Egyptian Rheumatologist最新文献

Background

Idiopathic granulomatous mastitis (IGM) cases have been increasingly recognized in the context of autoimmune diseases. Hence rheumatologists need to be acquainted with IGM detection and management. Although studies evaluating the response to the emerging immunosuppressive drugs were promising, prospective studies still remain scarce.

Aim of the work

This prospective study aimed to evaluate previous immunosuppressive regimens in the management of IGM cases.

Patients and methods

Seventy seven female IGM patients were followed up, and stratified into 2 groups based on the treatment modalities received: double therapy (Group D, n = 17) who received steroids and methotrexate (MTX), and triple therapy (Group T, n = 60) who received steroids, MTX and mycophenolate mofetil (MMF). Each group was followed up monthly till the end of treatment then every 3 months after stopping treatment for at least 2 years, and the patients' data were recorded on 3 visits (V1, V2, and V3).

Results

Female patients mean age was 33.9±6.2 years. IGM lesions improved in the form of pain relief, resolution of lumps; replacement of inflammatory lesions by granulation tissue, with superiority of triple therapy group T over double therapy in group D regarding significantly shorter duration of treatment (26.5±3.1 vs 18.1±4.4 months)(p < 0.001), and decreased time needed to steroid tapering (14.1±3.6 vs 5.5±5.2 months)(p < 0.001). No recurrence was noticed.

Conclusions

Treatment of IGM has been successful using MTX, or MTX and MMF besides to steroid therapy. Triple therapy was significantly superior with shorter duration of treatment and faster feasibility of steroid tapering.

Aim of the work

To investigate the clinical utility of serum interleukin-26 (IL-26) in patients with systemic lupus erythematosus (SLE).

Patients and methods

The study was carried out on 42 SLE patients and 42 matched controls. SLE disease activity index 2000 (SLEDAI-2K) and Systemic Lupus International Collaborating Clinics Damage Index (SLICC-DI) were assessed. Serum IL-26 was measured.

Results

The mean age of patients was 28.8±11.4 years with 78.6% females. 76.2% of patients were active; 7.1% very-high grade, 45.2% high, 16.7% moderate and 31% mild. 42.9% of patients had nephritis. The mean SLEDAI-2K was 10.4±6.4 and SLICC-DI 1.19±1.15. IL26 level was significantly higher in patients (64±76.4 pg/ml) compared to control (8.7±2.6 pg/ml), in active cases (79.2±81.9 pg/ml) compared to those inactive (15.3±4.8 pg/ml) and in those with nephritis (n = 18) (113.4±92.2 pg/ml) compared to those without (n = 24) (23.1±7.6 pg/ml).IL-26 level was significantly higher among cases receiving both steroids and mycophenolate mofetil than those receiving steroids with azathioprine (p = 0.005). There was a significant negative correlation between IL26 and serum albumin, hemoglobin and complement 3 (C3) levels (p < 0.001, p < 0.001 and p = 0.006 respectively). There was also a significant correlation between IL26 and both SLEDAI-2K (r = 0.95, p < 0.001) and SLICC-DI (r = 0.68, p < 0.001). At cut off value 16.3 pg/ml, IL26 differentiated patients and control; sensitivity 90.5%, specificity 100% (F. 2) and at 20 pg/ml detects active from non-active; sensitivity and specificity 100%.

Conclusion

IL-26 is a promising biomarker of SLE with high sensitivity and specificity. There is a relation of IL-26 with disease activity, damage and nephritis.

Aim of the work: To identify factors associated with damage in systemic lupus erythematosus (SLE) patients. Patients and methods: Based on Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index (SDI) patients were divided into 2 groups; patients with damage (SDI ≥ 1) and without (SDI = 0). Groups were compared regarding demographic features, co-morbidities, cumulative clinical features, treatment and assessment of the modified SLE disease activity index (M−SLEDAI) at baseline and every 6 months till the end of follow up.Results: The study included172 patients; 152 (88.4%) females and 20 (11.6%) males with a mean age of 35.5 ± 8.6 years and disease duration of9.8 ± 1.2 years.Eighty-five (49.4%) patients had damage with a mean SDI of 1.04 ± 1.36. The musculoskeletal, renal and neuropsychiatric systems were damaged in 17.4%, 12.8% and 10.4% of patients, respectively. A comparison between patients with and without damage identified male gender (p = 0.001); older age (p = 0.002), age at onset (p < 0.001); hypertension (p = 0.001); renal (p = 0.007) and neuropsychiatric involvement (p = 0.019); vasculitis (p = 0.044); M−SLEDAI last-visit (p = 0.004), average M−SLEDAI (p = 0.007), number and frequency of visits with active disease (p < 0.001 for both); number of flares (p = 0.001); use and cumulative dose of pulse steroids (p < 0.001 and p = 0.042, respectively), overall cumulative steroid dose (p = 0.007), cyclophosphamide use (p < 0.001), hydroxychloroquine dose (p = 0.029) and less use of leflunomide(p = 0.01) as factors associated with damage. On multivariate regression, the association between damage and male gender (p = 0.02), hypertension (p = 0.016) and number of visits with active disease (p = 0.002) was retained. Conclusion: Male gender, hypertension and prolonged disease activity in SLE contribute to damage occurrence.

Aim of the work

Anti-citrullinated protein antibodies (ACPAs), is a highly specific markers for rheumatoid arthritis, can also be found in psoriatic arthritis (PsA). This work aimed to look into the frequency of rheumatoid factor (RF) and ACPA in PsA and psoriasis patients without clinical evidence of arthritis (PSO), and to correlate findings with demographics, disease characteristics, laboratory findings, and radiological damage in PsA. Patients and methods: The study included 78 PsA patients, 47 PSO patients, and 69 normal controls. Full clinical assessments, RF and ACPA assays, and modified radiological Steinbroker score (Mss) for PsA were performed. Results: The age of the patients was 45.6 ± 8.7 years and the M:F 59:66 (M:F 0.9:1). Positive RF was not significantly different between PsA and PSO groups (p = 0.35), but positive ACPA was significantly more common in PsA patients (p < 0.001) than in PSO and controls. No significant difference was observed between the PSO and controls (p = 0.08). In PsA, RF titers correlated significantly with ESR (p = 0.002), swollen joint count (SJC)(p = 0.02), tender joint count (TJC)(p = 0.02), and mSS (p = 0.001), while in the PSO RF correlated significantly with ESR (p = 0.011) and CRP levels (p = 0.02). In the PsA, ACPA titer significantly correlated with CRP levels (p < 0.001), SJC (p = 0.002), TJC (p = 0.003), mSS (p < 0.001) and PASI (p < 0.001), but with none of these in the PSO. Conclusion: PsA patients have more frequent positive RF and ACPA than PSO patients. ACPA values are significantly correlated with markers of inflammation, swollen and tender joint count and radiological damage in PsA and not in PSO patients.

Aim of the work

To assess serum amyloid A (SAA) level and study its relation to musculoskeletal ultrasound (MSUS) findings and to clinical disease activity indices in rheumatoid arthritis (RA) patients.

Patients and methods

60 RA patients and 60 matched controls were enrolled. Disease activity score-C-reactive protein (DAS-28-CRP) and simplified disease activity index (SDAI) and clinical disease activity Index (CDAI) were determined. MSUS evaluation was done using 12 -joint power Doppler ultrasound (PDUS) score. SAA was analyzed using an enzyme-linked immunosorbent assay.

Results

SAA levels were highly significant in patients (35.1 ± 3.6 mg/l) than in controls (1.6 ± 0.12 mg/l)(p < 0.001). There was significantly higher SAA level among steroid users (56.7 %)(p = 0.001) and a lower level among leflunomide users (30 %)(p = 0.04). SAA and PDUS significantly increased in patients with low disease activity (n = 13) compared to those in remission (n = 10)(p < 0.001). SAA significantly correlated with disease duration (p = 0.004), morning stiffness duration, swollen joint count, tender joint count, rheumatoid factor, anti-cyclic citrullinated peptide, DAS-28-CRP, SDAI, CDAI, erythrocyte sedimentation rate, CRP and total 12-joint PDUS score (p < 0.001). The highest discriminatory ability of active RA and remission was attributed to the combination of SAA, PDUS and CRP (accuracy = 96.7 %, AUC = 0.99; sensitivity 96 % and specificity 100 %).

Conclusion

RA patients have a significantly increased level of SAA which indicates a key pathogenic role in the disease. SAA level is a potentially effective biomarker in the assessment of disease activity in RAand allied to PDUS. Combining SAA, PDUS and CRP provide the highest sensitivity and specificity in discrimination of active RA from remission.

Aim of the work

To screen for the new development of fibromyalgia syndrome (FMS) and anxiety in rheumatic diseases (RDs) patients and control who recovered from coronavirus disease 2019 (COVID-19).

Patients and methods

The study included 200 RDs patients and 100 matched controls with no previous history of FMS and who recovered from COVID-19. The patients’ RDs included rheumatoid arthritis (RA) (n = 50), systemic lupus erythematosus (SLE) (n = 50), juvenile idiopathic arthritis (JIA) (n = 40) and spondyloarthritis (SpA) (n = 60). The fibromyalgia symptom scale (FS), fibromyalgia impact questionnaire (FIQ) and Hamilton Anxiety rating scale were assessed.

Results

The mean age of patients was 35.9 ± 8.5 years with female: male 2.6:1. Fibromyalgia and anxiety were significantly higher in cases than control (22.5 % vs 12 % and 27 % vs16 %, p = 0.002, p = 0.03 respectively). Hypertension, obesity, anxiety, severe COVID-19, frequency of SLE and SpA were significantly higher in patients with FMS compared to those without (31.1 % vs 11.6 %, 68.9 % vs 21.9 %, 84.4 % vs 10.3 %, 48.9 % vs 16.8 %, 31.1 % vs 23.2 % and 40 % vs 27.1; p = 0.002, p < 0.001, p < 0.001, p < 0.001, p = 0.014, p = 0.004 respectively).Severity of COVID-19, diabetes and anxiety were significant predictors of FMS(β = 1.1, p = 0.007; β = 3.03, p = 0.001 and β = 4.44, p < 0.001 respectively). Fibromyalgia increases with increase anxiety grade; the percentage of fibromyalgia was 4.7 %, 50 %, 90 % and 100 % among patients with no anxiety, mild, moderate, and severe anxiety respectively (p < 0.001).

Conclusion

Fibromyalgia is common in RDs patients post-COVID-19. Diabetes, COVID-19 infection severity and anxiety predict the risk of developing post-COVID-19 fibromyalgia. Post-COVID-19 fibromyalgia occurred more in hypertensive, obese, anxious and patients with severe COVID infection.

Background

Despite its potential impact on disease outcome, peripheral nervous (PN) system involvement in systemic lupus erythematosus (SLE) has received little attention.

Aim of the work

To assess the frequency and clinical features of PN system involvement in SLE patients.

Patients and methods

The medical records of 100 patients were revised. Cases with diabetes, hepatitis, vitamin B12 deficiency or carpal tunnel syndrome were excluded. Detailed history, clinical examination and laboratory investigations were recorded. PN events were documented. The SLE disease activity index (SLEDAI) and systemic lupus international collaborating clinics damage index (SLICC-DI) were evaluated.

Results

Patients were 88 females and 12 males (F:M 7.3:1), mean age was 34.2 ± 8.3 years and disease duration 12.7 ± 5.4 years. The frequency of PN system involvement was 8 %; polyneuropathy (n = 5), mononeuritis multiplex (n = 2) and Guillain-Barré syndrome (n = 1). PN was associated with a significantly higher frequency of musculoskeletal (100 %), neuropsychiatric (100 %), pulmonary (62.5 %) and cardiovascular (37.5 %) manifestations as well as Raynaud's phenomenon (37.5 %) and secondary vasculitis (50 %) compared to those without (56.5 %,7.6 %,26.1 %,7.6 %,7.6 % and 12 %;p = 0.02,p < 0.001,p = 0.04,p = 0.03,p = 0.03,p = 0.017 respectively).anti-nuclear antibodies (87.5 % vs 92.4 %) and anti-double stranded DNA (71.4 % vs 69.6 %) positivity were comparable (p > 0.05). SLEDAI and SLICC-DI were significantly increased in patients with PN (26.5 ± 6.36 and 3.75 ± 0.98) compared to those without (11.5 ± 4.76 and 0.61 ± 0.56;p < 0.001 each).

Conclusion

SLE patients with PN involvement had a higher frequency of musculoskeletal, neuropsychiatric, pulmonary and cardiovascular manifestations in addition to Raynaud's and vasculitis. There is a potential association with disease activity and damage. Careful neurological assessment should be included in the workup of SLE patients.

Background

Glucocorticoids (GCs) are alleged as hazardous medications among Egyptian patients and their relatives.

Aim of the work

To highlight the beliefs held about GCs and the effect of these beliefs on adherence to GCs treatment.

Patients and methods

The study included 70 systemic lupus erythematosus (SLE) patients, 70 rheumatoid arthritis (RA) patients and 140 GC-naïve subjects as the control. The demographic and socioeconomic standards of the patients and control as well as the GCs use experience in patients were recorded. GCs perception was assessed by Beliefs about medication Questionnaire (BMQ). Adherence was assessed by Compliance Questionnaire of Rheumatology (CQR).

Results

GCs were significantly perceived as harmful and of low benefit by the control (p < 0.001, p < 0.001, respectively), a beneficial drug by SLE patients, while RA patients had significantly higher harm scores (p = 0.015 and p = 0.003 respectively). Most of SLE and RA patients were non-adherent (57.1% and 65.7%, respectively). Higher general-BMQ harm scores were significantly associated with a lower odd of adherence (OR: 0.25, 95%CI: 0.1–0.63). Reduced OR of necessity > concern was associated with higher socioeconomic standards and maximum oral GCs dose (OR:0.09 and 0.96, respectively). Increased OR of high necessity was significantly associated with number of currently used disease modifying anti-rheumatic drugs (DMARDs) (OR:5.54, p = 0.025). High OR of harm perception was significantly associated with higher socioeconomic standards (OR: 5.12, p = 0.016).

Conclusion

GCs are perceived as pillars in management by SLE and RA patients. Concerns about side effects and dependency are still troublesome. Improvement of patients’ GCs perception impacts level of adherence to treatment.

Background

Mixed cryoglobulinemia syndrome (MCS) is a systemic vasculitis involving skin, joints, kidneys, and peripheral nerves. Hepatitis C virus (HCV) is a well-known etiologic agent. Therapy for HCV has been revolutionized by the approval of direct-acting antiviral (DAA) agents.

Aim of the work

To evaluate the effect of the new DAA treatment on MCS in HCV-infected patients. A prospective study with one year follow-up after induction therapy was undergone.

Patients and methods

Sixty patients with HCV-infection having ≥ 1 extrahepatic manifestations and attending the Rheumatology outpatient at Kasr Alainy for treatment of immune-mediated disease were included. Patients were examined at baseline (before receiving HCV treatment), after six months, and after one year following receiving HCV treatment by sofosbuvir based regimen in specialized centers. All patients were treatment-naïve; Assessment for arthritis, vasculitis and nephritis was performed.

Results

Patients’ mean age was 51.1 ± 8.8 (30–68) years; 44 females and 16 males (F:M 2.8:1). Arthritis was present in 43 (71.6 %), cutaneous vasculitis in 30 (50 %): purpura in 19 (31.7 %), skin ulcers in 18 (30 %), peripheral neuropathy in 16 (26.7 %), and nephritis in 14(23.3 %) patients. Absolute viral clearance was sustained up to one year follow-up. The frequency of patients affected with MCS-related manifestations arthritis, cutaneous vasculitis, peripheral neuropathy, and nephritis tended to decrease. CDAI significantly decreased at six months compared to baseline (p = 0.04). BVAS, numeric rating scale (NRS) for neuropathic pain/paresthesia and proteinuria insignificantly changed from baseline at six months and at one-year (p = 0.28, p = 0.58 and p = 0.96 respectively).

Conclusion

Clinical and immunological responses for MCS-related manifestations were less satisfactory than the virologic response.

Background

Rheumatoid arthritis (RA) is an autoimmune inflammatory disease characterized by synovitis, cartilage damage and bone resorption. Methylation of deoxyribonucleic acid plays a crucial role in repressing gene expression. Receptor activator of nuclear factor-kappa ligand (RANKL) controls bone homeostasis.

Aim of the work

To assess the serum level of RANKL and its gene promoter methylation in RA patients and to determine its association with clinical characteristics and disease activity.

Patients and methods

The study included 40 RA patients and 40 control. The disease activity score (DAS28) was assessed. Frequency of RANKL gene promoter methylation was determined by quantitative methylation specific PCR (QMSP) and serum RANKL level by enzyme linked immunosorbant assay (ELISA).

Results

Patients mean age was 46.8 ± 10.6 years, 36 females and 4 males (F:M 9:1) with median disease duration 4.5 years. Positive rheumatoid factor, anti-cyclic citrullinated peptide and C-reactive protein were present in 65 %, 75 % and 55 % of cases. Methylation percentage of RANKL gene promoter was significantly lower in patients (3.4 %) than in controls (3.7 %)(p = 0.035) while serum level was significantly increased in patients (9.1 ng/ml,5.3–11.8 ng/ml) than in controls (5.7 ng/ml, 4.5–8 ng/ml)(p = 0.003). RANKL methylation frequency was inversely associated with serum level (rs = -0.21,p = 0.06). There was no significant correlation of RANKL serum level and methylation with DAS28 (r = 0.03,p = 0.87 and r = 0.06,p = 0.73 respectively). RANKL serum level (>9.5 ng/ml) and methylation percentage (≤9%) significantly discriminate RA cases from control (sensitivity 47.5 %, specificity 91.9 %; p = 0.001 and sensitivity 100 %, specificity 40 %; p = 0.03 respectively).

Conclusion

RA patients expressed elevated serum RANKL with low methylation.