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   2020| June  | Volume 15 | Issue 2  
    Online since May 29, 2020

 
 
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EDITORIAL
Interleukin-6 and other cytokine blockade in COVID-19 hyperinflammation
Latika Gupta, Vikas Agarwal, Athimalaipet V Ramanan
June 2020, 15(2):65-69
DOI:10.4103/injr.injr_64_20  
  3,187 361 2
EDITORIALS
COVID-19: An update on vaccine development
Deepak Tripathi, Guohua Yi, Ramakrishna Vankayalapati
June 2020, 15(2):70-72
DOI:10.4103/0973-3698.285394  
  1,604 246 1
REVIEW ARTICLE
Coronavirus disease-19 and rheumatological disorders: A narrative review
Arghya Chattopadhyay, Debashish Mishra, Vikas Sharma, G SRSN K Naidu, Aman Sharma
June 2020, 15(2):122-129
DOI:10.4103/injr.injr_73_20  
The global spread of coronavirus disease-19 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2, which originated from Wuhan, China, is likely to have an impact on the rheumatological practices due to a dilemma in both continuing and initiating immunosuppressive medications. We reviewed the risk stratification of patients with rheumatological disorders, the safety of various anti-rheumatological drugs, and the role of multiple drugs used by the rheumatologists in managing COVID-19. The score-based risk stratification is helpful in therapeutic decision-making such as self-isolation, continuation, or initiation of immunosuppressive therapy. Most of the immunosuppressive therapies need not be discontinued unless there is an overwhelming infection. The treatment interruption should not be made in fear, and there should be shared decision-making in consultation with the patient. The proposed role of different anti-rheumatic drugs such as hydroxychloroquine and tocilizumab in COVID-19 based on some initial uncontrolled trials and case reports will become clearer when the results of various ongoing well-planned studies become available.
  1,632 173 2
ORIGINAL ARTICLES
Impact of ultrasonography-detected pes anserine bursitis on pain and function in patients with primary knee osteoarthritis
Mohamed Mortada, Yomna A Amer, Rabab S Zaghlol
June 2020, 15(2):73-78
DOI:10.4103/injr.injr_185_19  
Background: Pes anserine bursitis (PAB) is one of the most common causes of knee pain. Hence, this study aimed to compare the pain and function among all primary knee osteoarthritis (KOA) patients with or without ultrasonic-detected PAB and the associated clinical and radiological findings. Methods: A single-center cross-sectional study was conducted on 245 patients with primary KOA. The more symptomatic knee examined with musculoskeletal ultrasound (MSUS), were then categorized into two groups according to the presence of PAB; PAB was graded from 0 to 2 on a semi-quantitative scale. Radiological grades of Kellgren–Lawrence were recorded. Pain and functional status was assessed by visual analog scale (VAS), Health Assessment Questionnaire-II (HAQ-II), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Results: A total of 110 (44.9%) patients were diagnosed with PAB where 91 (82.7%) of them had Grade 1 and only 19 (17.3%) had Grade 2. The presence of PAB was statistically significant related (P < 0.05*) with age, VAS, HAQ-II, WOMAC subscales, synovitis, and radiographic Grades 3 and 4. However, there was no statistically significant difference (P ≥ 0.05) between KOA patients without PAB and KOA patients with PAB, regarding sex, body mass index, Baker cyst, and effusion. Conclusion: The presence of PAB on MUS is associated with increased pain and disability in KOA. MSUS should be more widely used to establish the association between PAB and symptom severity and disability among KOA patients.
  1,478 196 -
Prevalence of thyroid dysfunction in patients with systemic lupus erythematosus: A descriptive cross sectional study
Anasuya S Desai, Sara Chandy, Shine J Pakalomattom, Vineeta Shobha
June 2020, 15(2):79-83
DOI:10.4103/injr.injr_165_19  
Background: Estimate of prevalence of thyroid dysfunction in systemic lupus erythematosus (SLE) patients from India is scarce. The present study evaluated the prevalence of thyroid dysfunction and anti-thyroid peroxidase (TPO) antibodies in SLE patients, and the most prominent clinical features of thyroid dysfunction were noted. Materials and Methods: This descriptive, cross-sectional study involved 100 adult patients diagnosed with SLE at a tertiary teaching hospital, Bengaluru, India. The study excluded patients on medications that are known to cause thyroid dysfunctions, those with a history of thyroidectomy, and those with other systemic autoimmune diseases. Results: Among the 100 recruited patients, 99 were females, and most (47%) belonged to the age group of 20–30 years, the median duration of lupus was 24 months. Thyroid dysfunction was observed in 42% (n = 42), and hypothyroidism was the most common thyroid abnormality. None of the patients had hyperthyroidism. Among the patients with thyroid dysfunction, the corresponding number of patients with clinical hypothyroidism and subclinical hypothyroidism were 71% (n = 30) and 29% (n = 12). Of 25 patients with elevated anti-TPO, 48% (n = 12) had clinical hypothyroidism, 20% (n = 5) had subclinical hypothyroidism, and 32% (n = 8) had normal thyroid-stimulating hormone and free T4. Most of the patients with thyroid dysfunction were newly diagnosed, and the predominant symptoms noted were fatigue (75%), hair loss (75%), and joint pain (63%). Conclusions: The prevalence of thyroid dysfunction was found to be higher in SLE than previously published cohorts in India and the rest of the world. It does not affect lupus activity.
  1,217 174 -
Impact of obesity on leptin, leptin receptor gene polymorphism, and some adipokines in egyptian patients with knee osteoarthritis
Adel A H. Abdel-Rahman, Hala E Hamouda, Ibrahim F Zeid, Amal M El-Barbary, Aya A Al-Ashwah
June 2020, 15(2):84-91
DOI:10.4103/injr.injr_71_19  
Aim: The aim of this study was to investigate the role of leptin receptor (LEPR) gene polymorphism and adipokines in the pathogenesis of knee osteoarthritis (OA) in Egyptian female patients. Materials and Methods: Ninety-five Egyptian females were classified into three groups: group I (control): 32 healthy females, Group II: included 30 non obese knee osteoarthritic patients and Group III: included 33 obese knee osteoarthritic patients. Genotyping of rs1137101 at LEPR gene was analyzed using allelic discrimination assay by real-time polymerase chain reaction technique, and then, adipokines and nitric oxide (NO) levels were measured. Results: The frequency of GG genotype was found to be significantly higher in Group III when compared to Group II and controls (26% to 4%, 1%) (P < 0.001), while AA genotype was the most frequent in the control group (75%) (P < 0.001). rs1137101 was correlated with knee OA in the dominant genetic model (GG + GA vs. AA) in Group II (odds ratio = 8, 95% CI [2.6–24.2], P <.001). Moreover, there was a significant increase in serum levels of leptin, resistin, and NO with a concomitant decrease in adiponectin level in Group III as compared to the other two groups confirming the role of these adipokines in OA. Conclusion: Our findings suggested that the genetic variation in rs1137101 is involved in the pathogenesis of both obesity and knee OA in Egyptian female patients. In addition, it seems that adipokines and oxidative stress are important factors linking obesity, adiposity, and inflammation in OA.
  1,040 143 -
End of induction treatment outcomes with a novel cyclophosphamide-based regimen for severe lupus nephritis: Single-center experience from South India
V Jayaprakash, T Dineshkumar, J Dhanapriya, D Rajasekar, R Sakthirajan, T Balasubramaniyan, Anila A Kurien, N Gopalakrishnan
June 2020, 15(2):100-105
DOI:10.4103/injr.injr_160_19  
Background: Cyclophosphamide is commonly used along with pulse steroids for induction immunosuppression treatment of severe forms of lupus nephritis (LN). Renal outcome data for proliferative forms of LN treated with cyclophosphamide from the southern parts of Indian subcontinent are sparse. Subjects and Methods: It was an observational study done for 2 years. All patients with severe proliferative forms of LN were included. They were treated with fixed monthly single doses of 500 mg intravenous cyclophosphamide-based induction therapy along with pulse and oral steroids, as per protocol. Renal remission rates were assessed at the end of 6 months. Adverse events during the induction therapy were documented. Results: The study included 41 patients. Of them, 37 (90.24%) patients were female and 4 (9.75%) patients were male. Nephrotic syndrome was the most common renal presentation (53.66%). The most common histological class was Class IV A (75.61%). At the end of induction therapy, complete renal remission occurred in 31.7% of cases and partial remission in 34.14% of cases. Infections were the most common adverse events that occurred in 48.4% of cases. Conclusions: Renal remission was observed in 65.85% of cases. Fixed low-dose cyclophosphamide-based induction can also be given over a 6-month period. Younger age was a significant risk factor for poor renal outcomes. Failure to achieve renal remission was a risk factor for mortality.
  908 95 -
BRIEF REPORT
Tuberculosis is a significant problem in children on biologics for rheumatic illnesses: Results from a survey conducted among practicing rheumatologists in India
G Chengappa Kavadichanda, Latika Gupta, Suma Balan
June 2020, 15(2):130-133
DOI:10.4103/injr.injr_191_19  
Background: India is endemic for tuberculosis (TB) and the use of immunosuppressants is likely to accentuate the problem. Whilst steroids and conventional disease modifying anti-rheumatic drugs (DMARDs) are believed to increase the risk for tuberculosis, certain biologics such as B cell depleting agents and Interleukin-17 inhibitors are not perceived in the same light. Thus, an attempt was made to capture physicians' perspectives and patterns of biologic DMARDs use in paediatric rheumatology as well as their experience with the occurrence of Tuberculosis in children with rheumatic and musculoskeletal diseases (RMD). Methods: An electronic survey developed on an online cloud-based website (Survey Monkey®) was served to physicians practicing rheumatology in India. Eligible participants (physicians practicing rheumatology) had a week to voluntarily complete the three-minute long questionnaire. While factual set explored observations, opinion set of questions graded perspectives using the Likert scale. Descriptive statistics and figures were obtained from surveymonkey.com. Results: Of the 52 respondents, most of whom were practicing rheumatologists (86.5%), 23 (44.2%) recalled the occurrence of TB after starting biologics. Of these, 13 (25%) encountered this situation in more than one patient. Extra-pulmonary forms of TB were more common (26 of 42, 61.9%), though TB was reported more often while the patient was on biologics than after discontinuing them (n=20 versus 8). Screening strategies varied, with Mantoux, interferon gamma release assay and chest radiographs being used together by most (21, 40%) physicians. Nineteen (52.8%) believed that TB in this setting required longer therapy while 7 (20%) thought adverse drug effects were seen often. Equal number of respondents thought that TB induced diosease flares. Conclusion: TB occurs often in children with RMDs treated with bDMARDs in India. Extra-pulmonary forms are more common and consensus on screening strategies poor. Amongst physicians, there is a perceived risk of prolonged anti-tubercular therapy and adverse drug effects though not of disease flares induced by TB.
  902 74 -
CASE BASED REVIEW
Immunoglobulin G4-related disease, constitutional symptoms, human leukocyte antigen b27 positivity, and sacroiliitis
Shallu Verma, Lubna Khurshid, Prasad Rao Voleti, Anand Narayan Malaviya
June 2020, 15(2):141-144
DOI:10.4103/injr.injr_1_20  
IgG4-related disease (IgG4-RD) is a relatively new clinical entity with protean manifestations that pose diagnostic difficulties especially so if the clinical features are atypical. Here we present a 55-year-old man with back-buttock pains, a knee and ankle arthritis with moderately severe constitutional symptoms. The acute phase reactants were high, and the test for HLA B27 was positive. Spondyloarthritis (SpA) was suspected but, because of the symptom-onset >45 years of age, infection and malignancy were also considered. Detailed investigations including a whole-body positron-emission tomography (PET) scan that showed hypermetabolic soft tissue thickening in the periaortic recess and at the base of the heart encasing root and ascending aorta. Fluorodeoxyglucose (FDG) uptake was also seen in the peripheral zones of the prostate, bilateral, parotid nodes, and in the right sacroiliac joint. A biopsy of the parotid gland nodule confirmed the diagnosis of IgG4-RD. The presence of features of inflammatory back-buttock pains, lower extremity oligoarthritis, good relief to non-steroidal anti-inflammatory drugs (NSAIDs), presence of HLA B27, and an acute involvement of the right sacroiliac joint were typical of spondyloarthritis. However, the moderately severe constitutional symptoms were not typical of SpA. Thus, this patient had both the IgG4-RD as well as SpA. Was the presence of HLA B27 incidental and the sacroiliitis was due to the infiltration of IgG4 cells or, he had true SpA with sacroiliitis and the IgG4 cell infiltration was incidental? This issue has been discussed in depth.
  835 112 -
ORIGINAL ARTICLES
Clinical Outcomes in Patients with Cardiac Lupus: A Retrospective Study
K Maria Koshy, Tarun George, Sohini Das, JV Punitha, Sudha Jasmine Rajan, Bijesh Yadav, Thambu David Sudarsanam, Vijay Prakash Turaka
June 2020, 15(2):116-121
DOI:10.4103/injr.injr_127_19  
Objectives: Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect every organ system. The study aimed to analyze the clinical manifestations, laboratory findings, antibody associations, and clinical outcomes of patients with cardiac lupus. Materials and Methods: Biomedical records of patients admitted during 2014–2017 who had a diagnosis of SLE were reviewed. Using predetermined inclusion criteria patients with cardiac lupus were identified. Disease manifestations, antibody associations, and clinical outcomes were studied. The Cox proportional hazards model was used to study factors associated with mortality. Results: Over a 3-year period, a total of 372 were admitted with a diagnosis of SLE, out of which 59 patients with cardiac lupus were identified. The patients were predominantly female (86.4%), fever and breathlessness were most common symptoms and the median SLE disease activity index score was 18. Myocardial disease (66.1%), pericardial disease (30.5%), and pulmonary artery hypertension (23.7%) were the most common cardiac manifestations. The mean ejection fraction was 46% ±11.4% with left ventricular systolic dysfunction present in 65.5% (n = 36). The inpatient mortality rate was 22% (n = 13). An elevated serum creatinine, elevated creatine Kinase–muscle/brain, neutrophilic leukocytosis, left ventricular systolic dysfunction, noninitiation of hydroxychloroquine, and the presence of neuropsychiatric lupus predicted mortality. On follow-up, 12 of the 13 echocardiograms demonstrated normal findings. Conclusion: Cardiac disease affects a significant proportion of patients with lupus. A high mortality rate as evident from this study, highlights the importance of recognizing the cardiac complications of SLE. Clinicians should diligently search for the same, as early interventions could reduce mortality and morbidity.
  809 97 -
High-resolution esophageal manometry in systemic sclerosis in the indian population: An observational study
S Kartik, Dharmendra Kumar, Gaurav Sikri, Deepanjan Dey, AB Srinivasa, Binit Kumar
June 2020, 15(2):106-110
DOI:10.4103/injr.injr_53_19  
Background: Systemic sclerosis (SSc) is a rare multisystemic autoimmune disorder in which the esophagus is the second most common organ to be affected after the skin, leading to dysmotility. Literature available on esophageal dysmotility in SSc is limited. Moreover, studies explaining the spectrum of esophageal dysmotility in the disease in the Indian population are sparse. Aim: The aim of this study was to characterize esophageal motility disorders in SSc using esophageal high-resolution manometry (HRM) in a representative of the Southwestern Indian population. Methods: Thirty-two SSc patients participated in the study. All of them met the inclusion and exclusion criteria and underwent esophageal HRM at the Gastrointestinal Physiology Laboratory, Department of Physiology, of our center. The findings were interpreted using the Chicago Classification v3.0 criteria. Results: Among patients of SSc with a mean age of 42.25 ± 10.45 years, 19 (59.38%) had “absent contractility (AC),” 3 (9.38%) had “ineffective esophageal motility (IEM),” 3 (9.38%) had “type I achalasia, 1 (3.13%) had “esophagogastric junction outflow obstruction,” and 6 (18.75%) had “normal” HRM findings. The HRM parameter of “basal lower esophageal sphincter pressure” differed significantly between “IEM type I achalasia” (P = 0.043) and “type I achalasia AC” groups (P = 0.032), while “median integral relaxation pressure” of “type I achalasia” groups showed significant difference with “normal, IEM, and AC” groups each (P < 0.001). Conclusions: The findings of the study suggest that varying degrees of esophageal motility disorders are present in SSc using HRM as defined by the Chicago Classification v3.0. Majority (59.38%) of patients had AC, but the rest of them showed other dysmotility patterns.
  789 89 -
Assessment of liver fibrosis by acoustic radiation force impulse elastography in rheumatic disease patients on long-term methotrexate treatment
Arindam Nandy Roy, Gayatri Senapathy, Vijay Kumar Bongu, Yarram Ashok Kumar, Syeda Sana Fatima, Regina Lata Thadigiri
June 2020, 15(2):111-115
DOI:10.4103/injr.injr_155_19  
Background: Methotrexate treatment has been associated with liver fibrosis in patients with rheumatic disease. Liver biopsy has been the gold standard for staging liver fibrosis. Acoustic Radiation Force Impulse (ARFI) imaging is a new accurate, non-invasive method for staging liver fibrosis. Till date, no study has been conducted to evaluate the diagnostic value of ARFI in patients with rheumatic disease undergoing methotrexate treatment. Study Objective: To assess the degree of liver fibrosis with non-invasive ARFI and to compare the findings with the biochemical parameters in rheumatic disease patients taking methotrexate for long duration. Study Method: We reviewed the medical records of rheumatoid arthritis patients who were administered methotrexate for more than 2 years. A total of 151 patients with rheumatic disease, aged ≥ 18 years were enrolled into the study. In addition, 24 healthy subjects (controls) were recruited to compare the ARFI values with that of patients with rheumatic disease. On the day of the ARFI examination, a series of biochemical parameters were also assessed in the patient group. Pre-defined cut-off ARFI values were used to assess the stage of liver disease. Results: The mean ARFI value in the patient group was 1.14. The mean ARFI values of different rheumatic disease patients were 1.13 (0.0), 1.26 (0.19), 1.16 (0.15), 0.945 (0.21) for Rhupus, rheumatoid arthritis, psoriatic arthritis and Sjogren's syndrome, respectively. Biochemical abnormalities (ALT/AST) were seen in 33 (21.85%) patients. Three patients had ARFI abnormalities (1: cirrhosis and 2: early stage fibrosis). There was no correlation between the ARFI values / biochemical parameters and the cumulative dose of methotrexate. However, the ARFI values correlated with the aspartate aminotransferase (AST), alanine aminotransferase (ALT) and AST to platelet ratio index. Liver fibrosis is rare in rheumatoid arthritis patients treated with a high cumulative dose of methotrexate, and is not accurately detected in patients with liver enzyme abnormalities. Conclusion: Considering the risk and benefit ratio of liver biopsy, ARFI may be a useful non- invasive diagnostic tool for the monitoring hepatic toxicity in patients with rheumatic disease undergoing methotrexate treatment.
  745 82 -
CASE-BASED REVIEW
Effect of repetitive transcranial magnetic stimulation in male patients of fibromyalgia
Vikas Kumar Tiwari, Srishti Nanda, Suvercha Arya, Uma Kumar, Renu Bhatia
June 2020, 15(2):134-140
DOI:10.4103/injr.injr_163_19  
Male patients with fibromyalgia are a rarely studied population, yet they remain refractory to conventional medication. Here, we report the effect of repetitive transcranial magnetic stimulation (rTMS) on pain status in four male patients (aged 40.3 ± 8.49 years, right-handed) with fibromyalgia. It was found that the pain intensity reported at baseline was 6.50 ± 1.29 on the 11-point numerical pain rating scale that changed to 2.00 ± 1.15 posttherapy. Minor headache was noted in the 1st week of the therapy. rTMS could be beneficial for pain relief in male patients with fibromyalgia. Future investigations may focus on investigating more treatment options, such as rTMS, for male patients with fibromyalgia.
  746 77 -
IMAGES IN RHEUMATOLOGY
Scurvy presenting as unilateral knee joint contracture
Harikrishnan Bhaskaran, Suma Balan
June 2020, 15(2):145-146
DOI:10.4103/injr.injr_194_19  
  588 87 -
ORIGINAL ARTICLE
Rheumatology practice and training in India – A perspective from rheumatology consultants
Durga Prasanna Misra, Vinod Ravindran, Aman Sharma, Anupam Wakhlu, Vir Singh Negi, Ved Chaturvedi, Vikas Agarwal
June 2020, 15(2):92-99
DOI:10.4103/injr.injr_42_20  
Background: We surveyed rheumatology consultants regarding their perceptions about rheumatology practice and training in India. Materials and Methods: A structured questionnaire was administered during two national rheumatology meetings to evaluate practice settings and demographic characteristics of patients seen. We also assessed perceptions regarding junior doctors, auxiliary health professionals (AHPs), ancillary facilities (daycare, intra-articular injections, musculoskeletal ultrasound [MSKUS]), and possible government-driven strategies for improving rheumatology care delivery. Results: The response rate was 56% (70/125); 68 complete responses were further analyzed. Most respondents were in the private sector (56/68), had been in practice for a mean of 11.5 (±8.4) years, attended to a mean of 150 (±91) patients every week, a majority of whom were educated upto intermediate level and belonged to the middle class. About 60% had junior doctors to assist them in care delivery; 82.5% (52/63) felt that junior doctors had limited competence in managing rheumatic diseases. More than 90% felt the need for AHPs in the clinic, although less than one-half had access to such personnel. Most utilized ancillary services like intra-articular injections (97%), daycare facilities for infusions (92%), and MSKUS (71%). More than 90% respondents felt that government-funded programs for the management of rheumatic diseases, coupled with a structured referral system, would be useful. Conclusion: Rheumatology practice in India may improve by better training junior doctors in skills related to rheumatology at the undergraduate and postgraduate internal medicine levels. The development of specialist AHPs may help enhance service delivery. Government programs for community management of rheumatic diseases and management guidelines suited to the needs of a developing economy majorly reliant on out-of-pocket expenditure for healthcare are significant areas for development.
  498 111 -
BOOK REVIEWS
Improving communications in healthcare
Vinod Ravindran
June 2020, 15(2):147-148
DOI:10.4103/injr.injr_78_20  
  372 72 1