461 CASE REPORT Chronic alcohol consumption as a predisposing factor for multiple tendon ruptures in unusual sites in a patient with rheumatoid arthritis L.A. Bourikas 1 , H.D. Kritikos 1 , O.G. Papakostantinou 2 , G.A. Katsikas 1 , D.T. Boumpas 1 P . P P I. Sidiropoulos 1 1 Department of Rheumatology, Allergy and Clinical Immunology, and 2 Department of Radiology, University Hospital of Heraklion Crete. Leonidas A. Bourikas, MD; Heraklis D. Kritikos, MD; Olympia G. Papakostantinou, MD; Georgios A. Katsikas, MD; Dimitrios T. Boumpas, MD, FACP; Prodromos I. Sidiropoulos, MD. Please address correspondence and reprint requests to: Prodromos I. Sidiropoulos MD, Department of Rheumatology, Clinical Immunology and Allergy, University of Crete, University Hospital, Voutes 71110, Heraklion, Greece. E-mail: sidiropp@med.uoc.gr Received on March 25, 2006; accepted in revised form on September 7, 2006. © Copyright CLINICAL AND EXPERIMENTAL RHEUMATOLOGY 2007. Key words: tendon rupture, rheumatoid arthritis, alcohol, IGF. Competing interests: none declared. Abstract Simultaneous bilateral patellar ten- don ruptures are a rare complication of rheumatoid arthritis (RA). Systemic inflammatory diseases (RA, systemic lu- pus erythematosus (SLE), chronic renal failure, primary and secondary hy- perparathyroidism, diabetes mellitus, obesity, sports activity, older age (>50) and drugs (prolonged use of high doses of steroids, local steroid injections and quinolones) are considered as potent predisposing factors for tendon rup- ture. We report a case of an alcoholic patient with RA and bilateral spontane- ous tendon ruptures of the knees. Cir- cumstantial evidence suggest that in this patient, chronic alcohol consump- tion, a very frequent cause of toxicity to striated and cardiac muscle, contribut- ed to the injury. Introduction Rheumatoid arthritis (RA) is a chronic autoimmune disease that leads to sub- stantial disability and reduced quality of life. In more than 50% of patients, ten- dons of the wrists are affected (1) and tendon ruptures may occur, possibly by overproduction of matrix metallopro- teinases (MMPs 1, 2, 3, 8, 13) (2). Although there are several case reports with bilateral simultaneous, non-trau- matic, tendon ruptures of the knees, no large single-center case series exists due to the rarity of this injury. Recently Kellersmann et al. analyzed all reports and predisposing factors of bilateral simultaneous patellar tendon ruptures reported during the last 43 years (3). In 62% of 50 cases, no known predispos- ing factors existed. This observation suggests that in such cases investiga- tion for additional predisposing factors is required. Case A 52-year-old man was referred to our clinic with a 6-year history of rheuma- toid arthritis with lung involvement. He had inadequate response to methotrex- ate and cyclosporine that had been dis- continued 3 years ago. He occasionally received 2 mg of methylprednizolone daily for small periods during the last 6 months. The patient experienced spontaneous bilateral tendon ruptures of his knees 4 months ago, while walking peacefully on a level surface and he underwent plastic reconstruction of patellar ten- dons with no sequela. Regarding his medical history, he re- ported consumption of more than 60 g of alcohol daily for the last 20 years and a serious car accident 12 years ago. Fifteen years ago he experienced a spontaneous rupture of the long head of the biceps brachii tendon of the right arm, but he did not seek medical atten- tion. He was divorced and worked as a barman for the last 20 years. He had no history of quinolone intake. Clinical examination revealed active RA (DAS28 = 7.35) and atrophy of the quadriceps muscles. Rales were present at the base of both lungs. The patient had nodulosis in the exterior surface of both elbows, while conventional radiographs of hands and feet showed soft tissue swelling and periarticular osteopenia of metacarpophalangeal and proximal interphalangeal joints of both hands, with no erosions. A muscular mass because of the rupture of the long head of the biceps brachii tendon was obvious in the middle of his right arm. Laboratory tests revealed macrocyto- sis due to alcohol abuse with no ane- mia, elevated lactate dehydrogenase (359U/l), hyperlipidemia (cholesterol = 253mg/dl, LDL-C = 179mg/dl), elevat- ed C- reactive protein (4.44 mg/dl) and high titer of rheumatoid factor (3260 IU/ml). Antinuclear antibodies and anti-neutophile cytoplasmic antibodies were negative. Thyroid tests and levels of parathormone were normal. A high-resolution computed tomogra- phy (HRCT) of the chest revealed inter- stitial lung disease with honeycombing and no evidence of active alveolitis. The histological examination of the sur- gical specimens from tendon and quad- riceps, muscle revealed signs of chronic inflammatory arthritis and degenerative disorders of the striated muscle. Magnetic resonance (MR) imaging The MR imaging study for both knees included a sagittal T1-weighted, an ax- ial T1-weighted and an axial short-tau inversion recovery (STIR) sequence. MR imaging revealed rupture of the Clinical and Experimental Rheumatology 2007; 25: 461-463.