Rheumatology 2014;53:1725–1731
doi:10.1093/rheumatology/ket459
Advance Access publication 30 January 2014
RHEUMATOLOGY
Review
Art and rheumatology: the artist and the
rheumatologist’s perspective
Andrea Hinojosa-Azaola1 and Jorge Alcocer-Varela1
The reflection of medicine in the universal arts has motivated several rheumatologists to discover features
of rheumatic diseases depicted by the artist’s eyes long before they were defined as specific pathologic
entities. The result has been the identification of several pieces of art dating from the Middle Ages, the
Renaissance, the Baroque and Post-Impressionist periods that depict clear features of several rheumatic
diseases such as RA, OA, camptodactyly and temporal arteritis, among others. On the other hand, great
artists such as Pierre-Auguste Renoir, Antoni Gaudı́, Raoul Dufy, Paul Klee, Frida Kahlo and Niki de Saint
Phalle are good examples of how rheumatic diseases such as RA, scleroderma and chronic pain can
influence the artist’s perspective, the technique used and the content of their work. Art can serve as a
powerful resource to understand the natural course of diseases. By learning through the artist’s eyes the
way illnesses behave and evolve in time, rheumatologists can trace the history of several conditions.
Key words: rheumatology, art, history.
Introduction
The reflection of medicine in the universal arts has both
intrigued and captivated the medical profession for centuries. This attraction has motivated several rheumatologists to look at catalogues and reproductions of paintings
with a magnifying glass, trying to discover features of
rheumatic diseases depicted by artists long before these
diseases were defined as specific pathologic entities.
Although a work of art may provide evidence of ancient
disease, the interpretation may be difficult, leading to
errors in diagnosis due to misinterpretation of the artistic
convention or technique [1]. The accurate diagnosis of
rheumatic diseases that are portrayed in the visual arts
therefore requires tracing the historical background of
the piece of art.
Evidence of rheumatic diseases in history dates from
1279 BC, during the reign of Ramses II. A retrospective
radiologic analysis of his mummy showed severe changes
associated with SpA, with post-inflammatory hip arthritis
and cervical ankylosis [2]. Moreover, evidence of the
origin of RA in 1400 AD (and not in 1800 AD, as
1
Department of Immunology and Rheumatology, Instituto Nacional de
Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
Submitted 12 August 2013; revised version accepted
27 November 2013.
Correspondence to: Jorge Alcocer-Varela, Department of Immunology
and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición
Salvador Zubirán, Vasco de Quiroga 15, Col. Sección XVI, Tlalpan, CP
14000, México D.F., México. E-mail: [email protected]
previously thought) stimulated certain experts to look for
traces of this disease before that time. These experts
identified paintings that date from 1400 to 1600 AD and
that depict hand changes suggestive of RA. It was in 1853
AD when the term progressive articular rheumatism was
described in Charcot’s thesis, and later, in 1859 AD,
Sir Alfred Baring Garrod adopted the term RA [3–5]. This
anecdote shows the delay in finding pictorial and scientific
evidence of the disease.
Discovering evidence of rheumatic diseases in the
visual arts raises the questions of whether the artist reflected what surrounded him in a realistic fashion or suffered from the disease himself and, in the latter case, how
the illness influenced his art. It is clear that art reflects
every moment of human thought, influenced by the historical backdrop. For example, in the 14th century, master
painters searched for perfection in human anatomy,
whereas artists from the 20th century created realities reflective more of their own inner visions than what lay
before them in nature. As a result, 20th century painting
movements and trends inspired artists to set out in many
divergent directions [6]. Painters and sculptors have long
been recognized as professionally prone to conditions
such as lead intoxication and stone dust silicone exposition, although the mean age at death for artists has been
described as higher than that of the general population [4].
The artist and the rheumatologist’s perspective converged in Andreas Vesalius, a brilliant anatomist of the
1500s with a remarkable practical skill in dissecting
bodies, and the author of De Humani Corporis Fabrica.
! The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: [email protected]
R EV I E W
Abstract
Andrea Hinojosa-Azaola and Jorge Alcocer-Varela
FIG. 1 Detail from clay hand dating to the classic Veracruz
period in Mexico (200–650 AD)
FIG. 2 Detail from Sandro Botticelli’s ‘Portrait of a Youth’
(tempera on panel, 1482/1485)
Swelling of the IP joint of the thumb represents a
Heberden’s node. Adapted from Alarcón-Segovia [9].
He served as imperial physician at the court of Emperor
Charles V and during that time he treated injuries from
battle and tournaments, but most important, he treated
Charles V, who was affected by gout [7, 8]. The
common situation in which the artist and rheumatologist
collide as both spectator and patient is the focus of this
review.
Rheumatic diseases depicted by artists
Many artists have depicted rheumatic diseases in their
work. Several characterizations are summarized in this
section in chronological order.
200–650 to 1200 AD
During the Middle Ages, Europe avoided renovation and
redefinition, so artistic and scientific production during
that period was very poor and strictly and solely dependent on approval by the church or monarchy. The medieval
man believed that the universe rotated around the Earth
and did not have free access to knowledge and therefore
was not an actor in the world in which he lived. Despite
this concept, there are several pieces of art that deserve
attention because they belong to that period of time in
America. A nearly life-size clay hand belonging to the classic Veracruz period in Mexico (200–650 AD) shows swelling of the IP joint of the thumb, representing a Heberden’s
node [9] (Fig. 1). Moreover, a sculpture of a male from
Jalisco, Mexico, dating from 300 BC to 200 AD exhibits
a suffering face due to a lesion of his right tibia, which is
possibly osteomyelitis, a fracture or a tumour [10].
1400–1500
The willingness to have a place in the universe before
God and man himself resulted in a generation of brilliant
intellectuals and poets (e.g. Dante Alighieri, Giovanni
Boccaccio and Francesco Petrarca) who transformed
Occidental ideology. The overwhelming enthusiasm accumulated during the 14th and 15th centuries gave place to
the most important artistic movement in history: the
Renaissance. During this period, the world observed a
1726
Swelling of the wrist, MCP and PIP joints of the hand
suggestive of possible JIA. National Gallery of Art,
Washington DC.
succession of men without precedents. Man, freed from
the medieval ties that restricted him, could now reflect the
human body in his art, with strict attachment to anatomy
and mathematics (perspective). During these years,
rheumatic features such as camptodactyly (congenital
fixed-flexion deformity of the proximal IP joint in combination with hyperextension of the MCP and DIP joints, with
a preference for the fifth finger) were depicted in paintings
by Dieric Bouts (1415–75) and his son, including ‘The Last
Supper’, ‘Mater Dolorosa’ and ‘The Ascension of Maria’
[11]. This deformity is not present in works by other artists
from the same time or later. In the panel of St. John the
Baptist in the ‘Adoration of the Lamb’ (1432) by Jan van
Eyck, a typical Heberden’s node can be observed on the
left thumb [12]. In the drawing ‘John IV, Duke of Brabant’
(1441) by the same Flemish artist, swan-neck and boutonnière deformities of the fingers are depicted [13]. In another famous painting by van Eyck, dating from 1436 and
known as ‘The Virgin with the Canon’, the artist characterises Canon Van der Paele’s left temporal region with
prominent arteries, scar formation, a loss of hair in front
of the left ear and from the eyebrows and diffuse swelling
of the left hand [14]. These findings are very suggestive of
TA with PMR. Horton et al. [15] first described TA as a
specific entity in 1932. Another depiction of the same vascular disease can be found in Piero di Cosimo’s portrait of
Francesco Giamberti, dating from 1505.
In 1983 Alarcón-Segovia et al. [16] described swelling of
the wrist, MCP and PIP of the hand depicted in ‘Portrait of
a Youth’ (1483) (Fig. 2) by the Florentine artist Sandro
Botticelli. These changes are suggestive of possible JIA
and were not ascribed to faulty technique. However,
1 year later, Dequeker [17] and Leden [18] questioned
these findings by mentioning other paintings by Botticelli
(i.e., ‘The Birth of Venus’) with similar characteristics of the
hands and swelling of the ankles and forefeet, suggesting
www.rheumatology.oxfordjournals.org
Art and rheumatology
stylistic configuration and artistic convention rather than a
diagnosis of arthritis.
Botticelli triumphed where Pollaiuolo failed by achieving
a perfect and harmonic scheme. By doing so, he sacrificed some resources: Botticelli’s figures seem less solid;
they are not as rightly drawn as the ones of Pollaiuolo or
Masaccio. The graceful movements and melodic lines that
form his compositions remind one of the gothic tradition of
Ghiberti and Fra Angelico, and the art of the 14th century,
including pieces by Simone Maritini and Lippo Memmi.
Botticelli took liberties with nature in order to achieve
graceful silhouettes, enhance beauty and harmony,
and give the impression of incredibly delicate human
beings [6].
Drawings and paintings serve as important tools
for understanding the natural history of diseases. One of
the most representative examples of this concept is the
famous medieval drawing ‘The Procession of the Cripples’
by the Dutch painter Hieronymus Bosch (1450–1516), in
which 31 disabled individuals are depicted [19]. An expert
analysis performed by a rheumatologist, an orthopaedic
surgeon and a neurologist showed that the drawing represents several diseases, including rheumatic entities
such as Pott’s disease, SpA, hyperostosis vertebralis
and post-infectious osteomyelitis.
Possible pagetoid lesions of the skull and clavicles
(osteitis deformans) are characterized in the painting
entitled ‘A Grotesque Old Woman’, attributed to the
Flemish artist Quinten Metsys (1465–1530) [20]. The
same artist also portrayed Erasmus of Rotterdam in
1517, depicting synovial thickening at the MCP joints
and hyperextension of the left thumb. Information from
paintings, drawings, letters and post-mortem reports suggest that this humanist of the Reformation period suffered
from pustulotic arthro-osteitis [21].
Arthritis-like lesions have been discovered in other
Flemish paintings dating from 1400 to 1700, including
the works of artists such as Jan Rombouts, Joos
(Justus) van Gent, Jacob Jordaens and Jan Gossaert
[13]. These findings support the recognition of the disease
before this condition was formally described.
1600–1800
These years comprised the Baroque period (1600–1750),
characterized by the splendour and flourish of God, and
the Neoclassical period (1750–1850), when art recaptured
Greco-Roman grace and grandeur. At the same time, the
Thirty Years’ War between Catholics and Protestants
occurred (1618–48), followed by the Enlightenment and
the Industrial Revolution (1760–1850). In 1608, the Italian
artist Caravaggio depicted JIA in his painting entitled ‘The
Sleeping Cupid’ [1]. Moreover, Peter Paul Rubens
(1577–1640), the Flemish Baroque painter, depicted features of hand arthritis in several paintings dating from
1609 to 1640, including ‘Saint Mathew’, ‘The Drunken
Sleeping Satyr’, ‘Suzanna and the Elders’, ‘Portrait of
Marie de Medici’, ‘Saint Augustine between Christ and
the Virgin’, and ‘The Holy Family with St Anne’ [22].
Furthermore, one of the later paintings by Rubens, ‘The
www.rheumatology.oxfordjournals.org
Three Graces’ (1638–40), depicts benign familial hypermobility syndrome and the Trendelenburg sign in
Rubens’ second wife and her sisters, showing that the
artist was a keen observer [23].
The presence of multiple progressive hand deformities
in Rubens’ paintings and the realism that characterized his
art have raised the question of whether such deformities
represent different models affected by the disease or
whether the artist projected his disease onto his models
(self-portraits of his rheumatic illness). The hypothesis
regarding Rubens’ rheumatic condition comes from his
paintings and letters. The disease affected his hands,
knees and feet and was chronic, disabling and complicated by flares. Possibilities include RA, chronic tophaceous gout and saturnine gout [22–24].
Evidence of rheumatic diseases represented in visual
arts dating from this period often includes religious personages. Examples of these are found in paintings by the
Catholic Dutch artist Claes Cornelisz Moeyaert dating
from 1631, as clinical signs of RA are depicted in portraits
of the priest Siebrandus Sixtius [25], and the painting
‘Archangel Raphael and Bishop Francisco Domonte’
(1680) by the Spanish Baroque painter Murillo, in which
several features of scleroderma are depicted in the
bishop’s face and hands (e.g. telangiectases, tight skin
and swollen fingers) [26].
Vincent van Gogh, the famous Dutch PostImpressionist artist, executed a group of portraits of the
Roulin family during his time in Arles. Among these portraits is ‘La Berceuse (Augustine Roulin)’ (1888), in which
features of hand arthritis are clearly depicted in the
woman portrayed [27].
The influence of rheumatic diseases
on artists
Rheumatic diseases have affected several artists from the
19th and 20th centuries in different ways, influencing their
techniques and legacies. The arts have served as a means
by which man expresses life’s broad range of emotions:
love, the appreciation of beauty, despair and loneliness.
However, the works of several prominent artists also reflect the pain and frustration of arthritis and other illnesses
from which they suffered [28].
The 20th century was characterized by the emergence of several artistic movements, including Fauvism,
Expressionism, Cubism, Futurism, Constructivism,
Dadaism and Surrealism. A poetic vision characterises
the art and ideology of the 20th century.
Surrealism, a powerful movement, emerged in the postwar period as a call for freedom and for the supremacy of
subjectivity and desire over objectivity. This movement
represents the part of man that cannot be reduced to
reason or science, which is his symbolic and oneiric part.
Impressionism, characterized by emphasis on the accurate depiction of light and its changing qualities, with
the inclusion of movement and unusual visual angles,
occurred during the 19th century. Among the most representative artists of this movement was the French painter
1727
Andrea Hinojosa-Azaola and Jorge Alcocer-Varela
Pierre-Auguste Renoir (1841–1919), who created 6000
works and suffered from severe RA for the last 25 years
of his life. Evidence from personal letters, photographs
and biographical notes gives testimony to the way that
the artist’s technique evolved to overcome the difficulties
of the rheumatic disease, which was enhanced by a
stroke that he suffered when he was 71. The so-called
painter of happiness did not know about the benefits conferred by disease-modifying anti-rheumatic drugs and
was treated with purges and antipyrine. As a result, he
was a victim of the natural course of the illness. He was
unable to wear shoes, had fixed flexion of his knees and
suffered from destruction and ankylosis of his right shoulder and ruptures of several extensor tendons of the
hands. Renoir also experienced complications such as
pleuritis, weight loss, nodules, cutaneous vasculitis and
bedsores. The progressive deformities and disability
obliged him to ask for his palette to be fixed on the arm
of his wheelchair and the brushes to be attached to his
hands with the aid of bandages to prevent maceration
when painting. Because of his illness, the artist made important changes to his technique and the materials used,
painting with small and rapid strokes and inventing the
moving canvas or picture roll [29, 30].
Antoni Gaudı́ i Cornet (1852–1926), a Catalan architect
with a unique style, suffered from a recurrent form of arthritis since he was 6 years old. Although little information is
available, it is known that he presented articular pain that
mainly involved the ankles and that he wore espadrilles,
followed a very strict vegetarian diet and underwent
homeopathic treatments. Among the diagnoses suggested are JIA and rheumatic fever, although other
joints, such as in the hands and the knees, were spared.
It is said that the artist’s disease influenced the development of his great skills: observational power and nature
analysis [31].
Raoul Dufy (1877–1953), a French Fauvist painter, suffered from RA from his early youth and later in life was one
of the first patients to receive corticosteroids (adrenocorticotropic hormone and cortisone acetate). During the first
years of the disease he received physiotherapy and chrysotherapy to ameliorate his condition and suffered from
severe flares that obliged him to use crutches and even a
wheelchair. The quality of Dufy’s art represents the benefit
of the treatment that he received. His medical history
shows how corticosteroids helped him to improve his
mobility and to squeeze his paint tubes unassisted, thus
his art became freer and the lines less laboured.
Nevertheless, due to his disease, the size of Dufy’s paintings was reduced, the plots were less accurate and the
subjects were restricted to what he could imagine or contemplate without moving. Furthermore, he represented
distorted, swollen and erased hands in his late paintings.
Dufy suffered from the adverse events that the treatment
caused, presenting with massive intestinal haemorrhages
that were produced by the combination of cortisone and
aspirin and which finally caused his death [32, 33].
Paul Klee (1879–1940), a very influential PostImpressionist artist, was diagnosed with scleroderma in
1728
FIG. 3 Paul Klee, ‘Little Regatta’, 1922 (watercolour on
paper, 14.6 22.8 cm)
This small-scale composition shows Klee’s detailed and
technical style before the diagnosis of scleroderma was
made. Reproduced with permission from The Phillips
Collection, Washington, DC.
1936 at the age of 57, 4 years before he died. The disease
was manifested as RP, characteristic skin changes, fatigue, exhaustion, dysphagia with weight loss, dyspnoea,
arthritic pain, disability, difficulty in holding paintbrushes
and ultimately heart failure. Klee’s early work was characterized by prints, etchings and pen and ink drawings
(Fig. 3). The diagnosis of scleroderma was associated
with an initial decrease in productivity and a subsequent
recovery in the last year of his life. Parallel to the illness his
paintings evolved, showing greater simplicity, intensity
and the use of rough materials such as burlap and newspaper (Fig. 4). Small-scale compositions were substituted
by larger pieces of a flat style, characterized by simple,
heavy, black crayon-like lines, symbols, dull colours
and titles that reflected suffering, death and war
(e.g. ‘Forgetful Angel’, ‘Hurt’, ‘The Sick One in the Boat’,
‘Death and Fire’) [34, 35]. The dramatic change in Klee’s
style reflected a new technique that made it easier for his
hands to hold larger brushes. Several of his later drawings
reflect disfigured faces and changes in the hands that resemble scleroderma, suggesting awareness of his condition. The precipitating cause of Klee’s scleroderma has
been speculated to be either a viral infection, such as
measles, that triggered an autoimmune process or exposure to toxic heavy metals [36].
Frida Kahlo (1907–54), a Mexican painter, political activist and feminist icon, was the first Western artist to
include anatomical interpretations of reproduction within
her art [37]. Her work was described by several as more
obstetric than aesthetic, because the art incorporated
overtly medical iconography, from scenes of childbirth to
her own wounds, using medical imagery to record her
story [38]. Affected by poliomyelitis, Kahlo was involved
in a tram accident when she was 18 and suffered devastating injuries (she was impaled through her pelvis by a
steel bar and sustained multiple fractures of the spine,
pelvis, right leg and foot). She underwent numerous
www.rheumatology.oxfordjournals.org
Art and rheumatology
FIG. 4 Paul Klee, ‘Young Moe’, 1938 (coloured paste on
newspaper on burlap, 53 70.1 cm)
FIG. 5 Frida Kahlo, ‘The Broken Column’, 1944 (oil on
masonite)
Simple and heavy lines, symbols, materials and colours
reveal a dramatic change in Klee’s technique as a result of
the disease. Reproduced with permission from The
Phillips Collection, Washington, DC.
orthopaedic operations and was confined to plaster corsets for several months. Certain experts believe that from
that time Kahlo suffered from widespread severe, chronic
pain and profound fatigue suggestive of post-traumatic
FM [39], although it is difficult to attribute all of the symptoms that she presented to only one medical condition.
The anguish and pain suffered due to the accident, more
than 30 surgeries and three therapeutic abortions, are reflected in her painting, which was a way of creating psychological aliveness from the deadness arising from her
tragic life experiences. Both the titles and content of her
paintings describe her pain: ‘Henry Ford Hospital’ (1932),
‘My Birth’ (1932), ‘The Broken Column’ (1944) (Fig. 5) and
‘Without Hope’ (1945) [40]. In Kahlo’s own words: ‘My
painting carries within it the message of pain . . . painting
completed my life. I lost three children . . . Painting substituted for all this. I believe that work is the best thing’ [41].
In the case of Niki de Saint Phalle (1930–2002), a French
painter and sculptor, it was occupational exposure to the
materials that she used in her work that presumably
caused several of her illnesses. She worked with materials
such as oil paint, plaster, wire netting, fabric, clay, polyester and polystyrene and had a special fondness for
glass, mirrors and ceramic. The artist suffered from several health problems, including mental crises and depression, chronic lung disease attributed to polystyrene
exposure, transient selective IgA deficiency and recurring
and debilitating attacks of erosive RA that prevented her
from continuing to model. She received treatment for RA
late in the course of the disease, after hand deformities
and weight loss, and developed several adverse events
related to corticosteroids. Her work reflected both anger
and violence as a product of her suffering, but she
emerged from each physical and emotional crisis with
new force and new ideas [33, 42].
www.rheumatology.oxfordjournals.org
This self-portrait embodies isolation, a broken body,
intense suffering and pain. Collection of Dolores Olmedo
Museum, Xochimilco, México. ! 2013, Banco de México,
‘Fiduciario’ en el Fideicomiso relativo a los Museos Diego
Rivera y Frida Kahlo (reproduced with permission).
These stories are good examples of painting as a creative act that cannot be observed apart from the artist’s
body. Painting constitutes a unit that encompasses the
artist and his personal history, the canvas and the influence of the environment.
Conclusions
Art can serve as a powerful resource to understand the
natural course of diseases. On the one hand, by learning
about the way in which illnesses behave and evolve over
time through the artist’s eyes, rheumatologists can trace
the history of several currently known conditions. Artists
are keen observers of nature and details; their legacy of
realism depicted through their perception is an outstanding source of information and a delightful way to catalyse
emotions. On the other hand, as patients suffering from
rheumatic diseases, artists have contributed enormously
to teaching rheumatologists about the importance of illnesses manifested in the changes that the artists made in
their artistic technique to cope with their disease. It is
through detailed and chronological analysis of the artists’
work that we can unravel certain aspects of rheumatic
diseases that science alone cannot elucidate.
1729
Andrea Hinojosa-Azaola and Jorge Alcocer-Varela
Rheumatology key messages
There is evidence of rheumatic diseases in art
before their description as pathological entities.
. Artists suffering from rheumatic diseases adapted
their technique and the content of their work.
. Art can serve as a powerful resource to understand
the natural course of a disease.
.
Acknowledgements
We are indebted to The Phillips Collection, Washington,
DC and to the Dolores Olmedo Museum, Xochimilco,
Mexico, who gave permission to reproduce Paul Klee’s
and Frida Kahlo’s paintings, respectively.
Disclosure statement: The authors have declared no
conflicts of interest.
References
1 Dequeker J. What can a rheumatologist learn from paintings? Acta Reumatol Port 2006;31:11–3.
2 Appelboom T, Russell A. Moses: did he inherit the spondylarthritis of the pharaohs? Arthritis Rheum 2003;49:
142–3.
3 Appelboom T, Ehrlich GE. Historical note: the concept of
gout in 1880. Arthritis Rheum 1998;41:1511–2.
4 Dequeker J. Medicine and the artist. Age Ageing 2008;37:
4–5.
5 Appelboom T. Arthropathy in art and the history of
pain management—through the centuries to
cyclooxygenase-2 inhibitors. Rheumatology 2002;
41(Suppl 1):28–34.
6 Gombrich EH. La historia del arte. New York: Phaidon,
1997.
7 Appelboom T. Vesalius, also a rheumatologist? Arthritis
Care Res 2002;47:109–10.
8 Couper R. The severe gout of Emperor Charles V. N Engl
J Med 2006;355:1935–6.
9 Alarcón-Segovia D. Pre-Columbian representation of
Heberden’s nodes. Arthritis Rheum 1976;19:125–6.
10 Appelboom T. Art and history: a large research avenue for
rheumatologists. Rheumatology 2004;43:803–5.
11 Hijmans W, Dequeker J. Camptodactyly in a painting
by Dirk Bouts (c. 1410–1475). J R Soc Med 2004;97:
549–51.
16 Alarcón-Segovia D, Laffón A, Alcocer-Varela J. Probable
depiction of juvenile arthritis by Sandro Botticelli. Arthritis
Rheum 1983;26:1266–8.
17 Dequeker J. Arthritis in the paintings of Sandro Botticelli.
Arthritis Rheum 1984;27:1196–7.
18 Leden I. Doubts about Sandro Botticelli’s depiction of
juvenile rheumatoid arthritis. Arthritis Rheum 1984;27:
1197–8.
19 Dequeker J, Fabry G, Vanopdenbosch L. Hieronymus
Bosch (1450–1516): paleopathology of the Medieval disabled and its relation to the bone and joint decade
2000–2010. Isr Med Assoc J 2001;3:864–71.
20 Dequeker J. Paget’s disease in a painting by Quinten
Metsys (Massys). Br Med J 1989;299:1579–81.
21 Dequeker J. Art, history, and rheumatism: the case
of Erasmus of Rotterdam 1466–1536 suffering
from pustulotic arthro-osteitis. Ann Rheum Dis 1991;50:
517–21.
22 Appelboom T, Boelpaepe C, Ehrlich GE et al. Rubens and
the question of antiquity of rheumatoid arthritis. JAMA
1981;245:483–6.
23 Dequeker J. Benign familial hypermobility syndrome and
Trendelenburg sign in a painting ‘‘The Three Graces’’ by
Peter Paul Rubens (1577–1640). Ann Rheum Dis 2001;60:
894–5.
24 Appelboom T. Hypothesis: Rubens—one of the first
victims of an epidemic of rheumatoid arthritis that
started in the 16th–17th century? Rheumatology 2005;44:
681–3.
25 Dequeker J. Siebrandus Sixtius: evidence of
rheumatoid arthritis of the robust reaction type in a
seventeenth century Dutch priest. Ann Rheum Dis 1992;
51:561–2.
26 Dequeker J, Vanopdenbosch L, Ojugas AC.
Early evidence of scleroderma. Br Med J 1995;311:
1714–5.
27 Weinberger A. The arthritis of Vincent van Gogh’s model,
Augustine Roulin. J Clin Rheumatol 1998;4:39–41.
28 Appelboom T. The past: a gallery of arthritics. Clin
Rheumatol 1989;8:442–52.
29 Boonen A, van de Rest J, Dequeker J et al. How Renoir
coped with rheumatoid arthritis. Br Med J 1997;315:
1704–8.
30 Zeidler H. Great artists with rheumatoid arthritis. What
did their disease and coping teach? Part I. Pierre-Auguste
Renoir and Alexej von Jawlensky. J Clin Rheumatol 2012;
18:376–81.
31 Azevedo VF, Diaz-Torne C. The arthritis of Antoni Gaudı́.
J Clin Rheumatol 2008;14:367–9.
12 Dequeker J, Luyten FP. The history of osteoarthritisosteoarthrosis. Ann Rheum Dis 2008;67:5–10.
32 Homburger F, Bonner CD. The treatment of Raoul Dufy’s
arthritis. N Engl J Med 1979;301:669–73.
13 Dequeker J. Arthritis in Flemish paintings (1400–1700).
Br Med J 1977;1:1203–5.
33 Zeidler H. Great artists with rheumatoid arthritis. What
did their disease and coping teach? Part II. Raoul
Dufy and Niki de Saint Phalle. J Clin Rheumatol 2012;18:
431–6.
14 Dequeker J. Polymyalgia rheumatica with temporal arteritis, as painted by Jan Van Eyck in 1436. Can Med Assoc J
1981;124:1597–8.
15 Horton BT, Magath TB, Brown GE. An undescribed form
of arteritis of temporal vessels. Proc Staff Meet Mayo Clin
1932;7:700–1.
1730
34 Varga J. Illness and art: the legacy of Paul Klee. Curr Opin
Rheumatol 2004;16:714–7.
35 Wolf G. Endure!: how Paul Klee’s illness influenced his art.
Lancet 1999;353:1516–8.
www.rheumatology.oxfordjournals.org
Art and rheumatology
36 Silver RM. Captive of art, not disease. Paul Klee and his
illness, scleroderma. Pharos Alpha Omega Alpha Honor
Med Soc 2008;71:16–24.
40 Goldsmith M. Frida Kahlo: abjection, psychic deadness,
and the creative impulse. Psychoanal Rev 2004;91:
723–58.
37 Bernstein HB, Villaseñor C. Frida Kahlo: realistic reproductive images in the early twentieth century. Am J Med
2008;121:1114–6.
41 Herrera H. Frida: A Biography of Frida Kahlo. New York:
Harper & Row, 1983.
38 Lomas D, Howell R. Medical imagery in the art of Frida
Kahlo. Br Med J 1989;299:1584–7.
39 Martı́nez-Lavı́n M, Amigo MC, Coindreau J et al.
Fibromyalgia in Frida Kahlo’s life and art. Arthritis Rheum
2000;43:708–9.
42 Zeidler H. Niki de Saint Phalle’s lifelong dialogue
between art and diseases: psychological trauma of
sexual abuse, transient selective IgA deficiency, occupational exposure to toxic plastic material, chronic lung
disease, rheumatoid arthritis. J Bone Spine 2013;80:
332–7.
Rheumatology 2014;53:1731
doi:10.1093/rheumatology/keu261
Advance Access publication 26 July 2014
Clinical vignette
Inflammatory arthropathy of the manubriosternal
joint
A 27-year-old woman presented with a history of 30–45
days of anterior chest pain, which began insidiously, evolving to an incapacitating pain with a visual analogue scale
(VAS) of 8 out of 10, exacerbated by movement and
deep breathing. On physical examination the patient had
sternal tenderness and mild acne on buttock skin. She
denied other symptoms or previous diseases and
FIG. 1 Manubroisternal joint arthritis
reported psoriasis in her father. MRI of the sternum
showed subchondral irregularities in the manubriosternal
joint with extensive osteitis (Fig. 1A and B). Bone scintigraphy showed increased uptake at the manubriosternal
joint (Fig. 1C). X-rays of sacroiliac joints showed no
signs of sacroiliitis. HLA*B27 was positive. After 2
months of treatment with NSAIDs the patient was almost
asymptomatic (pain VAS 1.5 out of 10). A new MRI after 12
months of follow-up showed persistence of osteitis, which
was less intense. The patient was diagnosed with undifferentiated spondyloarthropathy, although diagnosis of
SAPHO
syndrome
(synovitis,
acne,
pustulosis,
hyperostosis and osteitis) could not be discarded, since
the involvement of anterior chest wall joints and osteitis
are characteristic of this disease [1].
Disclosure statement: The authors have declared no
conflicts of interest.
Virginia Ruiz-Esquide1, Ana I. Garcı́a2,
Julio Ramı́rez1 and Núria Guañabens1
1
Rheumatology Service and 2Radiology Service, Hospital
Clı́nic de Barcelona, Barcelona, Spain.
Correspondence to: Virginia Ruiz-Esquide, Rheumatology
Service, Hospital Clı́nic de Barcelona, Villarroel 170, 08036
Barcelona, Spain. E-mail: [email protected] or
[email protected]
(A) Coronal T2-weighted fat suppressed and (B) sagittal
contrast-enhanced T1-weighted fat suppressed magnetic
resonance images of the sternum showing subchondral
irregularities (long arrows) and extensive signal change
with enhancement (short arrows) in the manubriosternal
joint. (C) Bone scintigraphy showing uptake in the manubriosternal joint (arrow).
Reference
1 Restrepo CS, Martinez S, Lemos DF et al. Imaging appearances of the sternum and sternoclavicular joints.
Radiographics 2009;29:839–59.
! The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: [email protected]
www.rheumatology.oxfordjournals.org
1731