Letters to the Editor Destructive arthritis of Eight months after the injury, radiography idly developing destructive arthritis follow- showed severe glenohumeral joint destruc- ing trauma in patients with rheumatic dis- the shoulder triggered by tion. A total shoulder arthroplasty was there- eases have been reported (5-7). Although the trauma in a patient with fore carried out in November 1997. During pathogenesis of this phenomenon has not the operation, severe synovitis and destruc- been elucidated, the exposition of self anti- polymyositis tion of the articular surfaces were found. His- gens after trauma could lead to an autoim- topathological findings at the humeral head mune reaction and, eventually, arthritis and Sir, indicated subchondral lymphoid infiltration joint destruction. Arthritis or arthralgia occurs in 25-50% of (Fig. 1). No calcific crystals were detected patients with polymyositis (PM). However, in the joint fluid or synovium. After the op- Y. TANI E. ISOYA the articular abnormalities are usually mild eration, the shoulder pain disappeared. How- N. TANAKA and without radiographic changes, erosion or ever, the patient's active range of motion did Department of Orthopaedic Surgery, deformity. These articular symptoms gener- not improve sufficiently due to muscle weak- Soseikai General Hospital, Kyoto, Japan. ally occur early in the course of PM. We re- ness. In the one-year follow up period, no Please address correspondence and reprint port an atypical case of destructive arthritis loosening or dislocation of the prosthesis was requests to: Dr. Yoshitaka Tani, Department of the shoulder following trauma in a patient observed. of Orthopaedic Surgery, Soseikai General with well-documented PM. Articular manifestations are generally mild, Hospital, Hiroosa-cho 1, Shimotoba, A 52-year-old Japanese male had a three-year with no radiographic changes, in PM patients. Fushimi-ku, Kyoto, 612-8473, Japan. history of PM. In 1995, he complained of However, some previous studies have de- proximal muscle weakness and polyarthral- scribed severe erosive and deforming arthri- References gia. He was diagnosed with PM on the basis tis in the hands due to periarticular calcifi- 1. BUNCH TW, O’DUFFY JD, MCLEOD RA: De- of elevated creatine phosphokinase and al- cation that has been identified as hydroxya- forming arthritis of the hands in polymyositis. dolase levels, myogenic changes on electro- patite (1, 2). The same pathogenesis is prob- Arthritis Rheum 1976; 19: 243-8. myography, and muscle biopsy findings. RF, ably involved in apatite-associated destruc- 2. KAZMERS IS, SCOVILLE CD, SCHUMACHER ANA and Jo-1 antibodies were negative. He tive arthritis (3). The "Milwaukee shoulder" HR: Polymyositis associated apatite arthritis. J Rheumatol 1988; 15: 1019-21. received medical treatment with low dose syndrome, which is caused by hydroxyapa- 3. DIEPPE PA, MACFARLAND DG, HUTTON CW, corticosteroids for 2 years. He did not ex- tite crystals, was defined as a combination BRADFIELD JW, WATT I: Apatite associated hibit severe arthritis or joint destruction. of the elevation and collapse of the humeral destructive arthritis. Br J Rheumatol 1984; 23: In April 1997 our patient bruised his right head, a massive cuff tear, and damage to the 84-91. shoulder during a fall. A few days after the glenohumeral joint with blood-stained effu- 4. MCCARTY DJ, HALVERSON PB, CARRERA GF, injury, he complained of painful swelling and sions in elderly patients, predominantly fe- BREWER BJ, KOZIN F: “Milwaukee shoulder”- impaired active motion in his right shoulder. males (4). In our case, periarticular calcific Association of microspheroids containing hy- Radiography showed no abnormal findings deposition was not seen on radiography, and droxyapatite crystals, active collagenase, and neutral protease with rotator cuff defects. Ar- such as erosion, sclerotic changes or peri- neither the joint fluid nor the synovium con- thritis Rheum 1981; 24: 464-73. articular calcific deposition. The acute phase tained calcium crystals. 5. WILLIAMS KA, SCOTT JT: Influence of trau- reactants CRP and ESR were elevated (CRP: Moreover, the diagnosis of Milwaukee shoul- ma on the development of chronic inflamma- 2.0 mg/dl, ESR: 36 mm/hr). Despite medical der syndrome or steroid-induced avascular tory polyarthritis. Ann Rheum Dis 1967; 26: treatment with corticosteroids and NSAIDs, necrosis were not supported in our case by 532-7. the arthritis continued in the shoulder. The the histopathological findings at the humeral 6. OLMERI I, GHERARDI S, BINI C, TRIPPI D, patient complained of a disturbed sleeping head, which showed subchondral lymphoid CIOMPI ML, PASERO G: Trauma and serone- patterns due to the shoulder pain. follicles indicative of RA. Other cases of rap- gative spondyloarthropathy: Rapid joint de- struction in peripheral arthritis triggered by physical injury. Ann Rheum Dis 1988; 47: 73- 6. 7. LANGEVITZ P, BUSKILA D, GLADMAN DD: Psoriatic arthritis precipitated by physical trau- ma. J Rheumatol 1990; 17: 695-7. Fig. 1. Marked chronic inflammatory infiltrates, in the form of lymphoid follicles, can be noted in the subchondral bone (hematoxylin and eosin stained). 514.