Advanced erosive osteoarthritis (EOA)

By Rodney S. Daniel, MD and Alan N. Brown, MD

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 &#64257;rst carpometacarpal joints bilaterally; changes on the right were greater than those on the left. Incidentally, chondrocalcinosis was seen in the triangular &#64257;brocartilage. </<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.

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>Kellgren JH, Moore R. Generalized osteoarthritis and Heberden's nodes. Br Med J.1952;1:181-187. </<span class="end-tag" />LI
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>Ehrlich GE. Erosive osteoarthritis: Presentation, clinical pearls, and therapy.Curr Rheumatol Rep.2001;3:484-488. </<span class="end-tag" />LI
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>Greenspan A. Erosive osteoarthritis. Semin Musculoskelet Radiol.2003;7(2):155-159. </<span class="end-tag" />LI
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>Punzi L, Ramonda R, Sfriso P. Erosive osteoarthritis. Best Pract Res Clin Rheumatol. 2004;18:739-758. </<span class="end-tag" />LI
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>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
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Advanced erosive osteoarthritis (EOA).  Appl Radiol. 

December 12, 2007
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