Diagnosis
Advanced erosive osteoarthritis (EOA) </<span class="end-tag"
/>P
Findings
Frontal and oblique radiographs of the left and right hand
showed diffuse mild osteopenia (Figures 1 and 2). There were
multiple areas of joint space narrowing with osteophyte formation;
these were most notable at the left third DIP joint and the right
second PIP interphalangeal joint. Several interphalangeal joints
contained central erosions, which were especially prominent in the
right second DIP. There was medial subluxation of the middle
phalanx as compared with the proximal phalanx of the right second
digit. Similar subluxation was also noted on the same level on the
left hand. Osteoarthritic changes were noted on the first carpometacarpal joints
bilaterally; changes on the right were greater than those on the
left. Incidentally, chondrocalcinosis was seen in the triangular
fibrocartilage. </<span
class="end-tag" />P
Discussion
Kellgren and Moore<
Sup>1
</<span class="end-tag" />Sup>&
#64257;rst described the condition that is
now known as erosive osteoarthritis in 1952. More recently,
Ehrlich<
Sup>2 </<span
class="end-tag" />Sup>coined the term &
ldquo;in&
#64258;ammatory osteoarthritis&
rdquo; to emphasize the clinical signs of
in&
#64258;ammation that are
routinely present: swelling, tenderness, erythema, and warmth.
Erosive osteoarthritis usually begins abruptly with pain and
morning stiffness in the DIP joints before advancing to the PIP
joints, whereas OA has a more insidious, generalized onset. Rarely,
large joints such as the hip and shoulder can become
involved.<
Sup>2,3
</<span class="end-tag" />Sup></<span
class="end-tag" />P
><
P
>The differential diagnosis of EOA includes
osteoarthritis of the hand, rheumatoid arthritis, gout, and
psoriatic arthritis. Osteophytes, Heberden&
rsquo;s nodes, Bouchard&
rsquo;s nodes, and joint space narrowing can
be seen in both EOA and osteoarthritis, but central erosions are
characteristic of only EOA. Instability and ankylosis of
interphalangeal joints are exclusively present in EOA when compared
with osteoarthritis. Compared with the central erosions of EOA,
rheumatoid arthritis erosions are typically marginal and do not
result in the &
ldquo;gull-wing&
rdquo; appearance seen in EOA. &
ldquo;Gull-winging&
rdquo; results from a central erosion on the
proximal plate with marginal proliferation in the distal plate at
both the DIP and PIP joints. This can be contrasted to psoriatic
arthritis, which exhibits marginal erosions in the proximal plate
and marginal periostitis in the distal plate at the DIP joints. In
gout, tophaceous deposits are present and the erosions appear as
&
ldquo;overhanging edges,&
rdquo; neither of which is seen in
EOA.<
Sup>3,4 </<span
class="end-tag" />Sup></<span class="end-tag"
/>P
><
P
>Erosive OA has been associated with systemic diseases,
including hypothyroidism, autoimmune thyroiditis,
hyperparathyroidism, chronic renal disease, scleroderma,
Sj&
ouml;gren&
rsquo;s syndrome, and calcium pyrophosphate
dihydrate arthropathy (CPPD). Some authors believe that these
associations are anecdotal. Our patient&
rsquo;s radiographs revealed
chondrocalcinosis of the triangular cartilage, which is suggestive
of CPPD, but synovial &
#64258;uid
crystal analysis was not pursued.<
Sup>4 </<span class="end-tag"
/>Sup></<span class="end-tag" />P
><
P
>Although the true etiology is unknown, several
investigators have suggested hormonal in&
#64258;uences, metabolic disorders, and
autoimmunity. Erosive OA exhibits a strong family history and an
overwhelming female preponderance, with most women at or near
menopause.<
Sup>2,4
</<span class="end-tag" />Sup>Interestingly, our
patient&
rsquo;s 2 daughters and 1
granddaughter were present during the interview and examination.
The daughters were both in their sixties, and the granddaughter was
in her late thirties. All 3 women exhibited clinical &
#64257;ndings that were suggestive of EOA
(Figure 3). The eldest daughter carried the diagnosis of EOA, and
her sibling had previously undergone surgery to correct a worsening
deformity of the right third digit. </<span class="end-tag"
/>P
><
P
>Standardized trials for the treatment of EOA are
lacking, and no de&
#64257;nitive
therapeutic approach has been reported. Acetaminophen and
nonsteroidal anti-in&
#64258;ammatory drugs (NSAIDs) are the
recommended &
#64257;rst- and
second-line therapeutic interventions, respectively.<
Sup>2-4 </<span class="end-tag"
/>Sup>In small studies, hydroxychloroquine has been shown to
be effective and well-tolerated in NSAID-refractory EOA.<
Sup>5 </<span class="end-tag"
/>Sup>Our patient did not receive NSAIDs because of the
concern of exacerbating her renal insuf&
#64257;ciency, and she was started on
acetaminophen and hydroxychloroquine. </<span class="end-tag"
/>P
><
p><
B>CONCLUSION </<span
class="end-tag" />B></<span class="end-tag"
/>p><
P
>We have described a case of erosive osteoarthritis in 3
generations of women that supports a strong genetic component and
female preponderance of the disease.
<OL
type="1"
><LI
>Kellgren JH, Moore R. Generalized osteoarthritis and
Heberden's nodes. Br Med J.1952;1:181-187. </<span
class="end-tag" />LI
><LI
>Ehrlich GE. Erosive osteoarthritis: Presentation,
clinical pearls, and therapy.Curr Rheumatol Rep.2001;3:484-488.
</<span class="end-tag" />LI
><LI
>Greenspan A. Erosive osteoarthritis. Semin Musculoskelet
Radiol.2003;7(2):155-159. </<span class="end-tag"
/>LI
><LI
>Punzi L, Ramonda R, Sfriso P. Erosive osteoarthritis.
Best Pract Res Clin Rheumatol. 2004;18:739-758. </<span
class="end-tag" />LI
><LI
>Bryant LR, des Rosier KF, Carpenter MT.
Hydroxychloroquine in the treatment of erosive osteoarthritis. J
Rheumatol. 1995;22:1527-1531. </<span class="end-tag"
/>LI
></<span class="end-tag" />OL
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