An unusual cause of abnormal liver function in a patient with rheumatoid arthritis.

spine or from direct pressure by synovial pannus [2]. We present a case of periodontoid rheumatoid pannus formation in which symptomatic relief and regression of pannus (imaged by MRI scanning) was achieved following a short course of infliximab therapy. A 65-yr-old female with a 33-yr history of rheumatoid arthritis presented with a 2 month history of severe intractable cervical spine (neck) pain and occipital headaches. Her peripheral arthritis was controlled on 10mg of methotrexate. ESR was 11mm/hr and CRP was <7mg/l. Cervical spine X-rays showed marked osteoarthritis in the lower cervical spine. There was no instability on flexion and extension views, and in particular there was no atlanto-axial subluxation. An MRI scan of her cervical spine showed that there was abnormal low-signal intensity material, which was seen anterior and superior to the odontoid peg. This was in keeping with pannus formation associated with synovial hypertrophy, which extended into the spinal canal on the left side indenting the thecal sac (Fig. 1A). The patient subsequently received three infusions of 500mg of methylprednisolone intravenously in an attempt to relieve her symptoms. However, there was no resolution of the symptoms and a subsequent MRI scan showed no reduction in the size of the pannus. There was extensive pannus formation around the odontoid peg, which extended into the spinal canal (Fig. 1B). The patient’s occipital headaches persisted despite methylprednisolone therapy and a left occipital nerve block. Pregabalin was ineffective in relieving her symptoms. Neurological examination remained unremarkable at all stages of her treatment. The patient was subsequently given three infusions of infliximab therapy at 5mg/kg over a 6-week period. After the third infusion her symptoms of neck and occipital pain improved. A repeat MRI scan 4 months following the infliximab therapy revealed that the tissue plains around the odontoid peg were better defined when compared with the previous MRI scans with a significant reduction in the tissue bulk at this level (Fig. 1C). Infliximab therapy should be considered early in the treatment of symptomatic cervical spine disease where rheumatoid pannus is shown to be causing neurological symptoms or compromise. Early treatment with anti-TNF therapy may have a significant impact on the development of rheumatoid myelopathy and prevent the need for surgery.