Rheumatoid pannus presenting as a large epidural mass in the subaxial cervical spine: A case report

Rheumatoid arthritis (RA) is a debilitating inflammatory condition characterised by joint damage that affects the cervical spine most commonly at the atlantoaxial joint resulting in neck pain and myelopathy. The pathogenesis of RA involves the formation of a hyperplastic synovial tissue, termed pannus, which invades the local bone and causes osseous erosion. Here, we describe a case of rapid onset quadriparesis due to spinal cord compression at C5–C6 secondary to vertebral subluxation and mass effect from a large inflammatory pannus in the subaxial spine. Surgical decompression and resection of the subaxial pannus were performed, and the patient regained strength in all extremities. Histopathologic evaluation of the resected tissue confirmed the diagnosis of pannus over other more common epidural masses. Pannus formation commonly occurs in the peri-odontoid region; however, its presentation as a large soft tissue mass in the subaxial spine is not described in the current literature. Therefore, pannus should be considered in the differential diagnosis of epidural masses in the spine of RA patients. We use this case to discuss the pathology and radiological findings relevant to rheumatoid pannus formation in the subaxial cervical spine, as well as emphasise the importance of treatment in the context to severe degenerative disease.     

经胸超声心动图评估人工机械主动脉瓣血管翳清除术及再次置换术的安全性及有效性

目的：本研究对比人工机械主动脉瓣血管翳患者采用血管翳清除术与再次置换术两种手术方式的围手术期临床结果及术前、术后经胸超声心动图（transthoracic echocardiogram, TTE）参数，探讨人工机械主动脉瓣血管翳清除术及再次置换术的安全性及有效性。方法：复旦大学附属中山医院自2019年9月至2022年3月外科手术中证实41例人工机械主动脉瓣梗阻原因为血管翳。其中17例采取血管翳清除术，而保留原有的人工机械瓣，24例采取人工机械主动脉瓣再次置换术。结果：两种手术方式在术前及术后1周TTE检测指标跨瓣峰值流速（transvalvular peak velocity, Vmax），跨瓣峰值压差（transvalvular peak pressure gradient, PGmax），跨瓣平均压差（transvalvular mean pressure gradient, TMPG），左心室舒张末期内径（left ventricular end-diastolic diameter, LVEDD），左心室收缩末期内径（left ventricular end-systolic diameter, LVSDD）及左心室射血分数（left ventricular ejection fraction，LVEF）两组间均无统计学差异，术前TTE两组均符合手术指征，术后两组TMPG均低于20mmHg。术中再次置换组较血管翳清除组体外循环时间及主动脉夹闭时间明显延长，两者差异具有统计学意义（P<0.001），体外循环时间与术后第１天复查血清肌钙蛋白T（cardiac troponin T, cTnT）增高呈中等正相关关系（rs=0.543,P<0.001）。术后第1天再次置换组白细胞（white blood cell, WBC）高于血管翳清除组（P<0.05）。术后住院期间再次置换组的患者并发症发生共10例（41.6%），其中包括2例为严重的多器官功能障碍，住院期间死亡人数为4例（16.7%）；而血管翳清除组出现并发症仅有４例（23.5%），无围手术期死亡。结论：围手术期临床结果及TTE指标显示血管翳清除术是一种安全有效的手术方式。TTE是人工机械主动脉瓣置换术后长期随访有效影像学手段。     

Evaluation of protective efficacy of Spirulina platensis against collagen-induced arthritis in rats

Aim  To assess the protective efficacy of Spirulina platensis against collagen-induced arthritis (CIA) in female Wistar rats based on the changes in paws thickness, serum albumin, cholesterol, lipid peroxidation, alkaline phosphatase and acid phosphatase activities and histology of paw joints. Methods  Arthritis was induced by intradermal injection of Collagen and Freund’s adjuvant incomplete suspension at several sites on the back with a dose of 2 mg kg⁻¹ of body weight and boosted with 0.1 ml intradermally at the base of the tail. CIA rats were orally treated with 200 and 400 mg kg⁻¹ per oral of S. platensis from 0 to 45th day. Results   S. platensis at 400 mg kg⁻¹ per oral significantly elevates serum albumin and decreases the serum cholesterol, alkaline phosphatase and acid phosphatase activities, lipid peroxidation, paw thickness as well as normalize the joint histopathology of CIA rats. Conclusions   S. platensis (400 mg kg⁻¹) significantly normalizes changes observed in arthritic rats to near normal conditions, indicates that S. platensis has promising protective efficacy against CIA rats.     

类风湿关节炎与滑膜新生血管

类风湿关节炎(RA)是以对称性多关节炎为主要临床表现的异质性、系统性、自身免疫性疾病,多种炎性细胞因子在缺氧环境下相互作用,关节滑膜血管及血管翳形成,进一步侵蚀软骨及软骨下基质,最终导致关节畸形,功能丧失。因此,抑制RA中新生血管可能会成为未来治疗RA的有效策略。该文对近年来生成及抑制新生血管形成的机制研究及治疗靶点予以综述。     

Rheumatoid pannus formation: synovial cell attachment to the surface of cartilage

Abstract

As a part of the rheumatoid synovial tissue reaction, proliferating synovial cells penetrate the cartilage in the form of a pannus, and cartilage destruction takes place in the zone between the cells and cartilage. The cellular origin of rheumatoid pannus has been debated by many investigators, and it is accepted that fibroblast proliferation, endothelial cells proliferation and monocyte chemotaxis are probably involved. It has been observed that fibroblasts in the pannus share properties of the fibroblasts and chondrocytes. Mast cell activation is frequently associated with proinflammatory cytokine and metalloprotease expression, suggesting an important role for the mast cell in mediating matrix degradation. The mechanism of interaction of polymorphonuclear leukocytes with immune complexes trapped in rheumatoid cartilage resembles that associated with phenomenon of frustrated phagocytosis. Increased levels of IL-1 in the rheumatoid joint may play an important role in joint destruction by stimulation of pannus formation through induction of synovial cell attachment to the articular surface. Synovial cell attachment to cartilage may be the initial step in pannus formation. We have recently shown that the increased expression of VLA-5 and ICAM-1 at the cartilage-pannus junction may result from the interaction of synovial mononuclear cells with matrix proteins. Therefore, we have raised the possibility that VLA-5 may facilitate the growth of pannus by virtue of its ability to react with fibronectin with resulting proliferation of the synoviocytes of the pannus. Further study will be needed in order to understand the precise mechanism of cartilage erosion and pannus formation in the various arthritic disorders.     

Thrombolytic therapy with tissue plasminogen activator for the treatment of nonstructural malfunction of bileaflet cardiac valve prostheses

This study was conducted to determine the effect of thrombolytic therapy with tissue plasminogen activator (t-PA) for nonstructural malfunction of bileaflet cardiac valve prostheses. Twenty-seven patients with bileaflet prosthetic valve malfunction diagnosed by a combination of cineradiography and transthoracic echocardiography were treated with the administration of intravenous t-PA. The treatment resulted in complete success in 55.6% (15 of 27), partial success in 22.2% (6 of 27), and no change in 22.2% (6 of 27). In the complete success and partial success groups, the condition of the patients in 85.7% (18 of 21) of the cases improved within 24 h after the administration of t-PA. Six cases in whom thrombolytic therapy was instituted more than 1 month (ranged from 1 to 38 months, mean 14.7 months) after the diagnosis of prosthetic valve malfunction showed significantly less effectiveness of thrombolytic therapy with t-PA. Only one patient (3.7%) had a major complication (thromboembolism) after t-PA treatment. The results suggest that thrombolytic therapy with t-PA in patients with nonstructural malfunction of bileaflet cardiac valve prostheses is effective with low incidence of complication when the treatment is instituted early after the diagnosis.     

Cytokine enhancement of monocyte/synovial cell attachment to the surface of cartilage: a possible trigger of pannus formation in arthritis

Summary When rheumatoid articular cartilage samples were incubated with normal peripheral blood monocytes and cultured synovial cells in the presence of recombinant human interleukin-1 (IL-1) in vitro, large numbers of monocytes were seen to be attached to the articular surface. Significant numbers of monocytes invaded the cartilage tissue when the rheumatoid cartilage samples were pre-incubated with 10 U/ml of IL-1. Considerable numbers of monocytes were also attached to normal cartilage when these were pre-incubated with IL-1. It is of interest that recombinant human gamma interferon (-IFN) did not enhance monocyte attachment. However, there was a significantly greater attachment of monocytes to rheumatoid than to normal cartilage. When normal cartilage was exposed to collagenase and then incubated with monocytes or synovial cells in the presence of 10 U/ml of IL-1, large numbers of cells were attached to the natural cartilage surface but not to the cut surface. These phenomena were much more intense when the rheumatoid cartilage was pre-incubated with collagenase. These results indicate that increased levels of IL-1 in the rheumatoid joint may play an important role in joint destruction by stimulation of pannus formation by inducing synovial cell attachment to the articular surface.     

Avoidance sectors to reduce dosimetric impact of an irreproducible pannus on setup uncertainty in prostate SBRT VMAT: A case study

This work investigates whether the use of an avoidance sector in a two-arc volumetric modulated arc therapy (VMAT) prostate stereotactic body radiotherapy (SBRT) plan reduces dosimetric variations due to an irreproducible pannus. A morbidly obese patient with favorable-risk prostate cancer elected treatment with SBRT. The patient was treated with the avoidance arcs across the pannus to eliminate reproducibility issues created by daily pannus variability in set up. For post-treatment assessment, the case was planned using Varian Eclipse? treatment planning system (TPS) with two VMAT arcs with and without 100° avoidance sectors across the pannus. The dose was re-calculated using the external body contour from four daily treatment cone-beam computer tomography scans, and on two virtual body contours created by expanding the pannus region of the external contour by 5 and 10 mm. Dose differences between planned and re-calculated rectal wall mean dose and the V_24Gy were numerically larger in the absence of the avoidance sector for all fractions and for both simulated pannus variations, with maximum changes of 2.6% and 1.3%. Maximum point dose variations in the PTV, CTV, rectum, bladder, and femoral heads were 105 cGy or less for all cases, with and without the avoidance sector. The use of an avoidance sector across this large, asymmetrical pannus did not inhibit achieving dose constraints and provided a reduction in dose variability which was nominal in this case for 10 mm variations. Avoidance sectors can be safely implemented in cases with obvious reproducibility concerns in the setting of prostate VMAT SBRT.     

Mitral valve-sparing procedures and prosthetic heart valve failure: A case report

Prosthetic heart valve dysfunction due to thrombus or pannus formation can be a life-threatening complication. The present report describes a 47-year-old woman who developed valvular cardiomyopathy after chorda-sparing mitral valve replacement, and subsequently underwent heart transplantation for progressive heart failure. The explanted mitral valve prosthesis showed significant thrombus and pannus leading to reduced leaflet mobility and valvular stenosis. The present report illustrates the role of the subvalvular apparatus and pannus in prosthesis dysfunction.