martes, 19 de febrero de 2013

Artropatía de Jaccoud.



Paciente varón de 20 años que consulta por disnea de esfuerzo. A los 9 años tuvo dos episodios de poliartritis migratorios sugestivos de fiebre reumática. El examen cardiovascular mostró un soplo pansistólico en la punta.
En el examen físico presentaba deformidad en sus manos. Sus articulaciones estaban agrandadas pero no había evidencias de inflamación activa o alteraciones funcionales y no había nódulos subcutáneos. La eritrosedimentación era de 68 mm en la primera hora y la PCR estaba elevada a 120 mg/l. Los anticuerpos antiestreptolisina, factor reumatoideo, FAN, y anticuerpos contra péptido cíclico citrulinado fueron todos negativos.
Se hizo diagnóstico de artropatía de Jacccoud. 

La artropatía de Jaccoud es una condición reumatológica benigna sin daño funcional y necesita ser diferenciado de otras deformidades no corregibles como las del lupus y de la AR.  


Jaccoud's arthropathy

En la imagen A hay deformidades en flexión en las metacarpofalángicas y en las interfalángicas distales, y hay deformidad en hiperextensión en las interfalángicas proximales del segundo, tercero, cuarto y quinto dedos de ambas manos.
En B no hay evidencias de erosiones en la superficie articular de ninguna articulación.

Fuente:
Ajay S Chaurasia DM a, Jaywant M Nawale DM a, Sandeep N Patil DM a, Madhusudan A Yemul DM a, Dr Sachin M Mukhedkar DM a , Dhirender Singh MD a, Pranjal K Patil MD a, Rajendra V Chavan MD 
The Lancet,  4 January 2013

2 comentarios:

Ricardo Vigon dijo...

Tenía entendido que la vinculación de la artropatía de Jaccoud con el LES era muy significativa...

Juan Macaluso dijo...

Exacto Ricardo, yo tengo ese concepto. La artropatía de Jaccoud se ve fundamentalmente en fiebre reumática y en LES.

UoToDate dice al respecto:

Arthritis and arthralgias have been noted in up to 95 percent of patients with SLE. These symptoms may be mistaken for another type of inflammatory arthritis and can precede the diagnosis of SLE by months or years.

Clinical characteristics — Arthritic symptoms in patients with SLE have the following characteristics that are generally different from those in rheumatoid arthritis (RA) (table 1) [1-4]:

■The arthritis and arthralgias of SLE tend to be migratory; symptoms in a particular joint may be gone within 24 hours.
■Involvement is usually symmetrical and polyarticular with a predilection for the knees, carpal joints, and joints of the fingers, especially the proximal interphalangeal (PIP) joint. The ankles, elbows, shoulders, and hips are less frequently involved. Involvement of the sacroiliac joints and cervical spine may occur but is rare. Monoarticular arthritis is unusual and suggests an alternative cause such as infection.
■Morning stiffness is usually measured in minutes and is not prolonged as in rheumatoid arthritis (RA).
■The degree of pain often exceeds objective physical findings, and tenderness may be difficult to assess because of increased pain sensitivity in some patients, which can be associated with coexisting fibromyalgia.


Although the arthritis of SLE is generally considered to be nondeforming, flexion deformities, ulnar deviation, soft tissue laxity, and swan neck deformities, as seen in RA, have been noted in 15 to 50 percent of patients with SLE [1-6]. HOWEVER, UNLIKE RA, EROSIONS IN THE HAND ARE RARELY NOTED ON PLAIN RADIOGRAPHS OF THE HANDS IN SLE [4,7]. Similarly, in one study of 26 patients with SLE using ultrasonography, synovial proliferation and effusions were detected in the knees in 23 percent of patients, and synovitis was seen in 40 percent, although no erosions were detected [8]. More sensitive imaging methods, such as magnetic resonance imaging (MRI), more often reveal erosive changes and abnormalities of the soft tissues, including capsular swelling, proliferative tenosynovitis, and synovial overgrowth [6]. The presence of antibodies to citrullinated peptides/proteins (anti-CCP) antibodies (prevalent in 8 percent of patients with SLE) is strongly associated with erosive arthritis (odds ratio of 23 for anti-CCP positive versus negative patients) [9,10].

The hand deformity tends to occur in patients who have been receiving glucocorticoids, who have anti-Ro and/or anti-La antibodies [5], or who have longstanding disease [6]. In contrast to the typical findings in RA, these deformities are usually easily reducible; they are thought to be due to lax joint capsules, tendons, and ligaments that cause joint instability [6]. Thus, the hand deformities in patients with SLE resemble Jaccoud’s arthritis, a nonerosive chronic deforming arthritis that may follow acute rheumatic fever [11].

Tendons may also be involved in SLE. Tenosynovitis has been noted in 10 to 44 percent of patients, including epicondylitis, rotator cuff tendinitis, Achilles tendinitis, tibialis posterior tendinitis, and plantar fasciitis [4,6,12,13]. Infrapatellar and Achilles tendon ruptures are rare [14]. (See "Posterior and medial ankle tendinopathies not involving the Achilles tendon".)