Aseptic olecranon bursitis as a novel subcutaneous manifestation of dermatomyositis

ARTICLE

Auteur(s) : Yasuhiro Kawachi, Enmi Hori, Michiko Itoh, Yasuhiro Fujisawa, Junichi Furuta, Yasuhiro Nakamura, Yoshiyuki Ishii, Fujio Otsuka

Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan

A 32-year-old woman developed reddish macules on both eyelids and pruriginous edematous erythematous lesions on the shoulders and thighs. The patient also showed erythematous cutaneous lesions on the bilateral elbows and knees, bilateral extensor sites of the upper aspects of the arms, and the periungual nailfolds. Four months later, she presented with proximal muscular pain and weakness that became gradually worse. On referral to our clinic, physical examination revealed fluctuating cystic soft tissue swelling with superficial scaling erythema on the bilateral elbows (figure 1C) in addition to the typical observations of heliotrope periorbital edema (figure 1A), Gottron’s papules (figure 1B). The subcutaneous cystic masses showed slight tenderness but no spontaneous pain. The patient had not been aware of any injury or unusual mechanical stress on the affected elbows. Laboratory data indicated a slight increase in serum aldolase level (7.0 IU/dL; normal range, 1.7-5.7 IU/dL) with a normal serum level of creatine phosphokinase (CK) and moderately elevated C-reactive protein level (2.2 mg/dL). The patient was negative for anti-nuclear and anti-Jo-1 antibodies. A skin biopsy obtained from the erythematous eruption on the right elbow revealed slight liquefaction degeneration in the basal layer of the epidermis, and massive mononuclear cell infiltration was noted in fat lobules in subcutaneous layers. No apparent necrotizing vasculitis or crystal deposition was seen throughout the whole specimen. Magnetic resonance imaging (MRI) of the elbows revealed a bursa markedly distended by fluid and rim enhancement, which indicated inflammation around the bursa wall (figures 1D, E). Aspirated fluid from the lesion was negative on Gram staining. Repeated bursal fluid cultures of aspirated fluids yielded no microbial pathogens and revealed the bursitis of both elbows to be aseptic. Based on these findings, a diagnosis of dermatomyositis with aseptic olecranon bursitis was made and oral prednisolone was started at a dose of 50 mg daily. The patient showed rapid improvement of the eruptions, including the heliotrope periorbital edema and the Gottron’s papules, and steroid therapy resulted in a gradual decrease of redness and swelling due to the bursitis, and the serum aldolase level decreased to within the normal range, which allowed gradual tapering of the steroid dose. Four months after the initial treatment, the symptoms of bursitis at both elbows disappeared completely and MRI revealed no cystic masses or fluid retention in either elbow.

The most common cause of aseptic olecranon bursitis is chronic repetitive trauma with direct pressure on the olecranon, but with the exception of rheumatoid arthritis cases, aseptic bursitis associated with autoimmune connective tissue diseases is quite rare, and there have been no previous reports of aseptic bursitis associated with dermatomyositis. The skin manifestations are the distinguishing clinical features of dermatomyositis, with well-known primary classic cutaneous lesions of heliotrope periorbital rash, Gottron’s sign, atrophic poikilodermatous erythema, pruritic flagellate erythema, periungual telangiectasia, and photosensitivity. However, subcutaneous involvement during the course of this disease is uncommon. Previous reports described subcutaneous involvement, including panniculitis [1], vasculitis [2], massive calcinosis [3], and generalized edema [4, 5], as rare skin manifestations of dermatomyositis and indicators of poor prognosis. Here, we described a patient with dermatomyositis showing aseptic olecranon bursitis as a subcutaneous manifestation.

The present case showed panniculitis without vasculitis as well as bursitis in the surrounding subcutaneous tissue of the olecranon bursa. As MRI examination revealed bursal membrane inflammation without surrounding panniculitis (figures 1D, E; arrowheads), we feel that the bursitis arose first in this case and the panniculitis of the adjacent fat tissue occurred as a secondary effect due to extension of the inflammation. In summary, the observations in the present case indicated that aseptic effusive bursitis is a rare but cautionary manifestation of dermatomyositis.

Acknowledgements

References

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