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  Citation statistics : Table of Contents
   2018| March  | Volume 13 | Issue 1  
    Online since February 26, 2018

 
 
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ORIGINAL ARTICLES
Safety and efficacy of an Anti-CD20 Monoclonal antibody (RedituxTM) In Indian patients with seropositive rheumatoid arthritis
Arun Hegde, Vivek Vasdev, Krishnan Shanmuganandan, Kavita Singh, Sivasami Kartik, Abhishek Kumar
March 2018, 13(1):20-25
DOI:10.4103/injr.injr_98_17  
Background: Rituximab (RTX), an anti-CD 20 monoclonal antibody is one of the first line biological disease-modifying anti-rheumatoid drug indicated for the treatment of rheumatoid arthritis (RA) in patient's refractory to conventional Synthetic DMARDs (csDMARDs). Limited data are available about the safety and efficacy of biosimilar version of this molecule. In this study, we assessed the clinical efficacy and safety profile of biosimilar RTX, RedituxTM. Methods: In this prospective study, 36 adults with moderate disease activity measured by the European League Against Rheumatism (EULAR) disease activity score (DAS28-erythrocyte sedimentation rate [ESR] ≥3.2), who had failed conventional therapy with at least 2 csDMARDs were initiated on RTX, 1000 mg, given on day 0 and day 15, after taking informed consent. Biomarkers including ESR, C reactive protein, Immunoglobulin G and M (IgG, IgM) and DAS28-ESR scores were measured at baseline and repeated at 2, 4, 8, 12, 16, 20, and 24 weeks. The primary endpoint was attaining EULAR good/moderate response. Results: DAS28-ESR score showed a statistically significant decline at 24 weeks (P < 0.001). Seventy-five percent patients showed an EULAR moderate response while 25% showed no EULAR response at 24 weeks posttreatment. IgG and IgM levels declined by 24.9% (P < 0.001) and 37% (P = 0.020) at end of 24 wks. However, there were no infections noted during the period of study. The most common adverse event was infusion reaction seen in 16.6% of patients. Conclusions: RTX is a safe and effective drug for the management of seropositive RA with results comparable with the original molecule. No serious adverse effects were noted in the study except for mild infusion reactions and fall in immunoglobulin levels.
  3 1,545 195
IMAGES IN RHEUMATOLOGY
Sulfasalazine induced photo toxicity
Sham Santhanam, Nidhi Singh
March 2018, 13(1):64-65
DOI:10.4103/injr.injr_131_17  
  1 1,606 126
Rituximab-induced serum sickness: Not so uncommon
Vikramraj K Jain
March 2018, 13(1):66-68
DOI:10.4103/injr.injr_122_17  
  1 1,527 163
LETTERS TO EDITOR
Mycophenolate mofetil induced transfusion dependent anemia in lupus
Anand Prahalad Rao, Ayesha Romana, Jyothi Raghuram
March 2018, 13(1):69-70
DOI:10.4103/injr.injr_102_17  
  1 1,365 141
ORIGINAL ARTICLES
Long-term outcomes and predictors of biologic treatment in systemic juvenile idiopathic arthritis in a single-center experience in Thailand
Sirisucha Soponkanaporn, Suphaneewan Jaovisidha, Soamarat Vilaiyuk
March 2018, 13(1):26-32
DOI:10.4103/injr.injr_83_17  
Background: The outcomes of systemic juvenile idiopathic arthritis (SJIA) vary from mild disability to mortality. Due to the socioeconomic problems in Thailand, the delay in receiving some medications, especially biologic agents, might affect the outcomes of this disease. This study aimed to determine the long-term outcomes and predictors of biologic treatment in SJIA patients. Methods: Patients with SJIA were enrolled over the study period between April 1997 and January 2015. The data were collected from medical records at the initial presentation and the most recent clinical visit. Outcomes evaluated included disease status, functional impairment, and joint destruction. Results: Of the 68 SJIA patients, 64 (94%) were eligible. The median (interquartile range) age at disease onset and duration of follow-up were 4.4 (2.9–7.9) and 4.2 (2.3–5.9) years, respectively. Nine patients (14%) achieved complete remission, while 12 (18.8%) had persistent active disease and 3 patients died; 2 of them had macrophage activation syndrome, while the other had a severe infection. A predictor of moderate-to-severe disability (childhood health assessment questionnaire ≥0.75) was hip involvement (odds ratios [OR] 27, 95% confidence interval [CI] 3.20–228.05). In addition, the predictors of biologic treatment were female gender (OR 6.4, 95% CI 1.74–23.74), younger age of onset (OR 4.7, 95% CI 1.31–16.66), hepatosplenomegaly (OR 5.9, 95% CI 1.29–27.29), and positive antinuclear antibody (ANA) (OR 6.3, 95% CI 1.19–33.75). Bone erosion was found in 34.2% of SJIA patients. Conclusion: Hip involvement was the important predictor of moderate-to-severe disability in SJIA, whereas female gender, younger age of onset, hepatosplenomegaly, and positive ANA were the predictors of biologic treatment.
  1 1,442 165
Rheumatological manifestations of hansen's disease
Anupam Wakhlu, Kamal Kumar Sawlani, D Himanshu
March 2018, 13(1):14-19
DOI:10.4103/injr.injr_52_17  
Introduction: Hansen's disease (leprosy) most commonly presents with cutaneous and nerve involvement. Rheumatological manifestations occur commonly but are often under-recognized. Physicians and rheumatologists alike are often perplexed with the rheumatological manifestations, given that these may precede the diagnosis of leprosy or may suggest another disease, in addition to leprosy. We present our experience with patients of leprosy presenting with rheumatological manifestations. Methods: This was a retrospective study carried out in the Departments of Rheumatology and Medicine, King George's Medical University, Lucknow, a tertiary care hospital in North India. Those patients who had a confirmed diagnosis of leprosy were subsequently included. Demographic details and clinical presentations were documented. Results: Twenty-nine cases (19 males, mean age 38 ± 17.2 years) were included in the study. The mean duration of disease was 20.2 ± 18.4 months. Rheumatological manifestations seen included arthritis (n = 17), tenosynovitis (n = 5), swollen hands and feet syndrome (n = 6), painful swollen feet (n = 2), arthralgias (n = 3), and vasculitis (n = 1). The rheumatological diseases mimicked were rheumatoid arthritis (n = 10) and spondyloarthritis (n = 3), sarcoidosis (n = 2), relapsing polychondritis (n = 1), and vasculitis (n = 1). At some point in time, lepra reactions manifesting with arthritis, nodules, tenosynovitis and/or dactylitis were observed in 15 cases. Other classical clinical manifestations detected were paresthesia (n = 13) and anesthetic patches (n = 15). Thickened great auricular, ulnar and lateral popliteal nerve were seen in 20 cases. Five patients had pure neuritic leprosy with no cutaneous manifestations and had arthritis or tenosynovitis. Conclusion: Leprosy may mimic a number of common and uncommon rheumatological diseases, and these may be the presenting manifestation. Awareness and a high index of suspicion are required to arrive at a timely and accurate diagnosis.
  1 1,824 271
REVIEW ARTICLES
Why women or why not men? sex and autoimmune diseases
Gilberto Cincinelli, Elena Generali, Rajkiran Dudam, Vinod Ravindran, Carlo Selmi
March 2018, 13(1):44-50
DOI:10.4103/injr.injr_1_18  
The epidemiology of autoimmune diseases is characterized by a significant sex dimorphism, with the majority of disorders being more prevalent in women. In a parallel fashion, the immune system shows sex-dependent differences in number and functions of both its innate and its adaptive arms, with women capable to mount a more vigorous response compared to men. This enhanced reactivity may contribute to the stronger defense against infectious agents and to the reasons for which, on the other hand, women are more prone to develop autoimmune diseases. Several factors have been studied and implied to play a role for such an imbalance, most notably sex chromosomes, sex hormones, and gut microbiota differences between sexes. Experimental studies on rodents demonstrate that sex chromosome abnormalities, alterations of gut microbiota composition, and fluctuations of sex hormone concentrations decrease the susceptibility to autoimmunity in female probes or increase it in the male counterparts. Nevertheless, it would be reductive to consider sex only as a risk factor; based on clinical experience, autoimmune disease onset and course differ between men and women in terms of disease progression and severity. Eventually, research has focused on sex as a determinant of antirheumatic treatment response with promising evidence for a further personalized management of patients with autoimmune diseases.
  1 4,049 307
Paradigm shift in clinical trial regulations in India
Sandeep Lahiry, Rajasree Sinha, Shouvik Choudhury, Ayan Mukherjee, Suparna Chatterjee
March 2018, 13(1):51-55
DOI:10.4103/injr.injr_110_17  
India has the potential to contribute meaningfully to global clinical drug development. A critical enabler to achieve this potential is a balanced, predictable, and scientifically robust regulation involving clinical studies. In the past few years, the country's regulatory milieu has witnessed a positive transformation to favour ethical conduct of clinical trials, while appropriately supporting patient safety. Numerous amendments to existing policies governing the conduct of clinical studies are predicted to bring a paradigm shift in the overall regulatory scenario. In such view, it is important for us as academicians, to be abreast of such changes. We, therefore, discuss major regulatory highlights involving clinical research in India.
  1 3,978 625
CASE-BASED REVIEW
Kikuchi–Fujimoto disease presenting as pyrexia of unknown origin
Prasanta Padhan, Krishna Prasad Tripathy, Saroj Ranjan Sahoo, Debasish Maikup, Nachiketa Mahapatra
March 2018, 13(1):56-59
DOI:10.4103/injr.injr_101_17  
Kikuchi–Fujimoto disease (KFD), or histiocytic necrotizing lymphadenitis, is a rare benign, self-limiting disorder of unknown etiology. Mostly prevalent among Asian women, KFD manifests mostly with cervical and rarely generalized or retroperitoneal lymphadenopathy in addition to fever. It can closely mimic infective and immunological disorders. Here, we report a 23-year-old female who presented with fever of unknown origin with other constitutional symptoms. The infectious and malignancy screen was negative on extensive workup. The patient was found to have multiple abdominal and cervical lymph nodes on imaging, biopsy and immunohistochemistry revealed histiocytic necrotizing lymphadenitis, which confirmed the diagnosis of KFD. Although rare, clinicians should be aware of KFD condition, as early recognition of the disease will minimize potentially harmful and unnecessary evaluation and treatments.
  - 1,459 164
EDITORIALS
Medical council of India's amended qualifications for indian medical teachers: Well intended, yet half-hearted
Sunita V S Bandewar, Amita Aggarwal, Rajeev Kumar, Rakesh Aggarwal, Peush Sahni, Sanjay A Pai
March 2018, 13(1):6-8
DOI:10.4103/injr.injr_150_17  
  - 967 153
Getting around barriers in biologic treatment for systemic juvenile idiopathic arthritis patients in resource-poor countries
Mahesh Janarthanan
March 2018, 13(1):2-3
DOI:10.4103/0973-3698.226154  
  - 1,175 175
Greater access to safe and effective therapeutic options in rheumatoid arthritis
Rajkiran Dudam, Vinod Ravindran
March 2018, 13(1):4-5
DOI:10.4103/0973-3698.226155  
  - 1,140 150
FROM THE EDITORS DESK
From the Editor's Desk
Vinod Ravindran
March 2018, 13(1):1-1
DOI:10.4103/0973-3698.226156  
  - 1,149 147
IMAGES IN RHEUMATOLOGY
An early presentation of cervical myelopathy in rheumatoid arthritis
Urmila Dhakad, Rasmi Ranjan Sahoo, Danveer Bhadu, Saumya Ranjan Tripathy, Duurgesh Srivastava, Siddharth Kumar Das
March 2018, 13(1):60-61
DOI:10.4103/injr.injr_68_17  
  - 1,284 151
Signet ring cell gastric adenocarcinoma “Linitis Plastica” Masquerading as retroperitoneal fibrosis: A report of two co-existing uncommon entities
Kapil Chaudhary, Partho Mukherjee, Emma Monga, Antony Devasia
March 2018, 13(1):62-63
DOI:10.4103/injr.injr_71_17  
  - 1,200 69
LETTERS TO EDITOR
Kikuchi-Fujimoto Disease (Histiocytic Necrotizing Lymphadenitis) associated with aseptic meningitis
CM Deepa, Anand Prahalad Rao
March 2018, 13(1):71-72
DOI:10.4103/injr.injr_119_17  
  - 890 56
Targeting radiation safety improvements through objective training in radiation synovectomy
Muhammad Omer Aamir, Iftikhar Ahmad
March 2018, 13(1):73-74
DOI:10.4103/injr.injr_3_18  
  - 575 50
Comment on: A comparison of 3 rheumatoid arthritis disease activity indices in routine clinical practice
Durga Prasanna Misra, Vikas Agarwal
March 2018, 13(1):75-75
DOI:10.4103/injr.injr_152_17  
  - 552 72
ORIGINAL ARTICLES
Serum levels of tumor necrosis factor-alpha and vascular endothelial growth factor as markers of disease activity in patients with axial spondyloarthritis
Mahendran Bhuvanesh, Chilkuri Balaji, Chinnadurai Saranya, Ramamoorthy Ramesh, Trichangode Natesan Tamilselvam, Sankaralingam Rajeswari
March 2018, 13(1):9-13
DOI:10.4103/injr.injr_64_17  
Background: Assessment of disease activity in axial spondyloarthritis (axSpA) has remained a challenge. This study aims to investigate the role of vascular endothelial growth factor (VEGF) and tumor necrosis factor-alpha (TNF-α) as markers of disease activity in patients with axSpA. Methods: A total of 40 patients with axSpA were included in this study. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)/Bath Ankylosing Spondylitis Functional Index (BASFI), serum TNF-α, and VEGF levels were assessed at baseline and the same parameters were assessed after 24 weeks of therapy with either etanercept or NSAIDs (20 patients in each group). Twenty healthy age- and sex-matched controls were also recruited for the study. Results: Patients with axSpA had higher levels of serum TNF-α (mean 341 pg/ml) and VEGF (mean 791 pg/ml) as compared with healthy controls (mean 72.5 pg/ml, P < 0.001 and mean 269 pg/ml, P < 0.001). There was significant reduction in serum TNF-α and VEGF levels after 24 weeks of treatment with etanercept (mean 161 pg/ml, P < 0.001 and mean 442 pg/ml, P < 0.001, respectively) but not with NSAID (P = 0.29, P = 0.25). Both TNF-α and VEGF had a positive correlation with BASDAI (r = 0.57, P < 0.01 and r = 0.44, P < 0.01) and BASFI (r = 0.61, P < 0.01 and r = 0.33, P = 0.03) at baseline. The levels of TNF-α and VEGF showed no correlation with ESR and CRP (P = 0.48, P = 0.07 and P = 0.21, P = 0.06, respectively) at baseline. There was no correlation between BASDAI and levels of ESR, CRP (P = 0.27 and P = 0.49, respectively). Conclusion: Serum levels of TNF-α and VEGF serve as better markers of disease activity as compared with ESR and CRP in axSpA.
  - 1,490 209
Effect of HLA-B27 status and body mass index on the clinical response to infliximab in ankylosing spondylitis patients
Mohammed Hadi Al-Osami, Ekhlas Khalid Hameed, Ali Mohammed Al-Hamadani
March 2018, 13(1):33-37
DOI:10.4103/injr.injr_89_17  
Background: Tumor necrosis factor-alpha inhibitors (infliximab) have changed the therapeutic approach to ankylosing spondylitis (AS). Body mass index (BMI) and HLA-B27 status may affect the response to infliximab. Methods: One hundred and seventy AS patients with active disease were enrolled in the study. Age, sex, disease duration, HLA-B27 status, and other demographics were obtained. Patients were classified according to their BMI to three groups clinical response was monitored using Bath AS disease activity index, at the time of initiation of treatment and 6 months later. Clinical response was defined as BASDAI50. Results: At baseline, all the groups were comparable. The median BMI of the responders was 25.4 kg/m2 while for the nonresponders it was 27 kg/m2. The normal weight and overweight AS patients have achieved the BASDAI 50 response after 6 months of infliximab treatment (P < 0.001) while the obese AS patients fail to achieve this response by infliximab alone and they need another drug (nonsteroidal anti-inflammatory drugs). The response was higher in HLA-B27 positive patients (42.5%) compared to the HLA-B27 negative patients (29%), the difference, however, was statistically insignificant. Conclusion: Obese AS patients are less likely to achieve a response to infliximab than normal weight AS patients.
  - 1,280 138
Human leukocyte Antigen-B*27 allele subtype prevalence and disease association of ankylosing spondylitis among south indian population
Vikram Haridas, Praveenkumar Shetty, M Nirmal Kumar, KC Vasanthakumar, Kiran Haridas, Vitthal Khode, Anil Bargale
March 2018, 13(1):38-43
DOI:10.4103/injr.injr_95_17  
Aim: Ankylosing spondylitis (AS) is a chronic inflammatory arthritis mainly affecting articular and extraarticular structures. AS clinical manifestations also involve sacroiliac joints and spine. Genetic factors play a key role in AS susceptibility. AS-associated subtypes of human leukocyte antigen (HLA)-B27 and other HLA-B alleles vary in different ethnic populations. There are no reports of HLA B genotype association to South Indian AS patients. In the current study, we have analyzed the HLA-B genotype association with 105 AS patients and 100 respective controls, we have also verified whether any specific clinical manifestation of AS has any pattern of HLA-B subtype association. Methods: The patients with AS were diagnosed fulfilling ASAS criteria. Before enrolling the patients, the written informed consent was obtained. The peripheral blood DNA genotyping of HLA-B27 was performed in Applied Biotechnologies 3130/3500 sequencer using SeCore HLA B Class I typing high-resolution kit from Invitrogen. Results: HLA B27 allele frequency in AS patients (74%) is significantly higher than healthy controls (3%). Most of the earlier studies associated AS with HLA B27 antigen. The current data illustrate that only 21% of AS patients presented HLA B27 antigen. HLA B27:05 and HLA B27:04 are the predominant subtypes. Early-onset of AS manifestations is seen in HLA B27 phenotypes than non-HLA B27 phenotypes. HLA B27 associated AS patients presented more severe axial manifestations such as bilateral sacroiliitis, erosions, and extra-articular features such as uveitis than non-HLA types. Positivity for HLA B27 allele predicts more severe disease course in South Indian patients with AS, similar to that in other populations. Conclusion: The current study indicates that a majority of South Indian AS patients are associated with HLA-B*27 alleles. In addtion we found that HLA-B*27 associated AS patients presented with more severe axial manifestations.
  - 2,497 229