Articular Symptoms Research Articles

Upadacitinib for Spondyloarthritis; A new treatment option.

Axial spondyloarthritis, often known as ankylosing spondylitis (AS), is an inflammatory condition that mostly affects the axial skeleton. Axial spondyloarthritis is further subdivided into non-radiographic and radiographic AS. For radiographic axial spondyloarthritis, the male-to-female ratio is two to one, while for non-radiographic axial spondyloarthritis, it is one to one, often manifesting in the third decade of life. Effective treatment for AS includes non-steroidal anti-inflammatory medications (NSAIDs) and TNF blockers. All articular symptoms of AS have been seen to improve significantly when treated with TNF inhibitors such as Etanercept, Adalimumab, Infliximab, Certolizumab, and Golimumab. Upadacitinib, has proven to be significantly efficacious in the management of active non-radiographic axial spondyloarthritis (nr-axSpA), with MRI-based or blood tests displaying objective evidence of inflammation, an increased C-reactive protein, and an unsatisfactory response to Non-steroidal anti-inflammatory drug (NSAIDs). the lack of oral therapy options, and the stigma associated with surgical intervention makes it crucial to offer an unambiguous treatment choice, especially in light of the disease's strong heredity. Thus, Upadacitinib's usage in the treatment of nr-axSpA and its clinical trial is a significant step toward the availability of an internationally-approved medicine for the treatment of nr-axSpA.

Epidemiology and clinical characteristics of psoriatic arthritis-related uveitis in Madrid, Spain.

To describe the epidemiology and clinical characteristics of psoriatic arthritis (PsA) related uveitis in Madrid, Spain. A case series nested in a retrospective single-center cohort of 494 patients with PsA was performed. Patients older than 18years old whit a clinical diagnosis PsA-related uveitis who attended the Ramon y Cajal University Hospital in Madrid, Spain, between 1st January 2017 and 31st December 2019 were included in the study. Epidemiological and clinical data were retrieved from the electronic medical records. Thirteen cases of psoriatic arthritis-related uveitis (6 men and 7 women) were included. PsA-related uveitis showed an incidence of 0.05 cases per 100,000 persons/year (CI95 0.00-0.35), and a prevalence of 2.19 cases per 100,000 persons (CI95 1.24-3.79). The prevalence of active uveitis in the cohort of PsA patients was 2.6%. The first episode of uveitis (mean age of 48.15 ± 15.41years) was anterior and unilateral in 92.31% of the cases. Most of the patients had a recurrent course (69.2%) with 0.92 flare-ups per patient/year (CI95 0.85-0.96). The uveitis preceded the diagnosis of psoriatic arthritis in 62.5% of the patients. In patients with PsA-related uveitis, HLA-B27 was present in 23.1%, HLA-Cw6 in 7.7%. Uveitis is a PsA manifestation that affects roughly 1 in 37 PsA patients, and that may precede the articular symptoms. It generally presents as a unilateral acute anterior uveitis and has a recurrent course. The most frequent observed complications are elevated intraocular pressure and cataracts.

Early detection of cochlear hearing loss in rheumatoid arthritis patients: a cross-sectional study

BackgroundRheumatoid arthritis (RA) is an inflammatory autoimmune disorder that has cardinal articular and peri-articular symptoms. Extra-articular manifestations (EAMs) are also reported among RA patients. In the current study, we assessed hearing function in 50 RA patients. An extensive audiological assessment including pure tone audiometry (PTA), extended high-frequency audiometry (EHFA), tympanometry, and acoustic reflex in addition to the oto-acoustic emission (OAEs) were done.ResultsOur data demonstrates that among the 50 participants with median disease duration of 8 years, about 80% had normal hearing using PTA and EHFA. However, 46% of them had—interestingly—demonstrated absent OAEs, suggesting early stages of cochlear hearing loss.ConclusionWe conclude that rheumatoid arthritis can cause hearing impairment that can be early diagnosed by TEOAEs.

MRI Semi-Quantitative Evaluation of Clinical Features of Cartilage Injury in Patients with Osteoarthritis

This study aimed to investigate the correlation between magnetic resonance imaging (MRI) findings of articular cartilage and clinical symptoms in patients with osteoarthritis (OA). Eighty patients with OA were selected as the study subjects (OA group) and 80 healthy subjects during the same period were also selected as the control group. All subjects underwent knee sagittal PDW-SPAIR, sagittal T1WI-aTSE, sagittal T2WI-TSE, coronal PDW-SPAIR, sagittal 3D-WATSc, and sagittal T2 mapping scans. Thereafter, all subjects underwent clinical assessment. The whole-organ MRI score (WORMS) was adopted for MRI examination and semiquantitative analysis, and the T2 value was calculated. The correlation among T2 value, WORMS, and Western Ontario and Mc Master University OA Index (WOMAC) was then compared and analyzed. The correlation coefficients between T2 values and WORMS in each sub-region of patients with OA were 0.8, 0.55, −0.038, 0.811, and 0.743; the correlation coefficients between WORMS and WOAMC were 0.66, 0.71, 0.46, and 0.88; and the correlation coefficients between T2 values and WOAMC were 0.483, 0.33, 0.282, and 0.636, respectively. There was a significant positive correlation between the results of MRI semiquantitative analysis and clinical symptoms as well as disease severity in patients with OA.

Psychological complications in patients with acromegaly: relationships with sex, arthropathy, and quality of life

PurposeCurrent treatment of acromegaly restores a normal life expectancy in most cases. So, the study of persistent complications affecting patients’ quality of life (QoL) is of paramount importance, especially motor disability and depression. In a large cohort of acromegalic patients we aimed at establishing the prevalence of depression, to look for clinical and sociodemographic factors associated with it, and to investigate the respective roles (and interactions) of depression and arthropathy in influencing QoL.MethodsOne hundred and seventy-one acromegalic patients (95 women and 76 men, aged 20–85 years) among those recruited in a cross-sectional Italian multicentric study were investigated. Each patient filled in three validated questionnaires: AcroQoL, WOMAC (measuring articular pain, stiffness and functionality), and AIMS (evaluating articular symptoms and depression).ResultsA very high (up to 28%) depression rate was detected in acromegalic subjects. Two patients showing pathological AIMS depression scores, committed suicide during the three years observational period. In our population poor psychological status was significantly associated with female sex. Furthermore, a significant strong correlation was found between AIMS depression score and WOMAC score. Both depression and arthropathy-related motor disability turned out to independently contribute with similar strength to the impairment of QoL.ConclusionsWe report a high prevalence of depression in acromegaly, which is associated with female sex and arthropathy. Both depression and arthropathy strongly and independently contribute to the impaired QoL of patients. Our study shows that assessment and monitoring of psychological status is mandatory in acromegaly, also suggesting an inexpensive tool for this assessment.

Gonococcal arthritis: case series of 58 hospital cases.

Extra-genital manifestations of gonococcal infection are rare (0.5-3%). Among them, gonococcal arthritis (GA) is the most frequent, accounting for 30-90% of disseminated infections. Our study aimed to describe all hospital cases of GA in Reunion Island, a French overseas territory. We conducted a retrospective, multicentric, observational study of all cases of certain, probable or possible GA from 2008 to 2020. We identified 58 cases of GA, mostly certain cases (n = 48). Sex ratio was balanced, but men were older than women (51 vs 27years, p < 0.001). A total of 41% had travelled abroad during the previous 3months, mostly in Madagascar or South-East Asia. The most frequently infected joint was the knee, followed by ankle, wrist and fingers or carpal joints. Only 16% of cases had genital symptoms, but 50% had another extra-genital manifestation, mainly skin lesions (40%). Positivity rate of joint puncture was 91%, with a purulent liquid. Only 58% had a positive culture, and 33% had only a positive PCR. There was no 3GC-resistant strain. In comparison with gonococcal infection without arthritis, patients were older and had fewer genital but more extra-genital symptoms. On discharge 60% had persistent articular symptoms. GA represented 18% of all hospitalised septic arthritis cases with microbial identification in 2019. GA is rare but it is important to make an early diagnosis and treat promptly, as joint destruction may be important, leading to persistent symptoms after discharge. PCR use in joint puncture is useful in cases with negative culture.

Recent Advances in Basic and Clinical Aspects of Rheumatoid Arthritis-associated Interstitial Lung Diseases.

Rheumatoid arthritis (RA) is a common autoimmune disease that mainly affects the joints and systemic organs, such as the skin, eyes, heart, gastrointestinal tract, and lungs. In particular, among various pulmonary involvements, interstitial lung disease (ILD) is closely related to the selection of anti-rheumatic drugs and the long-term prognosis of patients with RA. Although the exact pathogenesis of RA-ILD is not well defined, several mechanistic pathways, similar to those of idiopathic pulmonary fibrosis, have been elucidated recently. Conversely, RA-related autoantibodies, including anti-cyclic citrullinated peptide antibody, are detectable in circulation and in the lungs, even in the absence of articular symptoms. RA-ILD can also predate years before the occurrence of joint symptoms. This evidence supports the fact that local dysregulated mucosal immunity in the lung causes systemic autoimmunity, resulting in clinically evident polyarthritis of RA. Because the early diagnosis of RA-ILD is important, imaging tests, such as computed tomography and pulmonary function tests, are being used for early diagnosis, but there is no clear guideline for the early diagnosis of RA-ILD and selection of optimal disease-modifying anti-rheumatic drugs for the treatment of patients with RA with ILD. In addition, the efficacy of nintedanib, a new anti-fibrotic agent, for RA-ILD treatment, has been investigated recently. This review collectively discusses the basic and clinical aspects, such as pathogenesis, animal models, diagnosis, and treatment, of RA-ILD.

Retrospective study of 98 patients with X-linked agammaglobulinemia complicated with arthritis.

We preformed this retrospective study of clinical manifestation, imaging feature, and mutations to describe joint involvement in X-linked agammaglobulinemia (XLA) patients, aimed to provide recommendation for physicians. A total number of 98 XLA patients who have been diagnosed between January 2000 and February 2020 were enrolled and grouped based on whether they developed arthritis and analyzed for the clinical, imaging, and gene mutation data using the t test or the Mann-Whitney test. Forty-five out of 98 patients (45.9%) had joint involvement, 40.8% had symptom prior to the diagnosis of XLA, and 54.1% had no articular symptom. Patients with joint involvement had a higher median diagnostic age of XLA and initial IgG level than patients without it, while their intravenous immunoglobulin was lower (p < 0.05). Knee, hip, and ankle were the most frequent joint, and oligoarthritis (≦ 4 joints) was more common than polyarthritis (88.9% vs 11.1%). Red and tenderness were the most frequent clinical symptoms (80%) with 24.4% reporting limited activity and 8.9% reporting deformity. Imaging data collected from 32 patients indicated that joint effusion (53.3%), synovitis (15.5%), and swollen soft tissue (15.5%) were the most common feature. Seventeen patients were treated by antibiotics plus intravenous immunoglobulin (IVIG) with an effective rate of 70.6%, and 28 patients only received IVIG with an effective rate of 67.9%. In comparison to patients without arthritis who have higher frequency nonsense and frameshift mutation, patients with arthritis had a higher incidence of missense mutation (p < 0.05). High prevalence of arthritis among X-linked agammaglobulinemia patients and subsequent progression through IVIG replacement therapy highlight the importance of timely diagnosis and better management of these patients. Our finding indicated a potential correlation between genotype and phenotype, and further research on the mechanism of arthritis in XLA patients could increase physicians' awareness and improve patients' prognosis. Key Points • This study described the feature of arthritis in XLA patients and indicated a potential correlation between this complication and genotype.

Взаємозв’язок остеопорозу і вегетативної дисфункції при ревматоїдному артриті

Актуальність. Ревматоїдний артрит (РА) належить до найбільш частих запальних хвороб суглобів, і кількість хворих із цією патологією всюди збільшується, що пов’язано з величезними медико-соціальними й економічними збитками. Важлива роль в патогенезі РА відводиться порушенням функції вегетативної нервової системи (ВНС), стан якої тісно пов’язаний з кістковим метаболізмом та мінеральною щільністю кістки. Мета і задачі: оцінити частоту остеопорозу при різному «вегетативному паспорті» хворих на РА, вивчити взаємозв’язки ознак вегетативної дисфункції (ВД) з характером щільності кістки. Матеріал і методи. Обстежено 173 хворих на РА віком від 18 до 79 років (середній вік 46 років), серед яких було 21 % чоловіків і 79 % жінок. Тривалість маніфестації захворювання становила 10 років, серопозитивний за ревматоїдним фактором та протицитруліновими антитілами варіант РА встановлено в 3/4 випадків, позасуглобову (системну) форму хвороби діагностовано в 37 % спостережень. Результати. Остеопороз розвивається у 2/3 від числа хворих на РА, а патогенетичні побудови його пов’язані з наявністю ВД, тяжкість перебігу якої корелює з показниками щільності кістки, причому ті, у свою чергу, — з параметрами варіаційної пульсометрії, активністю й кістково-деструктивними складовими артикулярного синдрому, залежать від вегетативного типу пацієнтів (для хворих з остеопорозом більшою мірою характерна ваготонія, а для інших пацієнтів — симпатотонія). Дисбаланс маркерів кісткового метаболізму у хворих на РА посилює існуючі порушення ВНС, а рівень магнемії має прогностичну значущість відносно ВД. Тяжкість останньої взаємопов’язана з вираженістю остеопорозу, при цьому прогностично несприятливими є показники в крові кальцію більше 80 мг/л і активності лужної фосфатази більше 180 О/л. Висновок. Розвиток остеопорозу взаємопов’язаний не лише з особливостями перебігу суглобового синдрому та екстраартикулярних ознак РА, а й із станом ВНС, яка бере участь в патогенетичних побудовах зменшення щільності кістки і дисбалансі маркерів кісткового метаболізму. У майбутньому буде корисним активне виявлення ВД для подальших своєчасних реабілітаційних заходів.

Lyme Disease: A Zoonosis Tick-Borne Borrelia Bacterium [1/4

Lyme disease, also called Lyme borreliosis, is a polymorphic disease associating cutaneous, neurological, cardiac, and articular symptoms. Lyme disease syndrome is erythema migrans, fever, headaches, tiredness, musculoskeletal pain, and cognitive complaints

Articular manifestations in patients with inflammatory bowel diseases treated with anti-TNF

ObjectiveTo describe and identify factors associated with articular manifestations occurring in patients treated with anti-tumour necrosis factor (TNF) for inflammatory bowel diseases (IBDs).MethodsRetrospective monocentric study, including all patients who received...

Joint involvement in Noonan syndrome. A retrospective paediatric descriptive study.

Noonan syndrome is a rare genetic disorder characterized mainly by congenital heart disease, occasional intellectual disability, and varied orthopaedic, rheumatological and haematologic anomalies. Despite potentially serious functional consequences, joint involvement has been rarely studied in the literature. Our objective was to perform a retrospective study evaluating the prevalence and characteristics of joint involvement in Noonan syndrome. We recorded articular symptoms, including their type and frequency, in patients with Noonan syndrome followed up in French hospitals. Patients were included if the diagnosis was confirmed before the age of 20 based on the van der Burgt criteria or genetic analysis. Data are presented as frequencies or medians (ranges), and patient groups were compared using chi-square or Fisher tests. Seventy-one patients were included from 4 centres. The average age was 12.5 years (range: 2-36). Musculoskeletal pain was found in 18 patients (25%) and joint stiffness in 10 (14%) located in the wrists, elbows, ankles, knees and hips, which was usually bilateral. Only one destructive form was described (multiple villonodular synovitis and a giant cell lesion of the jaw). There were no cases of systemic lupus erythaematosus (SLE) or other autoimmune arthritis. Raynaud's phenomenon was observed in 3 patients. Only 50% of joint complaints led to additional exploration. SOS1 mutations (P<0.05) and treatment with growth hormone (GH) (P<0.05) were the only factors significantly related to musculoskeletal pain. Patients treated with GH did not have more SOS1 mutations. Patients experiencing pain were not more likely to experience stiffness, joint hypermobility, or coagulation abnormalities. Joint manifestations were frequent in Noonan syndrome, predominant in large joints, and rarely explored. Multiple villonodular synovitis is characteristic but rare. Auto-immune disorders were not described in this cohort. A more multidisciplinary approach could be recommended for the early detection of possibly disabling rheumatologic manifestations.

Anti-TNF-alpha-induced lupus in patients with non-infectious uveitis.

Anti-TNF-α-induced lupus (ATIL) is a rare condition considered as a drug-induced lupus (DIL) in patients under anti-TNF-α therapies. Nowadays it is still unclear if ATIL is a classical DIL or represent a distinct syndrome. Some characteristics of DIL have been described specifically associated with patients with lupus-like syndrome receiving anti-TNF-α therapy: the severity of the disease, incidence/prevalence of dsDNA antibodies (anti-dsDNA) and hypocomplementaemia. The objective of this study is to describe the development of ATIL in patients with non-infectious uveitis in a single tertiary center. Retrospective description of a case series. We describe three patients with noninfectious uveitis (NIU) of different etiologies who developed antinuclear antibody (ANA) and anti-dsDNA antibody positivity, arthritis and, in one case, skin lesions under adalimumab treatment. The condition resolved in all of them after adalimumab withdrawal. Corticosteroids were required in one patient, non-steroidal anti-inflammatory drugs in two patients, and hydroxychloroquine in one of them. None required another immunosuppressive drug. A subsequent control of the NIU could continue to be carried out without anti-TNF-α therapy in two patients and in the remaining a switch was made to another anti-TNF-α (golimumab). The current report describes three cases of ATIL in patients with different types of NIU which share some common features: ANA positivity, articular symptoms, and a temporal relationship between symptoms onset and anti-TNF-α treatment. A review of the literature and comparison with the few previous reported ATIL cases was conducted as well.

Beneficial effects of apremilast on genital ulcers, skin lesions, and arthritis in patients with Behçet's disease: A systematic review and meta-analysis.

This study aimed to determine the clinical efficacy of apremilast for oral ulcers (OUs), extra-oral manifestations, and overall disease activity in patients with Behçet's disease (BD). A systematic literature search was performed in PubMed, Embase, Cochrane Library, and Web of Science Core Collection. Studies assessing the treatment effects of apremilast in BD were included. The odds ratios (ORs) of being symptom-free for individual manifestations and mean difference (MD) of Behçet's Disease Current Activity Form (BDCAF) scores were calculated with 95% confidence intervals (CIs) at 12 and 24 weeks using a random-model meta-analysis. Of 259 screened articles, eight were included. After 12 weeks of apremilast treatment the OR of symptom-free was as followings: OUs, 45.76 (95% CI, 13.23-158.31); genital ulcers, 4.56 (95% CI, 2.47-8.44); erythema nodosum, 3.59 (95% CI, 1.11-11.61); pseudofolliculitis, 2.81 (95% CI, 1.29-6.15); and arthritis, 3.55 (95% CI, 1.71-7.40). Furthermore, BDCAF scores at 12 weeks were significantly reduced (MD=-1.38; -1.78 to -0.99). However, the proportion of oral-ulcer-free patients increased at 24 weeks (OR = 14.88; 4.81 to 46.07). The currently accumulated data indicate an improvement in mucocutaneous and articular symptoms by short-term apremilast treatment in patients with BD.

Toxic mechanisms of cigarette smoke and heat-not-burn tobacco vapor inhalation on rheumatoid arthritis

Tobacco combustion exposure worsens rheumatoid arthritis (RA). Non-combustible tobacco devices, as heat-not-burn tobacco (HNBT), are emerging as harm reduction to smokers by releasing nicotine and lower combustible tobacco products. Nevertheless, HNBT toxicity remains unclear. Hence, here we investigated the impacts of the tobacco combustible product (cigarette smoke; CS) or HNBT vapor exposures on antigen-induced arthritis (AIA) in C57BL/6 mice. Animals were exposed to airflow, HNBT vapor, or CS during 1 h/twice a day, under the Health Canada Intense (HCI) smoking regime, between days 14 to 20 after the first immunization. At day 21, 16 h after the last exposures, mice were i.a. challenged and the AIA effects were evaluated 24 h later. CS- or HNBT-exposed mice presented equivalent blood nicotine levels. CS exposure worsened articular symptoms, pulmonary inflammation, and expression of lung metallothioneins. Nevertheless, CS or HNBT exposures reduced lymphoid organs' cellularity, splenocyte proliferation and IL-2 secretion. Additional in vitro CS or HNBT exposures confirmed the harmful effects on splenocytes, which were partially mediated by the activation of nicotine/α7nAchR pathway. Associated, data demonstrate the toxic mechanisms of CS or HNBT inhalation at HCI regime on RA, and highlight that further investigations are fundamental to assure the toxicity of emerging tobacco products on the immune system during specific challenges.

Neutrophil-mediated mechanisms of damage and in-vitro protective effect of colchicine in non-vascular Behçet's syndrome.

Behçet’s syndrome (BS) is a systemic vasculitis with several clinical manifestations. Neutrophil hyperactivation mediates vascular BS pathogenesis, via both a massive reactive oxygen species (ROS) production and neutrophil extracellular traps (NETs) release. Here, we investigated neutrophil‐mediated mechanisms of damage in non‐vascular BS manifestations and explored the in‐vitro effects of colchicine in counteracting these mechanisms. NETs and intracellular ROS production was assessed in blood samples from 80 BS patients (46 with active non‐vascular BS, 34 with inactive disease) and 80 healthy controls. Moreover, isolated neutrophils were incubated for 1 h with an oxidating agent [2,2′‐azobis (2‐amidinopropane) dihydrochloride; 250 nM] and the ability of pure colchicine pretreatment (100 ng/ml) to counteract oxidation‐induced damage was assessed. Patients with active non‐vascular BS showed remarkably increased NET levels [21.2, interquartile range (IQR) = 18.3–25.9 mU/ml] compared to patients with inactive disease (16.8, IQR = 13.3–20.2 mU/ml) and to controls (7.1, IQR = 5.1–8.7 mU/ml, p < 0.001]. Also, intracellular ROS tended to increase in active BS, although not significantly. In active non‐vascular BS, NETs correlated with neutrophil ROS production (p < 0.001) and were particularly increased in patients with active mucosal (p < 0.001), articular (p = 0.004) and gastrointestinal symptoms (p = 0.006). In isolated neutrophils, colchicine significantly reduced oxidation‐induced NET production and cell apoptosis, although not via an anti‐oxidant activity. Neutrophil‐mediated mechanisms might be directly involved in non‐vascular BS, and NETs, more than ROS, might drive the pathogenesis of mucosal, articular and intestinal manifestations. Colchicine might be effective in counteracting neutrophils‐mediated damage in BS, although further studies are needed.

Silent acro-osteolysis in a patient with psoriatic disease and recurrent micro-trauma.

Abstract A 42-year-old woman with a 15-year history of psoriatic disease with skin, nail and joint involvement presented for routine follow-up visit. The patient did not complain of relevant articular symptoms, physical examination was unremarkable excepted for feet nail onychodystrophy and routine laboratory tests were unaltered.

FEVER OF UNKNOWN ORIGIN IN THE ICU: A CASE OF "GOUTY SEPSIS"

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gout associated with systemic inflammatory response syndrome is well described but underappreciated in clinical practice. A prospective analysis of cases admitted to the hospital estimate that 4.5% are associated with fever. We present a case of a critically ill patient with persistent fever of unknown origin diagnosed with polyarticular gout two months into his hospitalization. CASE PRESENTATION: A 67-year-old man with a history of gout, atrial fibrillation, and type 2 diabetes was admitted with a left MCA territory stroke and underwent emergent thrombectomy. He had a period of relative neurologic recovery but became encephalopathic necessitating intubation for airway protection. He developed aspiration pneumonia and progressive renal failure requiring dialysis and underwent percutaneous tracheostomy. Over a period of several weeks, he demonstrated recurrent fevers and persistent leukocytosis and received multiple courses of empiric broad spectrum antimicrobials. Serial cultures, evaluation for atypical pathogens, cross-sectional imaging, lumbar puncture, and autoimmune serologies did not identify an etiology, and he was trialed on bromocriptine for presumed central fever. Repeat physical exam elicited multiple swollen and tender joints. Arthrocentesis was performed and notable for monosodium urate crystals. Acute polyarticular gout was diagnosed, and he was started on dexamethasone and later switched over to anakinra (due to uncontrolled hyperglycemia), with resolution of fevers and articular symptoms. After defervescing his neurologic status significantly improved and he was able to successfully liberate from the ventilator. He was ultimately discharged to rehab on hospital day 112. DISCUSSION: Fever is present in up to 70% of ICU patients and when prolonged is associated with increased morbidity and mortality. This case highlights the difficulty of recognizing non-infectious etiologies of fever in the critically ill patient and the potential harms in a missed diagnosis. These include unnecessary antimicrobial exposure, invasive procedures, and prolonged hospital stay. Sedation and encephalopathy often complicate history-taking and diagnosis. Here, careful physical examination led to the diagnosis of an underappreciated manifestation (fever) of a common condition (gout). While the incidence of gout flares in the ICU is unknown, medical stress, dehydration, and diuretics are frequent triggers and common in critically ill patients. Treatment may be challenging as high rates of renal insufficiency can preclude the use of common therapies such as NSAIDs or colchicine, and steroids may potentiate issues with glycemic control. CONCLUSIONS: Polyarticular gout should be routinely considered as a possible cause of fever in the ICU. REFERENCE #1: Schäfer VS. Systemic Inflammatory Polyarticular Gout Syndrome - Description of a Previously Neglected Entity. JSM Arthritis. 2017;2(2): 1024. REFERENCE #2: Circiumaru B, Baldock G, Cohen J. A prospective study of fever in the intensive care unit. Intensive Care Med. 1999. Jul;25(7): 668-73. REFERENCE #3: Raddatz DA, Mahowald ML and Bilka PJ. Acute polyarticular gout. Ann Rheum Dis. 1983;42: 112-117. DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: 2014-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: 2019-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Advisory Committee Member relationship with Vapotherm, Inc Please note: 2020 Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Tracey Liu, source=Web Response No relevant relationships by Scott Oh, source=Web Response No relevant relationships by Jared Wilkinson, source=Web Response

Зв’язок реологічних властивостей сироватки крові зі станом вегетативної нервової системи при ревматоїдному артриті

Актуальність. Ревматоїдний артрит (РА) належить до найбільш частих запальних хвороб суглобів, і численність таких пацієнтів всюди збільшується, завдаючи величезного медико-соціального й економічного збитку. Важлива роль у патогенезі РА відводиться порушенням функції вегетативної нервової системи (ВНС), стан якої тісно пов’язаний із реологічними властивостями сироватки крові (РВСК). Мета дослідження: оцінити співвідношення «вегетативного паспорта» хворих на РА і вегетативної дисфункції з РВСК при різних варіантах перебігу хвороби. Матеріали та методи. Обстежено 173 хворих на РА у віці від 18 до 79 років (в середньому 46 років), серед яких було 21 % чоловіків та 79 % жінок. Тривалість маніфестації захворювання становила 10 років, серопозитивний за ревматоїдним фактором і антицитруліновими антитілами варіант РА встановлено в 3/4 випадків, позасуглобову (системну) форму хвороби діагностовано в 37 % спостережень. З використанням комп’ютерного тензіометру «PAT2-Sinterface» (Німеччина) визначали поверхневі показники сироватки крові — в’язкість, пружність, натяг, релаксацію й модуль в’язкоеластичності. Результати. «Вегетативний паспорт» визначав інтегральні клініко-лабораторні та інструментальні ознаки РА, при цьому тяжкість вегетативної дисфункції прямо корелювала з темпами прогресування патології суглобів, а у симпатотоніків — з початковими параметрами ревматоїдного фактора в крові й ступенем активності РА. Зміни РВСК супроводжувались збільшенням рівноважного (статичного) поверхневого натягу, що реєструвалося в 70 % випадків. Інтегральний стан міжфазної активності, релаксаційних та в’язкоеластичних характеристик крові визначав тип ВНС і наявність у хворих вегетативної дисфункції (ваготонікам властиві підвищення модуля в’язкоеластичності й зниження поверхневого натягу, симпатотонікам — підвищення поверхневого натягу та зниження поверхневої в’язкості). Параметри РВСК пов’язані з вираженістю вегетативних розладів, а показник поверхневої в’язкості має прогностичну значущість. Висновки. Розвиток вегетативної дисфункції пов’язаний не лише з особливостями перебігу суглобового синдрому і екстраартикулярних ознак РА, а й зі станом ВНС, що бере участь в порушеннях РВСК. У майбутньому буде корисною оцінка стану ВНС для подальших своєчасних реабілітаційних заходів щодо захворювання.

A Closer Look at the Role of Anti-CCP Antibodies in the Pathogenesis of Rheumatoid Arthritis-Associated Interstitial Lung Disease and Bronchiectasis.

Rheumatoid arthritis (RA) is an articular disease with extra-articular manifestations. Pulmonary manifestations are not uncommon and can involve all compartments of the lungs with airway disease in the form of bronchiectasis or bronchiolitis, interstitial lung disease (ILD), pleural effusions and parenchymal lung nodules. The pulmonary features may present synchronously or after the articular disease, but, importantly, it may be the first presentation in 10% of patients in the absence of articular symptoms. Here we discuss the pathogenesis of RA lung involvement, particularly interstitial lung disease and bronchiectasis, focusing on the role anti-CCP antibodies (ACPAs). We highlight the complex interplay among genetic, environmental and immune factors. Furthermore, we explore the relationship of citrullination and smoking as well as the concept of interstitial pneumonia with autoimmune features (IPAF), where patients do not have evidence of another known cause of interstitial pneumonia and have incomplete features of connective tissue disease (CTD). We surmise that the frequency and titers of rheumatoid factor (RF) and ACPAs are increased in bronchiectasis and RA-bronchiectasis compared to RA patients without lung disease. ACPA is associated with more severe disease in both RA-ILD and RA-bronchiectasis even in the absence of articular symptoms. There is no clear prediction of development of articular RA with high ACPA levels in the context of positive ACPA and ILD; however, in RA-bronchiectasis, patients with positive antibodies can develop RA within a year after diagnosis of bronchiectasis. Though the primary focus of this narrative is to highlight the role of ACPA in pathogenesis and clinical practice, we also discuss the current treatment options and trials in RA-ILD and RA-bronchiectasis. Currently, there are no clear treatment guidelines. The treatments are now focusing on using a combination of immunosuppression and antifibrotic agents. Combination treatment targets both the fibrotic and inflammatory components of the disease process. Further studies are needed to identify the use of ACPA as a biomarker to tailor the treatment in RA-ILD and RA-bronchiectasis.