Rapidly destructive inflammatory arthritis of the hip

Abstract

Rapidly destructive coxarthrosis (RDC) is a rare syndrome that involves aggressive hip joint destruction within 6-12 months of symptom onset with no single diagnostic laboratory, pathological, or radiographic finding. We report an original case of RDC as an initial presentation of seronegative rheumatoid arthritis (RA) in a 57-year-old Caucasian woman presenting with 6 months of progressive right groin pain and no preceding trauma or chronic steroid use. Over 5 months, she was unable to ambulate and plain films showed complete resorption of the right femoral head and erosion of the acetabulum. There were inflammatory features seen on computed tomography (CT) and magnetic resonance imaging (MRI). She required a right total hip arthroplasty, but arthritis in other joints showed improvement with triple disease modifying antirheumatic drugs (DMARD) therapy and almost complete remission with the addition of adalimumab. We contrast our case of RDC as an initial presentation of RA to 8 RDC case reports of patients with established RA. Furthermore, this case highlights the importance of obtaining serial imaging to evaluate a patient with persistent hip symptoms and rapid functional deterioration.

Figure 1

(a) AP radiograph of the right hip. A focal area of subchondral lucency is present involving the superolateral aspect of the right femoral head (arrow). (b) The follow-up radiograph taken 5 months later reveals near complete destruction of the femoral head. (c) CT scan of the right hip in the axial plane shows loss of the femoral head with two bone fragments within the hip joint (arrows).

Figure 2

(a) Axial proton density with fat saturation sequence through the right hip joint (a) shows destruction of the femoral head (arrow) and a complex joint effusion (arrowhead). (b) Axial T1 fat saturated sequence after gadolinium reveals synovial thickening and enhancement (arrow).

Figure 3

(a) Papillary, hyperplastic, chronically inflamed synovium is shown with abundant fibrin covering the surface and multiple fragments of bone being degraded by histiocytes and multinucleated giant cells. (b) At higher magnification, fibrin is seen on the surface of the synovium with a hyperplastic synovium consistent with chronic inflammation. (c) Fibrin and bone are detailed at 40x magnification showing multiple bone fragments which is typical of a rapidly destructive joint process. (d) Bone is seen being further broken down by multinucleated giant cells.