Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor
doi: 10.4103/0378-6323.74999
PMID: 21220890

Dactylitis as a first manifestation of arthritis associated with hidradenitis suppurativa

Antonella Fioravanti1 , Maria Laura Flori2 , Giacomo Maria Guidelli1 , Nicola Giordano3
1 Department of Clinical Medicine and Immunology, Rheumatology Unit, University of Siena, Siena, Italy
2 Department of Clinical Medicine and Immunology, Dermatology Unit, University of Siena, Siena, Italy
3 Department of Internal Medicine, University of Siena, Siena, Italy

Correspondence Address:
Antonella Fioravanti
Department of Clinical Medicine and Immunology, Rheumatology Unit, University of Siena, Viale Bracci, 1 53100, Siena
How to cite this article:
Fioravanti A, Flori ML, Guidelli GM, Giordano N. Dactylitis as a first manifestation of arthritis associated with hidradenitis suppurativa. Indian J Dermatol Venereol Leprol 2011;77:74-76
Copyright: (C)2011 Indian Journal of Dermatology, Venereology, and Leprology


Dactylitis or "sausage digit" is a typical manifestation of spondyloarthropathy (SpA) [1] and it is so specific to SpA that it was included among the classification criteria of the whole disease group. [2] Dactylitis may sometimes occur alone for a long time as the only clinically manifestation of the SpA. [1]

We report here a patient with hidradenitis suppurativa (HS) in whom dactylitis occurred 2 years prior to the onset of a seronegative arthritis.

In October 2005, a 50-year-old Caucasian woman with a 10-year history of HS presented to the Dermatology Clinic with multiple pustules, nodules, abscesses, and cystic lesions in the axillary, mammary, and inguinal regions [Figure - 1]. Furthermore, she complained of severe swelling and pain of the third finger of her left hand of 3 months duration. Her family history was negative for SpA and other HLA B27-associated diseases. There was no history of trauma, psoriasis, diarrhea, sexually transmitted diseases, conjunctivitis, iritis, uveitis, mucosal ulceration, Raynaud′s phenomenon, sarcoidosis or gout. Clinical examination showed a swelling affecting the entire third finger of her left hand so pronounced that the patient could not flex it, and the presence of Heberden′s nodules [Figure - 2]. Laboratory studies showed an Erythrocyte Sedimentation Rate (ESR) of 101 mm/hour in the first hour, C-reactive protein (CRP) of 6.21 mg/dl, and a white blood cell count of 8.5 Χ 103/mm 3 . Rheumatoid factor (RF), antinuclear (ANA) and anti-cyclic citrullinated peptide (anti-CCP) antibodies, circulating immune-complexes (CIC), angiotensin converting enzyme, HLA-B27 and HLA-DR4 antigens were normal or negative. Blood, urine and fecal cultures were negative, whilst culture of the axillary drainage showed growth of Staphylococcus aureus. X-ray of her hands showed only a soft tissue swelling limited to the finger with dactylitis. Ultrasound (US) evaluation showed distension of the proximal interphalangeal joint capsule and fluid collection in the flexor synovial sheath of the same third finger. Magnetic resonance imaging showed normal sacroiliac joints. HS was treated with amoxicillin and isotretinoin, while steroid injections in the flexor synovial sheaths were used to cure dactylitis, giving good results. After 2 years, the patient presented an exacerbation of the skin lesions and simultaneously she complained of pain in all the metacarpophalangeal (MCP) joints of her left hand, left wrist, both ankles and a relapse of dactylitis in the same finger. She denied any recent history suggestive for another cause of her symptoms. Joint evaluation showed swelling and tenderness at her left wrist and homolateral MCP, as well as at both ankles. Laboratory analyses showed an increase of ESR and CRP; RF, CIC, ANA and anti-CCP were negative. Ultra sound examination showed effusion with mild synovitis at her left radiocarpal joint, bone erosion at the second MCP joint of her left hand, soft tissue edema at the perimalleolar region of the ankles and bilateral plantar fasciitis. X-rays of the pelvis, wrists, hands, ankles and feet showed only bone erosion of the second MCP joint of her left hand [Figure - 3] and bilateral calcaneal spurs. A presumptive diagnosis of reactive arthritis (ReA) associated with HS was made and a therapy with infliximab was proposed to the patient, but she refused.

Figure 1 :Hidradenitis suppurativa: Evidence of nodules and cystic lesions in the left axillary region
Figure 2 :Dactylitis: Evidence of severe swelling of the third finger of the left hand; as a collateral finding, we point out the presence of Heberden nodules on the second, fourth and fifth fingers
Figure 3 :Detail of X-ray of the left hand taken in 2007; relief of bone erosion of the second MCP joint

Arthritis associated with HS is rare, commonly asymmetrical and seronegative for the presence of RF. [3],[4],[5],[6] Most often, it affects the peripheral joints; radiological findings are nonspecific and include soft tissue swelling, periarticular osteoporosis, erosions and periosteal reactions. [3] The axial skeleton is less frequently involved and it is often asymptomatic. Cutaneous manifestations usually precede the onset of arthritis for many years. [3],[4]

The pathogenesis of this arthritis remains unknown and a genetic predisposition is not documented. [3],[4] The presence of enthesopathy would suggest that this is an ReA with a hypersensitive response to the bacterial antigens involved in the skin lesions. [3],[6] This phenomenon has analogies to other reactive arthritic syndromes such as SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) and Reiter′s syndrome. [4] Furthermore, the reports of positive CIC and ANA, and response of patients to prednisone and/or disease modifying anti-rheumatic drugs may be indicative of an autoimmune phenomenon. [3],[4] Recently, Mc Gonagle and co-workers hypothesized that enthesopathy is the primary lesion in SpA dactylitis, whilst the involvement of the various joint structures represents a secondary phenomenon caused by the release of pro-inflammatory cytokines from the inflamed entheses. [7]

To our knowledge, dactylitis has never been described in association with HS; in our case, as in other SpAs, this manifestation preceded the onset of arthritis. [1]

It is important to recognize the potential association between SpA dactylitis and HS for the purpose of differential diagnosis with other forms of inflammatory or infectious dactylitis and to monitor the patient over time for the possible onset of seronegative arthritis. This clinical observation can also expand the spectrum of possible causes of dactylitis.

Olivieri I, D'Angelo S, Scarano E, Padula A. What is the primary lesion in SpA dactylitis? Rheumatology (Oxford) 2008;47:561-2.
[Google Scholar]
Amor B, Dougados M, Mijiyawa M. Criteria of the classification of spondylarthropathies. Rev Rhum Mal Osteoartic 1990;57:85-9.
[Google Scholar]
Bhalla R, Sequeira W. Arthritis associated with hidradenitis suppurativa. Ann Rheum Dis 1994;53:64-6.
[Google Scholar]
Thein M, Hogarth MB, Acland K. Seronegative arthritis associated with the follicular occlusion triad. Clin Exp Dermatol 2004;29:550-2.
[Google Scholar]
Rosner IA, Burg CG, Wisnieski JJ, Schacter BZ, Richter DE. The clinical spectrum of the arthropathy associated with hidradenitis suppurativa and acne conglobata. J Rheumatol 1993;20:684-7.
[Google Scholar]
Marquardt AL, Hackshaw KV. Reactive arthritis associated with hidradenitis suppurativa. J Natl Med Assoc 2009;101:367-9.
[Google Scholar]
McGonagle D, Marzo-Ortega H, Benjamin M, Emery P. Report on the Second international Enthesitis Workshop. Arthritis Rheum 2003;48:896-905.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections