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  Citation statistics : Table of Contents
   2018| December  | Volume 13 | Issue 4  
    Online since November 18, 2018

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Real life experience of a screening strategy for latent tuberculosis before treatment with biologicals in indian patients with rheumatic diseases
Anand N Malaviya, Ravita Thakaran, Roopa Rawat, Sanjiv Kapoor, Shriram Garg, Sadhana S Baghel, Christy Messi, Vivekanand , Qamar Zaheer
December 2018, 13(4):233-239
Objective: The objective of the study was to study the effectiveness of a recommended screening strategy for latent tuberculosis infection (LTBI) in patients with systemic inflammatory rheumatic diseases (SIRDs) treated with biological disease-modifying antirheumatic drugs (bDMARDs). Methods: The study included patients being considered for bDMARD treatment. Screening strategy included screening with “4S symptom complex (current cough, fever, weight loss, and night sweats) for TB,” augmented Mantoux test using ten tuberculin unit (TU) strength simultaneously with QuantiFERON®-TB Gold (QFTG) test. Those with a Mantoux test reading of ≥10 mm induration at 48–72 h and/or with a positive QFTG test, were given TB prophylaxis before initiating bDMARDs. They were followed and monitored for any features of tuberculosis flare. Results: A total of 730 patients (265 rheumatoid arthritis, 400 axial spondyloarthritis [axSpA], 34 psoriatic arthritis, and 31 others) were considered for bDMARDs. Two hundred and sixty-seven (36.6%) were positive for LTBI. They were treated either with isoniazid monotherapy for 6 months or with rifampicin + isoniazid for 4 months. bDMARDs were started 1 month after initiating chemoprophylaxis. Five (0.68%) patients developed active TB disease in the follow-up. In a total of 2930 “control” patients with the same diseases but never having taken bDMARDs, 18 (0.61%) developed active TB disease. The proportion of patients developing active TBI during the same period of follow-up did not differ between those who were and those who were not treated with bDMARDs. None of the study participants had “4S” symptoms. Conclusion: The strategy of clinical screening for active TBI with “4S complex,” standard chest radiograph, and an augmented Mantoux testing (10 TU purified protein derivative, [PPD]) simultaneously with QFTG test for the screening of LTBI, was successful in identifying active TBI in patients treated with bDMARDs.
  3 3,679 355
Assessment of hepatic fibrosis in patients with rheumatoid arthritis on long-term methotrexate therapy using transient elastography
Abhishek Kumar, Vivek Vasdev, Manish Manrai, Aprajita Bhayana, Arun Hegde, MN Arjun, Kunal Kishore
December 2018, 13(4):246-251
Background: Methotrexate (MTX) is has been associated with hepatotoxicity including hepatic fibrosis; however, the incidence of severe hepatic fibrosis or cirrhosis with MTX use has remained a controversial issue. The gold standard test for detecting liver fibrosis has been a liver biopsy, which is an invasive procedure with potentially serious complications. The transient elastography (TE) is a noninvasive method of assessing hepatic fibrosis. The primary objective of this study was to assess the prevalence of hepatic fibrosis associated with long-term MTX therapy in patients with RA and the secondary objective was to assess the correlation of cumulative MTX dose with hepatic fibrosis as assessed by TE using Fibroscan. Methods: In this cross-sectional study patients with RA who had been on MTX treatment for >5 years were included. Hepatic fibrosis was determined by measuring the hepatic stiffness by TE method (by FibroScan) in kilopascal (kPa) in study patients. The hepatic stiffness of the patient group was compared with that of healthy controls. Results: A total of 160 patients and 63 healthy controls were included in the study. The mean age of the patients was 51±10.9 years and there were 139 female and 21 male patients.The median duration of MTX use was 317.5 weeks (range 260, 1302 years). Median MTX cumulative dose was 4225 mg (range 2340, 18,200 mg). Mean hepatic stiffness was 4.8 kPa (SD 1.35) in the patient group and 4.7 kPa (SD 1.07) in the control group (P = 0.550). Cumulative dose or duration of MTX treatment did not correlate with hepatic fibrosis. Conclusions: Severe hepatic fibrosis or cirrhosis as detected by the TE using Fibroscan was uncommon with high cumulative dose of MTX when administered in the low-dose weekly schedule. The cumulative dose of MTX did not correlate with hepatic fibrosis as assessed by FibroScan.
  3 3,238 364
Relevance of elevated microparticles in peripheral blood and synovial fluid of patients with rheumatoid arthritis
Benita N R Michael, Durga Prasanna Misra, KG Chengappa, Vir Singh Negi
December 2018, 13(4):222-228
Introduction: Microparticles (MPs) are submicron sized heterogeneous membrane-bound vesicles released from cells undergoing cell activation or apoptosis. Elevated platelet-derived MPs (PMPs) are reported in rheumatic diseases. We profiled Annexin-V+ MPs and CD61+ MPs in plasma and synovial fluid of patients with rheumatoid arthritis (RA) and their clinical correlates. Methods: Twenty-three newly diagnosed disease-modifying anti-rheumatic drug naïve patients with RA, 17 with osteoarthritis (OA) and 22 healthy controls (HC) were enrolled. Five milliliters of synovial fluid from the knee joint of patients with RA and OA was collected; 5 ml of peripheral blood was collected from patients with RA, OA, and HC. Cell-free synovial fluid and platelet poor plasma samples were stained with Annexin-V-APC and Anti-CD61-BV510 antibodies followed by flow cytometry analysis (FACSAria III) (results expressed as the mean ± standard deviation of % population). Results: Significantly greater levels of synovial fluid MPs (Annexin-V+ MPs) were observed in RA versus OA (P < 0.0001), significantly higher synovial fluid PMPs (Annexin V+ CD61+ MPs) levels in RA compared to HC (P = 0.0472). MPs other than those of platelet origin (Annexin V+ CD61 MPs) were also increased in the synovial fluid of RA patients compared to OA (P < 0.0001). Kruskal–Wallis test revealed the significant difference in the levels of plasma MPs (Annexin-V+), PMPs (Annexin V+ CD61+ MPs), and MPs other than those of platelet origin (Annexin V+ CD61 MPs) between RA, OA, and HC groups (P < 0.0001) with a higher percentage in RA group. Conclusions: Higher levels of Annexin-V+ MPs in both plasma and synovial fluid of RA suggest a role for MPs in the pathogenesis of RA. Elevated plasma PMPs (Annexin V+ CD61+ MPs) in RA may suggest their role in systemic involvement. Furthermore, increased levels of MPs other than those of platelet origin (Annexin V+ CD61 MPs) indicate the necessity to study the MPs from other cell lineages.
  2 2,584 320
Oral manifestations of autoimmune connective tissue diseases
Akshat Pandey, Mimansha Pandey, Ved Prakash Pandey, Vinod Ravindran
December 2018, 13(4):264-272
Autoimmune connective tissue diseases possess difficulty in diagnosis and treatment due to uncertainty in etiology, a wide array of clinical presentation, and unpredictable disease course. Many such diseases like Sjögren syndrome, Rheumatoid arthritis, Systemic Lupus Erythematosus, Systemic Sclerosis, have characteristic oral findings, the identification of which may allow for early diagnosis and treatment. For the purpose of this narrative review we searched the databases such as MEDLINE the Embase and Cochrane library using search terms including “rheumatic” “autoimmune,” “connective tissue diseases,” “dental,” “oral,” and “manifestations” and the names of individual known diseases and also a manual search of bibliographies of these articles and of previously published reviews and animal studies. In this review, we describe the oral manifestation and dental considerations associated with these diseases which will allow the practitioner in holistic management of these patients.
  2 14,676 1,046
Scurvy mimicking juvenile idiopathic arthritis in two pediatric patients
B Harikrishnan, Suma Balan
December 2018, 13(4):273-276
Scurvy, though previously reported from developing countries, is now being increasingly reported from developed countries. Although rare in pediatric population, it is well known to cause lower-extremity pain and refusal to walk in children. Here, we summarize two cases of scurvy in young children who presented with difficulty to walk. Both of them came with a provisional diagnosis of oligoarticular juvenile idiopathic arthritis. The first case underwent extensive evaluation before the diagnosis of scurvy was made. Dietary histories eventually revealed that both had limited intake of fruits and vegetables, as first patient existed on a diet of milk products and a nutritional supplement provided by the state government. The second patient had autism. Radiographic changes of long bones were observed in both patients. Both of them had a Vitamin C level of <0.1 mg/dl. After replacement with Vitamin C, both patients recovered and started to walk again. This case series highlights the importance for rheumatologists to have a higher index of suspicion for scurvy in children presenting with pain and difficulty to bear weight.
  1 2,880 259
Use of biologic response modifiers for the management of ocular inflammatory conditions
Erick Rivera-Grana, Jay Siak, James T Rosenbaum
December 2018, 13(4):259-263
Ocular inflammatory conditions can be challenging to manage due to their prolonged and complicated nature. While the mainstay treatment for most cases is oral or topical corticosteroids, it is very important that physicians know how other medications such as biologic response modifiers (biologics) could be used in certain cases. Through illustrative cases, we discuss how treatment with biologics can be helpful in the management of three challenging patients with ocular inflammatory conditions. We review and discuss, (1) a 60-year-old male with granulomatosis with polyangiitis and bilateral anterior scleritis who required rituximab; (2) a 25-year-old male with refractory, idiopathic, bilateral chronic panuveitis and retinal vasculitis, which was controlled with adalimumab after treatment failure with oral and topical corticosteroids, cyclosporine, and methotrexate; and (3) a 44-year-old female with unilateral blindness and juvenile psoriatic arthritis-related intermediate uveitis, who required adalimumab to control her complication of persistent macular edema. These cases highlight the considerations that are required when clinicians are faced with the need to commence biologic therapy for patients with refractory ocular inflammation.
  1 2,604 257
Pediatric rheumatology
Gummadi Anjani, Surjit Singh
December 2018, 13(4):293-293
  - 1,831 179
Fingerprint abnormalities in systemic sclerosis: Results of a single center pilot study
Kodishala Chanakya, Liza Rajasekhar
December 2018, 13(4):252-254
Background: Fingertip abnormalities in the form of digital ulcers and gangrene is well known in systemic sclerosis (SSc), but little has been described about the frequency and systemic associations of finger print (FP) abnormalities in these patients. Our objective was to study the FP abnormalities in SSc patients and find possible association with digital vasculopathy. Methods: Patients with SSc and SSc overlap with other connective tissue diseases were screened for FP abnormalities using a Standardization Testing and Quality Certification Directorate-certified biometric FP scanner. FP quality assessment was done by recording the National Institute of Standards and Technology FP Image Quality (NFIQ) scores. NFIQ's 5 levels of quality are intended to be predictive of fingerprint matching. NFIQ = 1 indicates high quality and NFIQ = 5 indicates poor quality FPs. Social difficulties due to fingerprint abnormalities were noted. Ten healthy controls were included for comparison. Results: Of 37 patients, 29 with SSc and 8 with overlap syndromes, 15 (40.5%) had FP abnormalities in the form of nonrecognition of at least one finger with a median of 2 fingers (range 1–6). The mean NFIQ score of these patients was 4.5 (poor) while mean NFIQ scores in SSc was 3.8. All FPs of 10 controls were recognized, and the mean NFIQ score was 2.2 indicating a better FPs quality. There was no association of FP abnormalities with digital vasculopathy. Conclusions: In this pilot study, we found that fingerprint abnormalities occur frequently in SSc patients. Documentation of this abnormality should allow the use of other biometric tools for personal identification.
  - 2,623 193
Efficacy of short term non steroidal anti-inflammatory drugs in Indian patients with axial spondyloarthritis
Shubha Bhalla, Shallu Verma, Anand Narayan Malaviya
December 2018, 13(4):255-258
Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered the first-line drugs for axial spondyloarthritis because of their high efficacy in controlling symptoms. However, the review of the literature shows that among Caucasian patients, only ~ 1/3rd with recent disease onset and only ~10% with the long-standing disease achieved partial or complete remission. The present study was, therefore, aimed at finding out how many Indian axSpA patients achieved low-disease activity state or remission over a short period of 12 weeks. Methods: This was a retrospective study including 35 patients, both nonradiographic and radiographic axSpA, classified according to the Assessment of Spondyloarthritis International Society criteria (2009). Information was extracted from the electronic medical records for patients who had only received NSAIDs without any disease-modifying anti-rheumatic drugs or biologicals. The primary objective was to analyze the effect of continuous use of NSAIDs on their disease activity status as measured by the Ankylosing Spondylitis Disease Activity Score (ASDAS)-C-reactive protein (CRP) cutoff values at the baseline as compared to that after 3 months. Results: A total of 31/35 patients continuously treated with NSAIDs for 12 weeks showed statistically significant improvement in their disease activity status as measured by ASDAS-CRP (P < 0.05). A total of 19/35 and 12/35 patients achieved remission (i.e., ASDAS-CRP < 1.3) and low disease state (i.e., ASDAS-CRP<2.1) after 12 weeks of treatment, respectively. A total of 4/35 patients were nonresponders; they were offered biologicals. Conclusion: NSAIDs are effective in reducing ASDAS-CRP disease activity status. The efficacy of NSAIDs observed in this study was much higher than that reported in European/North American patients. The reason for this difference needs further study.
  - 2,253 203
Improving knowledge and awareness regarding rheumatology at the undergraduate level in Indian medical colleges
Ghan Shyam Pangtey, Sameer Gulati, Anu Maheshwari
December 2018, 13(4):217-219
  - 2,276 281
Methotrexate and the liver: Think beyond the drug!
Pallavi Patro, Vikas Agarwal
December 2018, 13(4):220-221
  - 2,975 397
Miles to go before we sleep...........
Vinod Ravindran
December 2018, 13(4):215-216
  - 1,965 272
Complex regional pain syndrome with an unusual aetiology
Punit Pruthi, Pramod Arora, Kunal Bahrani, Manoj Mittal
December 2018, 13(4):277-279
  - 2,236 197
Acute pancreatitis presenting with polyarthritis
Shahanaze Javath Hussain, Deepak Amalnath, Mukta Wyawahare, DKS Subrahmanyam
December 2018, 13(4):280-281
  - 1,708 163
Reena Kumari Sharma, Mudita Gupta, Samriti Sood, Archit Gupta
December 2018, 13(4):282-283
  - 1,817 145
Juvenile eosinophilic fasciitis presenting with polyarthritis and koebner's phenomenon
Zakiya Saleh Al Mosawi, Muneera Jassim Al Hammadi, Batool Abdul Karim Ebrahim, Sara Mathew George
December 2018, 13(4):284-286
  - 2,135 174
Clinical manifestations of chikungunya fever in patients with ankylosing spondylitis
Akshat Pandey
December 2018, 13(4):287-288
  - 1,729 159
Treatment of eosinophilic myositis with mepolizumab
Saadia Waheed, Hafiz Muhammad Zubair, Farishta Waheed
December 2018, 13(4):289-290
  - 1,698 152
Comments on: Use and scope of ultrasonography in rheumatology in India
Sakir Ahmed
December 2018, 13(4):291-292
  - 1,520 127
Clinical utility of anti-cyclic citrullinated peptid and rheumatoid factor in chronic hepatitis B virus infection
Gokhan Sargin, Altay Kandemir
December 2018, 13(4):229-232
Background: It is necessary to distinguish whether musculoskeletal symptoms are associated with rheumatic diseases or hepatitis virus infection. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) may be detected in rheumatic diseases and also during infections. The objective of this study was to evaluate the clinical utility of anti-CCP and RF in patients with chronic hepatitis B virus (HBV) infection. Methods: Ninety-seven patients with chronic HBV infection, 35 patients with rheumatoid arthritis (RA), and 30 healthy controls were included in the study. HBV-DNA, hepatitis B e antigen, anti-HBe, RF, and anti-CCP were evaluated. Results: The rates of positivity for RF and anti-CCP were 14.4% and 4.1% respectively in patients with chronic HBV infection. Arthritis was present in 7 of 97 patients with chronic HBV infection. There was a statistically significant difference for anti-CCP positivity but not for RF positivity between patients with arthritis and without arthritis. No correlation was found between RF and anti-CCP, HBV-DNA, anti-CCP, and HBV-DNA in patients with HBV infection. Conclusions: Anti-CCP positivity was a determinant for polyarthritis in the context of HBV infection. It appears to be a more reliable parameter than RF in differentiating arthritis and nonarthritis group in patients with HBV infection.
  - 2,542 269
Clinical profile and treatment outcome in chronic recurrent multifocal osteomyelitis: Experience from a tertiary care center in Southern India
Sandeep Surendran, Suma Balan
December 2018, 13(4):240-245
Objective: The objective of this study was to describe clinical and radiological features and assess the treatment response in an Indian cohort of chronic recurrent multifocal osteomyelitis (CRMO). Methods: Case records of children who were diagnosed with CRMO between January 2014 and December 2017were reviewed retrospectively. The cases were diagnosed based on the typical history along with magnetic resonance imaging (MRI). Remission was defined as resolution of symptoms along with restoration of functional status and normalization of inflammatory markers. Where available, remission was also corroborated by a repeat MRI. Clinical, radiological and treatment details were compiled. Results: 20 children who were included, all had presented with bone pain. 10 children also has associated synovitis. The mean age at diagnosis was 11.75 years . The average period from the onset of the first CRMO symptoms to the diagnosis was 17.75 months (1–60 months) the most common bones (48%) involved the pelvic bones and femur. The mean number of lesions seen was 5.0. The initial diagnosis made were either of infection related osteomyelitis or juvenile arthritis. Nine of the 20 children had undergone bone biopsies. All 20 patients were initially started on an non-steroidal anti-inflammatory drugs (NSAIDs). Only one boy responded to just NSAIDs with all other needing second-line agents. Three patients were started on pamidronate infusions initially itself (in view of spinal involvement or difficulty in weight-bearing). A total of 15 patients were started on methotrexate as the initial second-line agent. However, four patients did not have disease control with disease-modifying anti-rheumatic drugs and later required pamidronate infusions (n = 3) and anti-tumor necrosis factor agents (n = 1). Conclusion: In CRMO delays in referral and diagnosis may lead to prolonged courses of antibiotics, unnecessary radiation exposure from scans and unwarranted surgical procedures including repeated bone biopsies. MRI helps in early diagnosis and can avoid both unnecessary X-rays and bone biopsies.
  - 2,903 279