DOI QR코드

DOI QR Code

Delayed Diagnosis of a Tibial Stress Fracture Associated with Glucocorticoid and Methotrexate Therapy in a Patient with Rheumatoid Arthritis: A Case Report

  • Shin, Hye Jeong (Department of Acupuncture and Moxibustion Medicine, Korean Medicine Hospital of Woosuk University) ;
  • Lim, Yi Gun (Department of Acupuncture and Moxibustion Medicine, Korean Medicine Hospital of Woosuk University) ;
  • Lee, Gi Hyang (Department of Internal Medicine, College of Korean Medicine, Woosuk University) ;
  • Lee, Hyun Seok (Department of Acupuncture and Moxibustion Medicine, Bundang Jaseng Hospital of Korean Medicine) ;
  • Song, Beom Yong (Department of Acupuncture and Moxibustion Medicine, Korean Medicine Hospital of Woosuk University) ;
  • Choi, Yoo Min (Department of Acupuncture and Moxibustion Medicine, Korean Medicine Hospital of Woosuk University)
  • 투고 : 2021.10.13
  • 심사 : 2021.12.29
  • 발행 : 2022.02.28

초록

The risk of stress fractures is associated with rheumatoid arthritis (RA), which can aggravate bone loss. We report the case of a patient who was on long-term medication for RA presenting with lower extremity pain on the left and swelling without trauma. Magnetic resonance imaging and plain radiographs at the previous hospital showed no signs of fracture, but radiographs performed later, revealed a stress fracture of the left distal tibia. The stress fracture may have occurred due to multiple reasons such as long-term use of methotrexate and glucocorticoids, active RA, postmenopausal state, and immobility. Suspicion of a stress fracture should not be ruled out especially in RA patients with persistent pain, even if the radiographical findings are normal. Additional imaging and follow-ups are essential. The patient's pain was relieved with Korean medicine treatments, which suggests their potential application for stress fractures in RA patients.

키워드

참고문헌

  1. A snapshot of arthritis in Australia 2010. Canberra (Australia): Australian Institute of Health and Welfare; 2010.
  2. Staa TV, Geusens P, Bijlsma JW, Leufkens HG, Cooper C. Clinical assessment of the long-term risk of fracture in patients with rheumatoid arthritis. Arthritis Rheum 2006;54:3104-3112. https://doi.org/10.1002/art.22117
  3. Devas M. Stress Fractures. London (England): Churchill Livingstone; 1975.
  4. Sambrook PN, Eisman JA, Champion GD, Yeates MG, Pocock NA, Eberl S. Determinants of axial bone loss in rheumatoid arthritis. Arthritis Rheum 1987;30:721-728. https://doi.org/10.1002/art.1780300701
  5. Reid DM, Kennedy NS, Smith MA, Tothill P, Nuki G. Total body calcium in rheumatoid arthritis: effects of disease activity and corticosteroids treatment. Br Med J (Clin Res Ed) 1982;285:330-332. https://doi.org/10.1136/bmj.285.6338.330
  6. Yurtsever A, Fagerberg SK, Rasmussen C. Insufficiency fractures of the knee, ankle, and foot in rheumatoid arthritis: A case series and case-control study. Eur J Rheumatol 2020;7:124-129. https://doi.org/10.5152/eurjrheum.2020.19196
  7. Elkayam O, Paran D, Flusser G, Wigler I, Yaron M, Caspi D. Insufficiency fractures in rheumatic patients: misdiagnosis and underlying characteristics. Clin Exp Rheumatol 2000;18:369-374.
  8. Chung YS. Glucocorticoid-induced Osteoporosis: From Pathogenesis to Treatment. J Korean Soc Osteoporos 2009;7:145-151.
  9. Meier L, van Tuyll van Sersooskerken AM, Liberton E, Kleijn L, Westgeest T, Polak M et al. Fractures of the proximal tibia associated with longterm use of methotrexate: 3 case reports and a review of literature. J Rheumatol 2010;37:2434-2438. https://doi.org/10.3899/jrheum.100385
  10. Preston SJ, Diamond T, Scott A, Laurent MR. Methotrexate osteopathy in rheumatic disease. Ann Rheum Dis 1993;52:582-585. https://doi.org/10.1136/ard.52.8.582
  11. Lingg GM, Soltesz I, Kessler S, Dreher R. Insufficiency and stress fractures of the long bones occurring in patients with rheumatoid arthritis and other inflammatory diseases, with a contribution on the possibilities of computed tomography. Eur J Radiol 1997;26:54-63. https://doi.org/10.1016/S0720-048X(97)00039-9
  12. Spina A, Clemente A, Vancini C, Fejzo M, Campioni P. Spontaneous talar and calcaneal fracture in rheumatoid arthritis: A case report. J Radiol Case Rep 2011;5:15-23. https://doi.org/10.3941/jrcr.v5i7.735
  13. Buckley LM, Leib ES, Cartularo KS, Vacek PM, Cooper SM. Effects of low dose methotrexate on the bone mineral density of patients with rheumatoid arthritis. J Rheumatol 1997;24:1489-1494.
  14. Trickey J, Barkham N. Foot and ankle insufficiency fracture in rheumatoid arthritis. MOJ Orthop Rheumatol 2015;3:00091.
  15. Alswat KA. Gender disparities in osteoporosis. J Clin Med Res 2017;9:382-387. https://doi.org/10.14740/jocmr2970w
  16. Malkoc M, Korkmaz O, Ormeci T, Oltulu I, Isyar M, Mahirogullari M. An unusual stress fracture: Bilateral posterior longitudinal stress fracture of tibia. Int J Surg Case Rep 2014;5:500-504. https://doi.org/10.1016/j.ijscr.2014.06.002
  17. Defoort S, Mertens P. Multiple tibial insufficiency fractures in the same tibia: A case report. Geriatr Orthop Surg Rehabil 2011;2:69-72. https://doi.org/10.1177/2151458510391986
  18. Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. The importance of increasing awareness amongst radiologists. Eur J Radiol 2007;62:16-26. https://doi.org/10.1016/j.ejrad.2007.01.014
  19. Alenfeld FE, Diessel E, Brezger M, Sieper J, Felsenberg D, Braun J. Detailed analyses of periarticular osteoporosis in rheumatoid arthritis. Osteoporos Int 2000;11:400-407. https://doi.org/10.1007/s001980070106
  20. Matin P. The appearance of bone scans following fractures, including immediate and long-term studies. J Nucl Med 1979;20:1227-1231.