Egyptian Rheumatologist最新文献

Aim of the work

to investigate and record cardiac side effects of long-term use of hydroxychloroquine (HCQ) in patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).

Patients and methods

This study included 25 patients with RA and 25 with SLE. The study population was either in remission or demonstrated low disease activity, as assessed by the SLE disease activity index 2000 (SLEDAI-2 K) for SLE patients and the disease activity score 28 (DAS28) for RA patients. All patients had been receiving HCQ for at least two years. They did not exhibit any symptoms of coronavirus disease-2019 (COVID-19) and received COVID-19 vaccination. Cardiac adverse events were assessed through electrocardiogram (ECG) and echocardiography (ECHO) examinations.

Results

94 % (n = 47) were females and 6 % (n = 3) were males. The age of the subjects ranged from 20 to 60 years, with a mean age of 41.6 ± 11.2 years. Out of the 50 ECGs assessed, 84 % (n = 42) exhibited no abnormalities. Additionally, all ECGs showed QTc within the normal range. Only 2 RA patients had heart failure characterized by reduced ejection fraction (EF). There was no significant association between the cumulative dosage of HCQ administered in SLE patients and the ECG abnormalities (p = 0.76), QTc (p = 0.228) or EF (p = 0.96). Moreover, there was no significant association between the cumulative dosage of HCQ administered in RA patients and the ECG abnormalities (p = 0.479), QTc (p = 0.85) or EF (p = 0.69).

Conclusion

This study affirms the cardiac tolerability of HCQ in the sustained therapeutic management of SLA and RA patients.

In rheumatic diseases, damage is a major concern and reflects irreversible organ scarring or tissue degradation. Quantifying damage or measuring its severity is an indispensable concern in determining the overall outcome. Damage considerably influences both longterm prognosis and quality of life. Rheumatic diseases (RD) represent a significant health burden. Organ damage is consistently associated with increased mortality. Monitoring damage is critical in the evaluation of patients and in appraising treatment efficacy. Proper assessment and early detection of damage paves way for modifying the disease course with effective medications and regimens may reduce organ damage, improve outcomes and decrease mortality. With the exception of systemic lupus erythematosus and vasculitis, most RDs lack an established damage index making it an ongoing demand to develop effective scores and prediction models for damage accrual early in the disease course. A better understanding of machine learning with the increasing availability of medical large data may facilitate the development of meaningful precision medicine for patients with RDs. An updated spectrum of clinical and radiological damage scores and indices as well as the role of machine learning are presented in this review for the key RDs.

Aim of the work

To evaluate the frequency of cardiovascular (CV) risk factors in psoriatic arthritis (PsA) patients.

Patients and methods

The study included 97 PsA patients and 30 control. Lipid profile and serum homocysteine level were assessed. The endothelium-dependent vasodilation (EDVD) evaluated. The QRISK-3 scale was used to assess CV risk. Disease activity PsA (DAPSA) and psoriasis area and severity index (PASI) were recorded.

Results

Reduced EDVD (<10 %) was significantly more frequent in PsA compared to control (75.3 % vs. 6.7 %, p < 0.001), with significant differences in lipid profile (p < 0.001), homocysteine (p < 0.001), QRISK (p < 0.001), CRP (p < 0.001), DAPSA (p < 0.001), and disease duration (p < 0.001) between PsA patients with reduced and normal EDVD. Average CV risk was 7.7 times higher than in control, and the classical risk factors did not account for the reduced EDVD. Linear regression analysis identified disease duration (β 0.5; OR 1.65, p < 0.001) and disease activity (β 0.09; OR 1.09, p < 0.001) as significant predictors of CV risk in PsA patients. The predictive accuracy of DAPSA (sensitivity 69 %, specificity 86.4 %, 95 % CI: 0.7–0.9; p < 0.001) and disease duration (sensitivity 91 %, specificity 55 %, 95 % CI: 0.95–1; p < 0.001) for CV risk was determined.

Conclusion

A heightened CV risk in PsA patients is highlightened independent of traditional risk factors. The significance of disease activity and disease duration as robust predictors of CV risk in PsA patients is emphasized. The data on hyperhomocysteinemia and its association with endothelial dysfunction emphasize the intricate link between PsA, homocysteine levels, and increased CV risk.

Aim of the work

To present a case of bilateral extensive steroid-associated osteonecrosis (SAON) of femur, tibia and patella that was successfully managed with combined antiresorptive and anabolic bone agents.

Case presentation

A 38-year-old female patient encountered an aggressive coronavirus disease 2019 (COVID-19) infection and was given systemic steroids for six months. The patient then began to experience bilateral lower limb pain. Tenderness over the knee joint margins was found, as well as tenderness of the lower end of the femur, upper tibia, and patella on both sides. The initial plain x-ray of the lower limb bones revealed subtle areas of sclerosis at the proximal metaphysis of tibial bones. The patient did not improve despite stopping steroids and repeated courses of simple analgesics, and the pain became progressive and more intense, to the point where the patient was unable to bear any weight and became wheel chair bound. Magnetic resonance imaging (MRI) was done revealing extensive osteonecrotic lesions involving the distal metaphysis of the femur with posterior extension into the medial and lateral condyles abutting the articular surfaces. Two anti-osteoporotic drugs were used; alendronate, used weekly to inhibit osteoclastic activity and limit the progression of the osteonecrotic lesions and teriparatide, an anabolic agent that increases osteoblasts, resulting in new trabecular and cortical bone growth. Clinical improvement, pain and ambulation, occurred after one month of initiation of treatment and follow up MRI study after 10 months showed marked radiological improvement.

Conclusion

Combined antiresorptive and anabolic bone agents remarkably reversed SAON.

Aim of the work

To investigate whether or not neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) may by indicators of disease activity in systemic lupus erythematosus (SLE) with and without lupus nephritis (LN).

Patients and methods

This research was carried out on 40 adult SLE patients (20 with LN and 20 without) and 20 controls. The NLR and PLR were calculated. The SLE disease activity index (SLEDAI) was assessed.

Results

The mean age of the patients was 36.2 ± 7.6 years, 38 females and 2 males (F:M 19:1), with a disease duration of4.3 ± 1.2 years. The mean SLEDAI was 15.1 ± 4.7 being significantly higher in those with LN (17.5 ± 3.5) compared to those without (12.6 ± 4.6) (p = 0.001). The mean NLR (6.1 ± 2.1) and PLR (236.6 ± 86.9) were significantly increased in patients compared to the control (2.7 ± 1.2 and 125.2 ± 38.8 respectively) (p < 0.001). The NLR and PLR were both significantly related to the serum creatinine (r = 0.35, p = 0.03 and r = 0.5, p = 0.001) and SLEDAI (r = 0.36, p = 0.03 and r = 0.34, p = 0.03 respectively). NLR can significantly predict activity of SLE at cut off 5.6 with a sensitivity 80%, specificity 65% (p = 0.007) and PLR at cut off 217 with sensitivity 75%, specificity 65% (p = 0.035). The NLR can significantly predict LN at cut off 3.6 (sensitivity 80%, specificity 40%; p = 0.007) and PLR at cut off 186 (sensitivity 70%, specificity 60%; p = 0.035).

Conclusion

There is a remarkable link between PLR and NLR with SLEDAI. Thus, both may serve as promising affordable indicators of inflammation in SLE. The notable relation to LN may signal renal involvement in patients with SLE.

Aim of the work: To assess the possible association of ALF transcription elongation factor 1 (AFF1)(rs340630) and signal transducer and activator of transcription 4 (STAT4)(rs7582694) genes polymorphism in Egyptian systemic lupus erythematosus (SLE) cases and their relation with disease activity. Patients and methods: The study included 103 SLE patients and 103 matched controls. SLE disease activity index (SLEDAI-2 K) was assessed. Genotyping was implemented with amplification refractory mutation system polymerase chain reaction (PCR) for AFF1 and allele-specific multiplex PCR for STAT4. Results: The median age of the patients was 38 years, disease duration was 7 years and were 97 females and 6 males (F:M 16.2:1). The median SLEDAI-2 K was 5. AFF1 ‘G’ allele was associated with SLE at 1.52 higher odds ratio (p = 0.042). AFF1 genotypes showed no significant association with existence of SLE (p = 0.08). In SLE patients with A/A genotype, seizures (28.6 %), pleurisy (42.9 %), consumed C3 (85.7 %) and consumed C4 (71.4 %) was significantly more frequent compared to G/A (5.7 %,7.5 %, 56.6 % and 39.6 %) and G/G (0 %, 9.3 %, 39.5 % and 14 % respectively; p = 0.01,p = 0.046,p = 0.04 and p = 0.001). There was a significant association between STAT4 gene polymorphism and the 'C' allele with the occurrence of SLE (p = 0.005 and p < 0.001 respectively). No significant difference was found in clinical manifestations, laboratory investigations or disease activity among STAT4 genotypes. Conclusion: STAT4 polymorphism revealed a significant association with increased SLE risk. However, AFF1 ‘polymorphism showed no significant association with existence of SLE. No significant difference was found in the proportions of AFF1 and STAT4 genotypes among activity grades of SLE.

Background

Dystrophic calcinosis cutis (CC) is rarely observed in systemic lupus erythematosus (SLE).

Aim of the work

To present a case of SLE with a rare cutaneous complication of generalised form of dystrophic CC, most prominent in right infragluteal region, which led to abscess formation.

Case presentation

A 36-years old female with SLE was admitted to the Institute of rheumatology in Belgrade due to worsening of her condition and post-coronavirus disease 2019 (COVID-19) neck vein thrombosis. She was febrile (up to 38.5 °C) and had fatigue, extensive erythema, livedo reticularis and palpable “orange-peel” skin indurations extending symmetrically to infragluteal, suprapatellar, suprapubic and calf regions. Right infragluteal region had skin inflammation signs with fluctuating central lesion. Her laboratory findings were significant for markedly elevated acute phase reactants. Skin ultrasound showed signs of panniculitis with hypodermal hyperechogenicity and posterior acoustic attenuation. Radiography findings were significant for extensive calcifications in the buttock and knee soft tissue areas and it was confirmed on histopathology of the biopsy. She was started with triple antibiotics (cephtriaxone, ciprofloxacin and metronidazole), high corticosteroids, low molecular weight heparin (LMWH) and the abscess was incised. After resolution of skin infection her immunosuppressive therapy was modified considering her SLE condition, vein thrombosis and calcinosis cutis.

Conclusion

Calcinosis cutis is a serious skin complication of SLE as it could predispose to infection. Various pharmacological therapeutic approaches are applied with modest success.

Aim of the work

To investigate the association of interleukin-37 (IL-37)(rs3811047) polymorphism with lupus nephritis (LN) in systemic lupus erythematosus (SLE) patients.

Patients and methods

The case-control study included 206 SLE patients, 97 with LN and 109 without LN, and 240 healthy controls. SLE disease activity index (SLEDAI) was assessed. Genotyping of the IL-37 (rs3811047) polymorphism was done using real time polymerase chain reaction (PCR). A bioinformatic analysis of IL-37 was also performed.

Results

The mean ages of SLE patients were 32.82 ± 10.43 years and female: male was 195:11 (F:M 17.7:1). The SLEDAI was significantly higher in the patients with LN (7.9 ± 6.6) compared to those without (1.9 ± 1.8) (p < 0.001). The AA genotype was more frequently represented in patients with LN (21.6%) compared to those without (7.3%) (p = 0.007), and carriers of AA genotype had four times increased susceptibility to acquire LN compared to GG and GA (OR: 4.1). Likewise, the A allele was more represented in patients with LN (43%) than in those without (30%)(p = 0.004), and the carriers of the A allele had nearly two times more risk of developing LN compared to carriers of G allele (OR: 1.79).The AA genotype was associated with LN susceptibility under the recessive genetic model (p = 0.002). Regression analyses revealed that A allele is an independent risk factor of proteinuria (p < 0.001), disease activity (p < 0.001), consumed C3 (p < 0.001) and C4 (0.003).

Conclusion

The AA genotype of the IL-37 (rs3811047) SNP contributes to the development of SLE in Egyptian patients with a doubled risk of acquiring LN in carriers of the allele A.

Background

Rheumatic disease (RD) patients are risky to severe coronavirus disease-2019 (COVID-19) infection, however, antirheumatic drugs may treat the infection and improve the outcome.

Aim of the work

To describe the clinical manifestations of COVID-19 infection in patients with rheumatic diseases and to investigate the relationship with antirheumatic therapy.

Patients and methods

The study included 215 RD patients. Patients' clinical characteristics and medications received were recorded as well as history of COVID-19 infection.

Results

The RD patients had systemic lupus erythematosus (SLE) (40.5%), rheumatoid arthritis (35.8%), psoriatic arthritis (PsA) (7.4%), ankylosing spondylitis (AS) (5.1%), gout (4.2%), systemic sclerosis (SSc) (3.3%), dermatomyositis (1.9%), Behςets disease (1.4%) and adult-onset Stills disease (0.5%). COVID-19 infection was reported in 124 (57.7%) RD patients. Body-ache was the commonest manifestation (n = 116;93.5%) followed by headache (n = 97;78%), fever (n = 90;72.5%). Infected patients were significantly older, with higher frequency of diabetes and hypertension without significant difference regarding type of RD or treatment except for lower frequency of biologics (n = 7;5.7%) compared to noninfected (n = 22;24.2%)(p < 0.001) patients. 95(76.6%) received home treatment, 27(21.7%) were hospitalized and 2(1.6%) needed intensive care. Hospitalized patients were significantly older (p < 0.001), had longer disease duration (p = 0.017), higher frequency of diabetes/hypertension (p < 0.001) and lower frequency of azathioprine intake (p < 0.034). Recovery period significantly correlated with disease duration (r = 0.197,p = 0.028) and age (r = 0.392,p < 0.001).

Conclusion

Body-aches, headache and fever were the commonest symptoms of COVID-19 infection in RD patients. Most infections were mild. Severe infection was related to older age, longer disease duration, diabetes and hypertension. The RDs and therapy were not associated with COVID-19 infection outcome.

Background

A general comprehension of coronavirus disease-2019 (COVID-19) characteristics in patients with autoimmune and/or rheumatic diseases (ARDs) is required

Aim of the work

To identify COVID-19 infection characteristics in hospitalized patients with ARDs and identify factors contributing to mortality in this population.

Patients and methods

This study enrolled symptomatic ARD patients with COVID-19 infection and a control group of COVID-19 infected subjects matched in age and gender. Clinical and laboratory data were obtained, and chest computerized tomography images were analyzed for severity using COVID-19 Reporting and Data System (CO-RADS) and CT total severity score (CT-TSS).

Results

The study included 50 ARD patients and 29 controls with COVID-19 infection. The ARD patients mean age was 49.8 ± 16.3 years and demonstrated a significant association with fever (p = 0.004), fatigue (p = 0.007), cough (p < 0.001), higher levels of serum bilirubin (p = 0.003), serum creatinine (p = 0.051) and D-dimer (p = 0.001). ARD patients were more frequently admitted to the intensive care unit (40% vs 10.3%, p = 0.005) and tended to have a higher mortality rate (32% vs 13.8%, p = 0.11). Ground glass opacity was the predominant pattern in ARD patients (74% vs 37.9%), while consolidation was predominant in the control (55.2% vs 20%). The respiratory rate (p = 0.002), oxygen saturation (p = 0.005), ICU admission (<0.001) and pulmonary consolidation (p < 0.001), CO-RADS (p = 0.03) and CT-TSS (p < 0.001) were significant predictors of mortality. CO-RADS predicts at cut off 4.5 (sensitivity 56.3%, specificity 70.6%) and CT-TSS at cut off 7.5 (sensitivity 75%, specificity 82.4%).

Conclusions

In-hospital mortality is high in COVID-19 patients with ARDs and many predictors are determined.