — group II. In both groups, most patients had II degree of radial process (60 and 54.5 %, respectively). But 66.6% of patients in group II had I degree of joints dysfunction, whereas II degree dysfunction dominated in group I (63.4 %). Except articular dysfunctions, tophi dominated in patients of group I (23.3 % of patients), while groups I and II did not differ in percent of diagnosed gouty kidney (10 and 9.1 %, respectively). Among accom-
UGLYAR T., ZHULKEVYCH I., NEDOSHITKO V. Ternopil State Medical University named after I.Ya. Gorbachevsky, Ternopil, Ukraine
Aseptic Necrosis of the Femoral Head as a Possible Consequence of Hodgkin Lymphoma Chemotherapy
Introduction. Four adult patients with malignant Hodg-kin's lymphoma were treated with combination chemotherapy including an alkylating agent and intermittent high-dose prednisone (in two cases). Twelve to 24 months after initiation of therapy, osteonecrosis of the femoral head developed. This was unilateral in all cases, and presumably didn't represent a complication of steroid administration, as two of the patients received 4 and 6 month of corticosteroids therapy. Necrosis of bone may be a low-frequency long-term complication of combination chemotherapy in lymphoma.
Administration of corticosteroids is known to be associated with the development of osteonecrosis, or avascular necrosis of bone, particularly of the femoral and humeral heads. In the main, this occurs in patients receiving doses in excess of physiologic replacement for prolonged periods of time. In recent years, increasing numbers of patients with malignant Hodgkin's lymphoma have been treated intermittently with combinations of chemotherapeutic agents, including corticosteroids.
Materials and methods. From 2009 through 2014, 283 patients were treated with chemotherapeutic regimens involving a combination of drugs for advanced Hodgkin's disease. Virtually all the patients were adults. The treatment programs consisted of intermittent administration of such schemes of chemotherapy as ABVD and BEACOPP. Drug dosages and scheduling have been described in detail elsewhere, but the BEACOPP combination includes the administration of 2 weeks of daily oral prednisone, 40 mg/m2 body surface area for 4—6 month. All charts of these lymphoma patients in whom a diagnosis of aseptic or avascular necrosis of bone had been recorded (two patients both ABVD and BEACOPP) were reviewed for this report. In all instances the bone abnormality involved the femoral head and developed after initiation of chemotherapy. The diagnoses were made by radiographic means, using standard criteria, and operative intervention has been required and performed in all these patients.
panying pathology in patients of both groups hypertension (63.3 and 42.4 %) and obesity (77.3 and 60.6 %) dominated. Hyperinsulinemia and diabetes significantly predominated in group I of patients, which correlated with a greater percentage of tophi in the same group.
While treatment the required level of uric acid 0.38 ± ± 0.01 mmol/l was gotten only in patients of group II, whereas uric acid was 0.46 ± 0.01 mmol/l in patients of group I.
Conclusion. Hereby long-term use of sartans in patients with gout leads not only to sustained reduction of uric acid contain in the blood serum, but also to improvement in the course of articular syndrome and reduction of the severity extraarticular dysfunctions and comorbidity percent.
Results. We wish to report the appearance of osteonecrosis in four such patients, two of whom were given 4 to 6 month of intermittent steroid therapy. These four cases of osteonecrosis arising after combination chemotherapy for lymphoma represent 1.4 % of all our patients so treated. The time from initiation of corticosteroid (and additional cytotoxic) therapy to radiographic diagnosis of osteonecro-sis was 12 and 16 months in the two patients in whom intermittent steroids were given. The other two patients, who hadn't received intermittent steroids, in 12 and 24 months abnormal roentgenogram occurred. This was unilateral in all cases. All but one were male, despite an approximately unitary sex ratio in our patient population. The symptoms of hip and lower extremity pain were typical, the surgical intervention was considered and performed in all four patients.
Conclusion and discussion. Several theories have been proposed to account for an increased incidence of os-teonecrosis after combined chemotherapy administration. Vascular obstruction by fatty emboli in areas of bone with poor collateral circulation is a mechanism that is often discussed, and both clinical and experimental supporting evidence have been described. These findings have not been confirmed by others, however; microtrauma in osteoporotic bone, possibly exacerbated by diminished sensibility from the antiinflammatory effects of steroids is among other suggested etiologic factors. Avascular necrosis of bone has complicated the treatment of a variety of diseases, including many in which this lesion is not part of the natural history of the disease. To our knowledge, osteonecrosis has previously been reported in the course of intermittent corticosteroid therapy of lymphoma, as well as in untreated lymphoma among the conditions associated with development of avascular necrosis of the femoral head. Steroids were administered to two of our patients for relatively long periods of time. In some reviews of the problem of aseptic necrosis complicating steroid therapy, the time from initiation of treatment to development of necrosis is stated to vary from 6 to 54 months. Daily prednisone dosage in most patients was 10—90 mg. Such articles point out that total steroid dose, daily dose, and duration of drug administration associated with osteonecrosis may be minimal. The possibility that our patients suffered from idiopathic necrosis of the femoral head should also
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be considered. This disease is reported to be rare but some authors think recognition of the entity is increasing. An increased incidence of the male sex, minor trauma, alcoholism, and hyperuricemia has been described in «idiopathic» cases. At least one of the latter three factors was questionably in all of our four patients. The importance, if any, in the development of bone necrosis of the cytotoxic drugs — an alkylating agent and vincristine in all instances, and procarbazine in two-administered to our patients — is yet unknown. We have assumed unlikely that the femoral
VERSHYNINA D.
Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
Changes in Bone Mineral Density of the Distal Forearm and Development of Erosive Joint Damage at Hand Joints MRI in Patients with Early Rheumatoid Arthritis
Introduction. Chances for better prognosis in rheumatoid arthritis (RA) much depend on the beginning of an adequate basic treatment for early, non-erosive stage disease (no later than 3 months after the start of the articular syndrome) as a new therapeutic paradigm involves the diagnosis of RA in the most initial stages of the disease. Newest methods of X-ray diagnosis of lesions of bones and joints allow using of a number of modern techniques for early diagnosis of rheumatoid arthritis, defining the degree of destructive changes and assessing of the progression of the disease. The introduction into clinical practice of MRI significantly enhanced the diagnosis of inflammatory changes of a wrist joint and a hand. Currently, the issues of early visualizing of the changes in the joints and bone which can be used as predictors of future joints structural damage are being discussed.
Aim. To assess changes in the bone mineral density (BMD) in patients with early rheumatoid arthritis (ERA) and how the BMD is related to the erosive changes of the wrist on MRI.
Methods. The study involved 112 patients with early rheumatoid arthritis (ERA) who had suffered of articular syndrome for 1 year (average 10.6 ± 2.2 months). The diagnosis was established against the RA classification criteria EULAR/ARC 2010. Mean age of the patients was 44.8 ± 7.4 years. Clinical and laboratory studies were included: rheumatologist examination, DAS28 test, ESR, concentrations of rheumatoid factor (RF) test, anti-cyclic citrullinated peptide (anti-CCP) and anti-modified citrullinated vimentin (anti-CMV) tests. Bone mineral density (BMD) of the distal radius and lumbar spine (L1-L4) were assessed by DEXA Challenger (DMS, France). MRIs of the patient's dominant wrist and 2nd — 5th metacarpophalangeal (MCP) joints were obtained using 1.5T MRI MAGNETOM Espree (Siemens) with contrast enhancement. The average score was determined for synovitis (0—9 for wrist joint, and 0—21 for wrist plus MCP joints), bone oedema (osteitis, 0—69) and bone erosions
head necrosis in our patients is related to the high dose but intermittent prednisone given in the combination chemotherapy protocols utilized in treatment of lymphoma. As the frequency of remission induction and disease-free survival of these patients improved long-term complications of intensive chemotherapy have become apparent. Osteonecrosis in a small percentage of intensively treated cases may be among these complications. And etiologic relationship of the corticosteroids to bone disease in such patients is uncertain.
(0—230) using the RAMRIS system. Statistical analysis of the results was also undertaken.
Results. The DEXA showed bone loss in patients with ERA. When analyzing the lumbar spine osteoporosis was found in 8 patients (7.14 %) and osteopenic syndrome was identified in 33 patients (29.4 %). In the study of the distal radius the more substantial bone loss was established. Thus, osteoporosis was diagnosed in 29 patients (25.9 %), osteopenic syndrome — in 67 patients (59.8 %). The BMD decrease at the distal radius correlated with DAS28 (r = -0.67; p < 0.001), ESR (r = -0.44; p < 0.05) and number of swollen joints (r = -0.40; p < 0.01). As for BMD of the lumbar spine, only the correlation with DAS28 was found. Osteopenia and osteoporosis were more frequently identified in patients with RF (+), anti-CCP (+) and ant-CMV (+). All patients with seropositive rheumatoid arthritis showed a significant decrease in bone mineral density at both the lumbar spine and distal radius. Bone erosions were identified with standard radiography in 28 patients. Most of the erosions were located in the bones of the wrist and in 7 patients they were located in the head section of metacarpal bones. vdHS system demonstrated the score of 15.0 ± 24.6 points of average erosions. Detection of erosions on radiographs correlated with the presence of synovitis hand joints. At the same time all patients with radiographic erosions suffered of the decrease in BMD of the distal radius (r = -0.72; p < 0.001). However, assessment of the changes in mineral density of the lumbar spine did not demonstrate such correlation. MRI of the dominant wrist revealed the following MR symptoms: swelling of the bone marrow — in 102 patients (91.07 %), synovitis — in 86 patients (76.8 %), erosion — in 71 patients (63.4 %). MRI detected the erosions 2.5 times more cases than the standard radiography. Strong correlation between BMD of the distal radius and the presence of erosions detected by MRI (r = -0.72; p < 0.001), and lumbar spine BMD and erosions (r = -0.48; p < 0.01) was established.
Conclusion. The results of this study prove that the decrease in BMD of the distal radius and lumbar spine correlates with the erosions of the dominant wrist and 2nd — 5th MCP joints detected by standard radiographs and MRI. Thus, the BMD changes can be predicted early by the development of erosive process in patients with ERA. The early loss of a wrist bone tissues, measured in the first year of the disease using the DRA is an independent predictor of erosive progression.
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Brnb. CyMo6u. Xpe6eT, ISSN 2224-1507
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