Rheumatology Advance Access originally published online on January 22, 2008
Rheumatology 2008 47(3):377-378; doi:10.1093/rheumatology/kem361
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Cholesterol crescents and plates in shoulder effusion of a rheumatoid patient
Princess of Wales Hospital, Coity Road, Bridgend, UK
Correspondence to: S. Ho, Princess of Wales Hospital, Coity Road, Bridgend CF31 1RQ, UK. E-mail: sookfun.ho{at}bromor-tr.wales.nhs.uk
SIR, While the occurrence of cholesterol effusions in patients with inflammatory arthropathy is a recognized phenomenon, the aetiology of this complication is not known. Whether there is any relationship to hyperlipidaemia remains speculative although a previous report has described clinical response to statin therapy [1]. We would like to report our experience of a patient with seronegative, erosive rheumatoid arthritis, whose disease was unresponsive to sequential DMARD monotherapy and also to oral steroid/DMARD combination treatment. In June 2005, he was commenced on etanercept and methotrexate combination therapy but stopped it perioperatively in December 2006 whilst he underwent knee replacement surgery. Later that month, he developed a large left shoulder effusion and aspiration yielded small quantities of turbid fluid. Ultrasound confirmed a large subacromial effusion with increased echogenicity suggesting partially solid material. Examination of the aspirates (by polarizing microscopy) demonstrated cholesterol crystals and cholesterol crescents (Fig. 1). The finding of cholesterol crescents is rare and they usually occur only in shoulder effusions (J. Denton, personal communication). Fasting serum cholesterol was normal.
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He was commenced on simvastatin 20 mg daily in February 2007 and methotrexate was switched to subcutaneous administration at a dose of 7.5 mg/week in March 2007. There was no improvement in disease status or in the shoulder effusion. His CRP was 41 mg/l. In May 2007, he suffered a further disease flare and oral prednisolone was increased from 5 mg daily to 20 mg daily temporarily. This resulted in an excellent clinical response with marked improvement in the shoulder effusion and normalization of CRP. Attempted re-aspiration of the shoulder was unsuccessful at this point.
The finding of cholesterol in rheumatoid arthritis is usually seen in the context of disease activity. Freemont and Denton [2] state that cholesterol is found in any blind-ended sac and is usually evidence of a previous long-standing inflammatory arthropathy. Cholesterol plates are found in aspirate from para-articular bursal sacs, and are evidence of long-term inflammatory arthropathy, most commonly rheumatoid disease. The lack of response in our patient to therapeutic doses of statin therapy and the marked improvement once the disease control was achieved is in keeping with this. Our experience suggests that cholesterol effusions are a manifestation of rheumatoid arthritis disease activity and resolution can be achieved by optimizing disease control. Cholesterol plates and crescents are only sporadically seen in rheumatoid arthritis and this may be due to doctors not requesting that the aspirate be examined for cholesterol crystals, or because the aspirates are from joints (as opposed to para-articular bursal sacs), or because of a lack of laboratory expertise in looking for these features.
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Acknowledgements |
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We thank J. Denton, Department of Laboratory Medicine, University of Manchester, for his comment.
Disclosure statement: The authors have declared no conflicts of interest.
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References |
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TopAcknowledgementsReferences |
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- Jansen TL. Atorvastatine for chronic synovitis due to massive intra-articular cholesterol monohydrate deposition in long-standing rheumatoid arthritis. Rheumatology (2006) 45:1577–8.
[Free Full Text] - Freemont A, Denton J. The "wet prep" examination and interpretation. In: Atlas of synovial fluid cytopathology, Vol. 18—Austin G, ed. (1981) 49. Dordrecht: Kluwer Academic Publishers.
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