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Letter to the Editor ical findings were unremarkable. The joint fluid contained 28,800 cells/mm3 with 98% of neutrophils and no microcrystals, organisms, or abnormal cells. Tests for autoimmunity were negative. A chest radiograph showed a mediastinal abnormality and computed tomography a 56 mm mass in the lower right lung lobe with right hilar lymphadenopathy. Histological examination of bronchial biopsy specimens established the diagnosis of poorly differentiated non-small-cell carcinoma (Fig. 2). Magnetic resonance imaging of the knee visualized a large joint effusion and bony edema of the lateral tibial plateau. Arthroscopy was performed to further investigate this isolated monoarthritis of unknown etiology. The synovial membrane was thick, inflammatory, and nodular. Advanced chondropathy was noted. Histological examination of a synovial membrane biopsy showed a poorly differentiated carcinoma comparable to that seen in the bronchial biopsies. No malignant cells were seen in the bone biopsies. Chemotherapy with pemetrexed and cisplatin was started. After the fifth course, the workup showed tumor progression in the left adrenal gland and persistent knee arthritis. The patient’s general health declined and palliative care was initiated.

Arthritis due to metastasis

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Keywords: Synovial metastasis Arthritis Cancer

1. Introduction Bone metastases account for most of the bone and joint lesions due to malignancies. Malignancy-related arthritis is usually a paraneoplastic syndrome. We report a case of monoarthritis due to a synovial-membrane metastasis. 2. Case report A 72-year-old man was referred to us for a 3-month history of monoarthritis of the left knee. He had benign prostatic hypertrophy, dyslipidemia, former smoking with a 20 pack-year history, and occasional alcohol use. He reported pain in his left knee with a mechanical time pattern and increasing severity over the last 3 months, as well as a limp and a joint effusion. The radiograph of the left knee and the bone scintigraphy did not show any sign of malignancy (Fig. 1). Joint aspiration followed by an intra-articular injection had been performed twice under the hypothesis of a congestive osteoarthritis flare. The physical examination showed a large effusion responsible for 30◦ of fixed flexion. The other phys-

3. Discussion Metastatic arthritis is rare. In 2002, Younes et al. identified 28 published cases. The knee was the most commonly involved joint (16/28) and the lung the most common site of the primary malignancy (12/28) [1]. Similar characteristics were reported in 2009 by Capovilla et al. based on 38 published cases: the knee was involved in 20/38 patients, the primary involved the lung in 14/38 cases, and histology showed an adenocarcinoma in 18/38 patients [2]. Joint fluid cytology showed malignant cells in 17 of 27 patients [2]. This finding supports the recommendation that a synovial membrane biopsy be performed routinely in patients with monoarthritis of unknown etiology [3].

Fig. 1. A. Anteroposterior and lateral radiographs of the left knee: filling of the suprapatellar pouch with no lesions of the bone or cartilage. B. Radionuclide bone scan showing increased uptake by the left knee related to the arthritis. There are no foci of increased uptake by bone.

Fig. 2. A. Histological appearance of a bronchial biopsy fragment: poorly differentiated, invasive, non-small cell carcinoma ( × 100, HES stain). B. Histological appearance of a synovial biopsy fragment: similar features ( × 100, HES stain).

http://dx.doi.org/10.1016/j.jbspin.2014.07.004 1297-319X/© 2014 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.

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Olivia Abramovici-Roels c Dominique Paillotin d Thierry Lequerré a Olivier Vittecoq a a Rhumatologie & Inserm, U905 (I.R.I.B.) CIC 1404, CHU Hôpitaux de Rouen, 1, rue de Germont, 76031 Rouen cedex 1, France b Orthopédie, CHU Hôpitaux de Rouen, 1, rue de Germont, 76031 Rouen cedex 1, France c Anatomopathologie, CHU Hôpitaux de Rouen, 1, rue de Germont, 76031 Rouen cedex 1, France d Pneumologie, CHU Hôpitaux de Rouen, 1, rue de Germont, 76031 Rouen cedex 1, France

4. Conclusion In a patient with monoarthritis of unknown etiology, a synovial metastasis should be considered and a synovial biopsy performed, as well as imaging studies of the thorax. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Younes M, Hayem G, Brissaud P, et al. Monoarthritis secondary to joint metastasis. Two case reports and literature review. Joint Bone Spine 2002;69:495–8. [2] Capovilla M, Durlach A, Fourati E, et al. Chronic monoarthritis and previous history of cancer: think about synovial metastasis. Clin Rheumatol 2007;26:60–3. [3] Ma L, Cranney A, Holroyd-Leduc JM. Acute monoarthritis: what is the cause of my patient’s painful swollen joint? CMAJ 2009;180:59–65.

∗ Corresponding author. Service de Rhumatologie, Hôpitaux de Rouen, CHU, 1, rue de Germont, 76031 Rouen Cedex 1, France. Tel.: +33 686 903 888. E-mail address: avenel [email protected] (G. Avenel)

Gilles Avenel a,∗ Thomas Rousseau b

Accepted 22 April 2014 Available online xxx

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(2014),