Objectives: Rheumatoid arthritis is sometimes misdiagnosed for other diseases, like psoriatic arthritis, erosive OA, viral arthritis, reactive arthritis, IBD arthritis, Lyme’s disease, and palindromic rheumatism. Secondary hyperparathyroidism was not included in the differential diagnosis of RA, though it sometimes presents with joint pains and tenderness, and even arthritis. Fibromyalgia is a psychosomatic disorder characterized by chronic widespread pain and tender areas. Mimicry of some manifestations of these diseases sometimes results in misdiagnosis as RA. Methods: Two hundred patients previously diagnosed as RA from outpatient clinics in Al-Azhar Faculty of Medicine, attended as not responding to medical treatment of RA. All patients were subjected to a re-evaluation of disease activity including HAQ, and DAS 28, CDAI, and SDAI. Also, we measured serum vitamin D3, PTH, total and ionized Calcium, Phosphorus, Uric acid, ACPA, and other routine lab. All patients were exposed to various radiological imaging modalities. Results: Cases not responding to RA treatment were reevaluated and were found to have a syndrome of fibromyalgia associated with vitamin D3 deficiency and secondary hyperparathyroidism. Conclusions: Fibromyalgia/Hyperparathyroidism syndrome is an underdiagnosed disease, which results from chronic vitamin D3 deficiency. SHPT can cause bone erosions, which are mostly shaggy in appearance and distributed in the radiocarpal, radioulnar, metacarpophalangeal and distal interphalangeal joints, in contrast to that which predominate proximal IP joints of rheumatoid arthritis. Radiology of FM/HPT syndrome patients revealed a sign of spur-like excrescences in terminal finger tufts unilaterally or bilaterally, which we think is pathognomonic.
References
[1]
Taylor, J.G. and Bushinsky, D.A. (2009) Calcium and Phosphorus Homeostasis. Blood Purification, 27, 387-394. https://doi.org/10.1159/000209740
[2]
Pepe, J., Cipriani, C., Pilotto, R., De Lucia, F., Castro, C., Lenge, L., et al. (2011) Sporadic and Hereditary Primary Hyperparathyroidism. Journal of Endocrinological Investigation, 34, 40-44.
[3]
Madkhali, T., Alhefdhi, A., Chen, H. and Elfenbein, D. (2016) Primary Hyperparathyroidism. Ulusal Cerrahi Dergisi, 32, 58-66.
[4]
Falkenburg, W.J.J. (2015) IgG Subclass Specificity Discriminates Restricted IgM Rheumatoid Factor Responses from More Mature Anti-Citrullinated Protein Antibody-Associated or Isotype-Switched IgA Responses. Arthritis & Rheumatology, 67, 3124-3134. https://doi.org/10.1002/art.39299
[5]
Edkins, A. and Cushley, W. (2012) The Jekyll and Hyde Nature of Antibodies. Biological Sciences Review, 25, 4.
[6]
Vossenaar, E.R., Smeets, T.J., Kraan, M.C., Raats, J.M., van Venrooij, W.J. and Tak, P.P. (2004) The Presence of Citrullinated Proteins Is Not Specific for Rheumatoid Synovial Tissue. Arthritis & Rheumatology, 50, 3485-3494. https://doi.org/10.1002/art.20584
[7]
Elbeialy, A. and Eldesouky, H. (2019) AB1261 Cadmium Toxicity as a Probable Cause of Osteopenia in Adolescents and Its Relation to Bad Dietary Habits. 2091-2092. https://doi.org/10.1136/annrheumdis-2019-eular.731
[8]
Kazantzis, G. (2004) Cadmium, Osteoporosis and Calcium Metabolism. BioMetals, 17, 493-498. https://doi.org/10.1023/B:BIOM.0000045727.76054.f3
[9]
Wang, Y., Zhu, J. and DeLuca, H.F. (2015) The Vitamin D Receptor in the Proximal Renal Tubule Is a Key Regulator of Serum 1α,25-Dihydroxyvitamin D3. The American Journal of Physiology-Endocrinology and Metabolism, 308, E201-E205. https://doi.org/10.1152/ajpendo.00422.2014
[10]
Kurata, Y., Katsuta, O., Doi, T., et al. (2014) Chronic Cadmium Treatment Induces Tubular Nephropathy and Osteomalacia Osteopenia in Ovariectomized Cynomolgus Monkeys. Veterinary Pathology, 51, 919-931. https://doi.org/10.1177/0300985813509384
[11]
Costa, J.M., Ranzolin, A., Costa Neto, C.A., Marques, C.D. and Duarte, A.L. (2016) High Frequency of Asymptomatic Hyperparathyroidism in Patients with Fibromyalgia: Random Association or Misdiagnosis? Revista Brasileira de Reumatologia, 56, 391-397. https://doi.org/10.1016/j.rbre.2016.03.008
[12]
Borgia, A.R., Cavallasca, J.A., Costa, C.A. and Musuruana, J.L. (2012) Hyperparathyroidism, a Forgotten Cause of Musculoskeletal Pain. Reumatología Clínica, 8, 299-301. https://doi.org/10.1016/j.reumae.2012.06.019
[13]
Mackenzie-Feder, J., Sirrs, S., Anderson, D., Sharif, J. and Khan, A. (2011) Primary Hyperparathyroidism: An Overview. International Journal of Endocrinology, 2011, Article ID: 251410.
[14]
Arnett, F.C., Edworthy, S.M., Bloch, D.A., McShane, D.J., Fries, J.F., Cooper, N.S., et al. (1988) The American Rheumatism Association 1987 Revised Criteria for the Classification of Rheumatoid Arthritis. Arthritis & Rheumatology, 31, 315-324. https://doi.org/10.1002/art.1780310302
[15]
Aletaha, D., Neogi, T., Silman, A.J., Funovits, J., Felson, D.T., Bingham, C.O., et al. (2010) 2010 Rheumatoid Arthritis Classification Criteria: An American College of Rheumatology/European League against Rheumatism Collaborative Initiative. Arthritis & Rheumatology, 62, 2569-2581. https://doi.org/10.1002/art.27584
[16]
Smolen, J.S. and Aletaha, D. (2014) Scores for All Seasons: SDAI and CDAI. Clinical and Experimental Rheumatology, 32, S-75-9.
[17]
Wolfe, F., Smythe, H.A., Yunus, M.B., Bennett, R.M., Bombardier, C., Goldenberg, D.L., et al. (1990) The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis & Rheumatology, 33, 160-172.
[18]
Wolfe, F., Clauw, D.J., Fitzcharles, M.A., Goldenberg, D.L., Katz, R.S., Mease, P., et al. (2010) The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care & Research, 62, 600-610. https://doi.org/10.1002/acr.20140
[19]
Helliwell, M. (1983) Rheumatic Symptoms in Primary Hyperparathyroidism. Postgraduate Medical Journal, 59, 236-240. https://doi.org/10.1136/pgmj.59.690.236
[20]
Bywaters, E.G.L., Dixon, A.S.J. and Scott, J.T. (1963) Joint Lesions of Hyperparathyroidism. Annals of the Rheumatic Diseases, 22, 171-187. https://doi.org/10.1136/ard.22.3.171
[21]
Zvaifler, N.J., Reefe, W.E. and Black, R.L. (1962) Articular Manifestations in Primary Hyperparathyroidism. Arthritis & Rheumatology, 5, 237-249. https://doi.org/10.1002/art.1780050304
[22]
Lipson, R.L., Williams, L.E., Zvaifler, N.J. and Howell, D.S. (1968) The “Connective Tissue Disorder” of Hyperparathyroidism. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology, 11, 198-205. https://doi.org/10.1002/art.1780110211
[23]
Duraywish, A.A. (2016) Chronic Unclassified Polyarthritis: A Rare Presentation of Primary Hyperparathyroidism. The Medical Journal of Cairo University, 84, 265-269.
[24]
Salari, M., Aboutorabi, R.B. and Rezaieyazdi, Z. (2015) Hypercalcemia and Lytic Bone Lesions Masquerading Inflammatory Arthritis Treated as Rheumatoid Arthritis. Archives of Iranian Medicine, 18, 720-723.
[25]
Feng, X. and McDonald, J.M. (2011) Disorders of Bone Remodeling. Annual Review of Pathology, 6, 121-145. https://doi.org/10.1146/annurev-pathol-011110-130203
[26]
Li, N., Li, X.M., Xu, L., Sun, W.J., Cheng, X.G. and Tian, W. (2013) Comparison of QCT and DXA: Osteoporosis Detection Rates in Postmenopausal Women. International Journal of Endocrinology, 2013, Article ID: 895474. https://doi.org/10.1155/2013/895474
[27]
Patel, A.A., Ramanathan, R., Kuban, J. and Willis, M.H. (2015) Imaging Findings and Evaluation of Metabolic Bone Disease. Advances in Radiology, 2015, Article ID: 812794. https://doi.org/10.1155/2015/812794
[28]
Killinger, Z., Payer, J., Lazúrová, I., Imrich, R., Homérová, Z., Kužma, M. and Rovensky, J. (2010) Arthropathy in Acromegaly. Rheumatic Disease Clinics of North America, 36, 713-720. https://doi.org/10.1016/j.rdc.2010.09.004
[29]
Freyschmidt, J., Brossmann, J., Sternberg, A., et al. (2003) Freyschmidt’s “Koehler/Zimmer’s Borderlands of Normal and Early Pathological Findings in Skeletal Radiography”.
