Letter to the Editor
Septic erosive mono arthritis and osteomyelitis of the wrist caused by Mycobacterium intracellulare in an immunocompetent patient
Monoartritis séptica erosiva y osteomielitis de la muñeca por Mycobacterium intracellulare en un paciente inmunocompetente
Read
Not available
Timeswas read the article
Total PDF
Total HTML
Share statistics
array:24 [ "pii" => "S2387020617303923" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.06.005" "estado" => "S300" "fechaPublicacion" => "2017-07-07" "aid" => "3947" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2017" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2017;149:44-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775317300817" "issn" => "00257753" "doi" => "10.1016/j.medcli.2017.01.010" "estado" => "S300" "fechaPublicacion" => "2017-07-07" "aid" => "3947" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2017;149:44-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 14 "formatos" => array:2 [ "HTML" => 12 "PDF" => 2 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Monoartritis séptica erosiva y osteomielitis de la muñeca por <span class="elsevierStyleItalic">Mycobacterium intracellulare</span> en un paciente inmunocompetente" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "44" "paginaFinal" => "45" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Septic erosive mono arthritis and osteomyelitis of the wrist caused by <span class="elsevierStyleItalic">Mycobacterium intracellulare</span> in an immunocompetent patient" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 797 "Ancho" => 1447 "Tamanyo" => 99364 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiografía de la muñeca en proyección anteroposterior y tac que muestran artrodesis de las articulaciones radiocarpiana y carpometacarpiana con fusión de los huesos del carpo. A nivel del radio distal se observa erosión y destrucción ósea.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Vanesa Antón Vázquez, Ana Coloma Conde, Hèctor Corominas" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Vanesa" "apellidos" => "Antón Vázquez" ] 1 => array:2 [ "nombre" => "Ana" "apellidos" => "Coloma Conde" ] 2 => array:2 [ "nombre" => "Hèctor" "apellidos" => "Corominas" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020617303923" "doi" => "10.1016/j.medcle.2017.06.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303923?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317300817?idApp=UINPBA00004N" "url" => "/00257753/0000014900000001/v1_201706170053/S0025775317300817/v1_201706170053/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020617303947" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.02.026" "estado" => "S300" "fechaPublicacion" => "2017-07-07" "aid" => "3970" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2017;149:46" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "<span class="elsevierStyleItalic">Moraxella catarrhalis</span> meningitis during certolizumab pegol treatment" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "46" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Meningitis por <span class="elsevierStyleItalic">Moraxella catarrhalis</span> durante tratamiento con certolizumab" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jonathan Franco, Jhon Ossenkopp, Georgina Peñarroja" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jonathan" "apellidos" => "Franco" ] 1 => array:2 [ "nombre" => "Jhon" "apellidos" => "Ossenkopp" ] 2 => array:2 [ "nombre" => "Georgina" "apellidos" => "Peñarroja" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775317301422" "doi" => "10.1016/j.medcli.2017.02.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317301422?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303947?idApp=UINPBA00004N" "url" => "/23870206/0000014900000001/v1_201707230028/S2387020617303947/v1_201707230028/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020617303911" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.01.029" "estado" => "S300" "fechaPublicacion" => "2017-07-07" "aid" => "3946" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2017;149:43-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Anastomotic recurrence 13 years after curative resection for rectal cancer" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "43" "paginaFinal" => "44" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recidiva en la anastomosis 13 años después de cirugía curativa para cáncer de recto" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Martín Bailón-Cuadrado, José I. Blanco-Álvarez, Mario Rodríguez-López" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Martín" "apellidos" => "Bailón-Cuadrado" ] 1 => array:2 [ "nombre" => "José I." "apellidos" => "Blanco-Álvarez" ] 2 => array:2 [ "nombre" => "Mario" "apellidos" => "Rodríguez-López" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775317300805" "doi" => "10.1016/j.medcli.2017.01.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317300805?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303911?idApp=UINPBA00004N" "url" => "/23870206/0000014900000001/v1_201707230028/S2387020617303911/v1_201707230028/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Septic erosive mono arthritis and osteomyelitis of the wrist caused by <span class="elsevierStyleItalic">Mycobacterium intracellulare</span> in an immunocompetent patient" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "44" "paginaFinal" => "45" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Vanesa Antón Vázquez, Ana Coloma Conde, Hèctor Corominas" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Vanesa" "apellidos" => "Antón Vázquez" "email" => array:1 [ 0 => "vanesa.anton.v@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ana" "apellidos" => "Coloma Conde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Hèctor" "apellidos" => "Corominas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Monoartritis séptica erosiva y osteomielitis de la muñeca por <span class="elsevierStyleItalic">Mycobacterium intracellulare</span> en un paciente inmunocompetente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 772 "Ancho" => 1401 "Tamanyo" => 107102 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">X-ray of the wrist in anteroposterior projection and CT scan showing arthrodesis of the radiocarpal and carpometacarpal joints with fusion of the carpal bones. Bone erosion and destruction are observed in distal radius.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Non-tuberculous mycobacteria, considered opportunistic pathogens, are an uncommon cause of osteoarticular infection. <span class="elsevierStyleItalic">Mycobacterium avium complex</span>, which includes <span class="elsevierStyleItalic">Mycobacterium intracellulare (M. intracellulare)</span> and <span class="elsevierStyleItalic">M. avium</span>, is made up of the most frequently involved causal species.</p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">M. intracellulare</span> is an extremely rare cause of arthritis and osteomyelitis, which in recent years has seen an increase in its incidence as a result of increased iatrogenic immunosuppression or HIV infection. However, isolated cases have been described in immunocompetent patients.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of an immunocompetent patient with infectious arthritis and osteomyelitis of the wrist caused by <span class="elsevierStyleItalic">M. intracellulare.</span></p><p id="par0020" class="elsevierStylePara elsevierViewall">81-Year-old male with a history of chondrocalcinosis at the right radiocarpal joint and carpal tunnel surgery 8 years earlier. For 7 years, he had pain in the right wrist, associated with inflammation in the previous 6 months, reason why he came to the emergency department.</p><p id="par0025" class="elsevierStylePara elsevierViewall">An arthrocentesis was performed at the emergency department, obtaining abundant purulent matter that was sent for a microbiology culture. While waiting for the results, the patient was discharged under empirical antibiotic treatment and follow-up by the outpatient's trauma service. After 2 weeks, the patient returned to the emergency department for persistent pain and purulent drainage through the area where the puncture was performed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Physical examination revealed significant right wrist oedema and inflammation, with drainage fistula in dorsal area. Following a suspected diagnosis of septic arthritis associated with fistulated osteomyelitis, a study was initiated. A Gallium scintigraphy was performed, which reports a right radioulnar carpal pathological radiotracer uptake, with greater activity in the distal ulna, compatible with septic arthritis of the wrist. The X-ray of the right wrist showed destruction of the right distal radioulnar and radiocarpal joint, and the CT scan shows bone destruction and subchondral geodes, affecting the radioulnar carpal, carpal and carpometacarpal joints (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The synovial fluid bacteriological/microbiological study was negative. The Ziehl–Neelsen method and cultures for mycobacteria and fungi were negative. Laboratory results revealed a white blood cell count of 15<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>, ESR 45, polymerase chain reaction 220, ANA, negative RF and anti-CCP, negative HIV serology and positive gamma interferon. Surgical debridement was performed in the operating room, under right axillary block, with sampling from the affected tissue and right wrist fistulectomy. The tissue obtained was analysed by microbiology and anatomical pathology. The Ziehl–Neelsen study, polymerase chain reaction for mycobacteria and fungal cultures were negative. Histology of the lesion reported chronic granulomatous inflammation with necrosis and calcifications. Finally, mycobacterial cultures were positive for <span class="elsevierStyleItalic">M. intracellulare</span>, after 9 weeks.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Once the diagnosis was established, the patient received treatment with 3 tuberculostatic drugs: rifampicin (600<span class="elsevierStyleHsp" style=""></span>mg/day), ethambutol (1200<span class="elsevierStyleHsp" style=""></span>mg/day) and clarithromycin (1000<span class="elsevierStyleHsp" style=""></span>mg/day) for a total of 12 months.</p><p id="par0045" class="elsevierStylePara elsevierViewall">2 months after surgery and antibiotic treatment initiation, the patient showed complete resolution of the inflammatory signs and cure of the fistula, without adverse reactions or complications from the treatment. At the 6-month follow-up visit, after treatment completion, there was no recurrence of the inflammatory process.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnostic suspicion of septic arthritis should be greater when several risk factors are identified, such as an underlying inflammatory or degenerative arthritis, a joint prosthesis, intraarticular injection of corticosteroids, cutaneous ulcers, injecting drug addicts, diabetics, alcoholism, iatrogenic immunosuppression or HIV infection.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with rheumatoid arthritis who have a symmetric polyarthritis are more likely to develop septic arthritis due to the underlying process itself and to the immunosuppressive effect of the medication they receive. Likewise, in patients with crystal deposition arthropathy, the frequency of septic arthritis increases, mainly those of pyogenic origin.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The characteristic symptoms of the underlying inflammatory arthropathy makes the diagnosis of an infectious aetiology more difficult and, therefore, the establishment of a correct therapy is sometimes delayed.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The foundation in the diagnosis of septic arthritis consists of establishing clinical suspicion, added to a microscopic analysis and culture of the joint's synovial fluid or tissue by open surgical biopsy. Since gram-staining and microscopy in synovial fluid only gives a positive result in 50% of septic arthritis, it is vital to perform aerobic and anaerobic cultures for mycobacteria and fungus.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The proposed route of spread is haematogenous due to surgery, penetrating wound or joint steroid injection, as is the case of our patient, with carpal tunnel surgery some years earlier. The treatment consists of the combination of wide debridement of the infected tissue and administration of the indicated antibiotic treatment. Sporadic cases of arthritis due to <span class="elsevierStyleItalic">M. intracellulare</span> have recently been reported in immunocompetent patients without prior manipulation or trauma.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Our case illustrates how non-tuberculous mycobacterial infections, although infrequent, should be included in the differential diagnosis of osteoarticular infections in immunocompetent patients with inflammatory or degenerative arthritis who have a torpid clinical course.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Antón Vázquez V, Coloma Conde A, Corominas H. Monoartritis séptica erosiva y osteomielitis de la muñeca por <span class="elsevierStyleItalic">Mycobacterium intracellulare</span> en un paciente inmunocompetente. Med Clin (Barc). 2017;149:44–45.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 772 "Ancho" => 1401 "Tamanyo" => 107102 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">X-ray of the wrist in anteroposterior projection and CT scan showing arthrodesis of the radiocarpal and carpometacarpal joints with fusion of the carpal bones. Bone erosion and destruction are observed in distal radius.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atypical <span class="elsevierStyleItalic">Mycobacterium</span> infections of the upper extremity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.H. Kozin" 1 => "A.T. Bishop" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/0363-5023(94)90067-1" "Revista" => array:6 [ "tituloSerie" => "J Hand Surg Am" "fecha" => "1994" "volumen" => "19" "paginaInicial" => "480" "paginaFinal" => "487" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8056979" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Mycobacterium avium-intracellulare</span> cellulitis occurring with septic arthritis after joint injection: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.M. Murdoch" 1 => "J.R. McDonald" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2334-7-9" "Revista" => array:6 [ "tituloSerie" => "BMC Infect Dis" "fecha" => "2007" "volumen" => "7" "paginaInicial" => "9" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17324257" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Skin and soft tissue infections caused by nontuberculous mycobacteria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.L. Atkins" 1 => "T. Gottlieb" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/QCO.0000000000000041" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Infect Dis" "fecha" => "2014" "volumen" => "27" "paginaInicial" => "137" "paginaFinal" => "145" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24464139" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Mycobacterium avium/Mycobacterium intracellulare complex</span>-associated arthritis masquerading as a seronegative rheumatoid arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.S. Kanik" 1 => "D.P. Greenwald" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Clin Rheumatol" "fecha" => "2000" "volumen" => "6" "paginaInicial" => "154" "paginaFinal" => "157" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19078465" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteomyelitis and arthritis of the wrist caused by <span class="elsevierStyleItalic">Mycobacterium intracellulare</span> in an immunocompetent patient: a case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K. Yano" 1 => "K. Kazuki" 2 => "M. Ikeda" 3 => "M. Yoneda" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Remittal Port" "fecha" => "2014" "volumen" => "39" "paginaInicial" => "176" "paginaFinal" => "181" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014900000001/v1_201707230028/S2387020617303923/v1_201707230028/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014900000001/v1_201707230028/S2387020617303923/v1_201707230028/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303923?idApp=UINPBA00004N" ]
