Rheumatology 1999; 38: 797-798
© 1999 British Society for Rheumatology
Letters to the Editor |
Acute anterior uveitis in a patient with sacroiliitis and acne conglobata
Departments of Rheumatology and
1 Ophthalmology, Hospital Universitario La Paz, P° de la Castellana 265, 28046 Madrid, Spain
Correspondence to:
V. Villaverde García, C/ Pradillo 26 5°B, 28002 Madrid, Spain.
SIR,
There are several arthropathies associated with cutaneous diseases such as palmoplantar pustulosis and acne conglobata. French authors use the term SAPHO to denominate these diseases [1]. The initials of this acronym represent the clinical features more characteristic of this syndrome: synovitis, acne, pustulosis, hyperostosis and osteitis [2, 3].
Acute anterior uveitis is restricted to the iris and ciliary body (iridocyclitis). It is the commonest form of uveitis and the severity of the inflammation depends on the HLA B27 allotype [4]. Approximately half of the cases are HLA B27 positive and have spondylarthropathy [4].
To our knowledge, association of SAPHO syndrome and acute anterior uveitis has not been described previously. We report a case with acute anterior uveitis and arthropathy associated with acne conglobata.
The patient was a 40-yr-old man with lumbar pain for 6 months. Two months after the lumbar pain started, he presented redness, pain, increased lachrymation, photophobia and blurred vision in the left eye for 2 days. The patient was diagnosed as having acute anterior uveitis by an ophthalmologist in the emergency unit of our hospital. Because of the lumbar pain, he was referred to the rheumatology unit. The low backache was of insidious onset, bilateral and worsened in the morning after sleeping. Pain did not extend down the back of the thighs. The patient did not have other symptoms.
Physical examination revealed pustules on the back, diagnosed as acne conglobata by dermatologists (Fig. 1
). The patient was not able to touch the floor with his fingertips while keeping the knees extended (fingertips–floor distance of 30 cm); Schober test was 13 cm. Direct pressure over the sacroiliac joint was not painful. Manoeuvres to elicit pain in the region of the sacroiliac joint were negative. The chest expansion was 5 cm. Ocular examination with a slit lamp revealed moderate inflammation of the ciliary body and the conjunctiva, some keratic precipitates in the lower third, Tyndall ++/++++ and pharmacological mydriasis in the left eye. Intraocular pressure was 16 mmHg in the right eye and 13 mmHg in the left eye. Eye fundus was normal.
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Blood and urine tests were normal. Syphilis serology was negative. HLA B27 was positive. Radiological examination showed bilateral symmetrical sacroiliitis in the lower thirds of the joints and calcification of the anterior vertebral ligament. Chest X-ray was normal.
Treatment with non-steroidal anti-inflammatory drugs (flurbiprofen 200 mg/day) and physical therapy was started, with clinical improvement of skeletal manifestations. Acne conglobata was treated with antibiotic therapy for external application (clindamycin) and oral isotretinoin (50 mg/day), and acute anterior uveitis was treated with corticosteroid eye-drops and mydriatrics for 2 weeks. The acute anterior uveitis disappeared and the lumbar pain improved after starting the treatment.
The association between acne conglobata, palmoplantar pustulosis and arthropathies is well established [3, 5]. Some authors use the term SAPHO to include these diseases in a unique syndrome [1, 2, 5, 7, 8, 9]. However, we have not found the association of SAPHO syndrome and acute anterior uveitis in the literature.
On the other hand, it seems logical to find this association if we consider that anterior uveitis can be an extra-articular manifestation of spondylarthropathies and SAPHO syndrome is considered as a spondylarthropathy by some authors, although the real nature of this syndrome is still open to speculation [6].
We report a patient with acne conglobata, sacroiliitis, hyperostosis and uveitis. Acute anterior uveitis could be another manifestation of the acne associated with arthritis that could have been underestimated until now. On the other hand, it is possible that this patient had a spondylarthropathy (sacroiliitis, HLA B27, iritis) and the acne conglobata could be entirely coincidental. Additional case reports are needed to support this association.
References
- Kahn MF, Bouvier M, Palazzo E, Tebib JG, Colson F. Sternoclavicular Pustulotic Osteitis (SAPHO); 20-year interval between skin and bone lesions. J Rheumatol 1991;18:1104–8.[Web of Science][Medline]
- Kahn MF. Why the SAPHO syndrome? J Rheumatol 1995; 22:2017–9.[Medline]
- Olive A, Tena X, Perea RJ, Rivas A. Clinical spectrum of Synovitis-Acne-Pustulosis-Hyperostosis-Osteomyelitis Syndrome. Br J Rheumatol 1993;32:1114.
- Bañares A, Jover JA, Fernandez-Gutierrez B, Benitez JM, Garcia J, Vargas E et al. Patterns of uveitis as a guide in making rheumatologic and immunologic diagnoses. Arthritis Rheum 1997;40:358–70.[Medline]
- Olive A, Tena X, Perea RJ. Acerca del síndrome SAPHO. Rev Esp Reumatol 1994;21:35.
- Boonen A, Verwilghen J, Dequeker J, Van der Liden S, Westhovens R. Is Sapho a spondylarthropathy? A vasculopathy? Report of a case. Rev Rhum (Engl Ed) 1997;64:424–7.
- Koh ET. Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome: a brief review of a rare condition. Ann Acad Med Singapore 1998;27:122–4.[Medline]
- Gutmer R, Herbst RA, Kapp A, Weiss J. SAPHO syndrome. Case description of three patients with acne conglobata and osteoarticular symptoms. Hautarzt 1997;48:186–90.[Medline]
- Suei Y, Taguchi A, Tanimoto K, Yamada T, Otani K, Fukuda T. Case report: synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome. Dentomaxillofac Radiol 1996;25:287–91.[Abstract]
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