Elevated Erythrocyte Sedimentation Rate Levels Research Articles

Laboratory features and pharmacological management of early and late-onset primary Sjögren’s syndrome

BackgroundPrimary Sjögren’s Syndrome (pSS) is a systemic chronic autoimmune disorder that contributes to dry mouth (xerostomia) and eyes (xerophthalmia). It mainly affects females between 40 and 60 years old. So far, there is no treatment to cure SS; however, there is a list of medications that can ameliorate the symptoms. In addition, there has been no single test until now to detect pSS, but clinical and immunological investigations are applied as diagnostic tools. Therefore, this study aimed to explore the characteristics of pSS in Saudi patients based on the onset of the disease through laboratory findings and pharmaceutical management.MethodologyThis retrospective study examined diagnosed patients with pSS between 2018 and 2023 from the National Guard Hospital, Saudi Arabia. Data of pSS patients was categorized into two groups: early (under 40 years old) and late-onset (40 years old and above). Data on demographic information, mortality rate, and blood tests such as complete blood count (CBC), creatinine, erythrocyte sedimentation rate (ESR), and vitamin levels, in addition to prescribed medications, were collected from the patient’s medical record. Chi-square and t-tests were mainly used, and statistical significance was determined at a P-value less than 0.05.ResultsA total of 453 patients were included in the study, where the early-onset group comprised 136 and the late-onset group comprised 317 patients. The mean age of the early and late onset was 34.2 and 60.4, respectively. ESR was significantly higher in the early (46.3 mm/hr) and late-onset (49.8 mm/hr). The most common medication used by all pSS patients was hydroxychloroquine. However, artificial tears were mainly observed in the late-onset group. Other medications, such as pilocarpine, methotrexate, and azathioprine, were prescribed to pSS patients to a lesser extent.ConclusionThis study suggests that the onset of pSS could occur even before the age of 40 among Saudi citizens. Notably, elevated ESR levels appeared to be a feature of pSS, which was consistent with other previous findings. The variability of some medications between early-onset and late-onset pSS may indicate disease progression. However, further investigations are required to confirm this observation.

Clinical characteristics of flares in patients with rheumatoid arthritis after total hip and total knee arthroplasty.

Clinical characteristics of flares in patients with rheumatoid arthritis after total hip and total knee arthroplasty.

Biochemical, Serological and Immunological Tests for Diagnosis of Coronavirus Disease 2019 (COVID-19) Patients: A Comprehensive Systematic Review and Meta-analysis.

Recent studies have suggested the role of primary laboratory tests in addition to clinical symptoms for patients suspected to have coronavirus disease 2019 (COVID-19), which play a significant role in the diagnosis of COVID-19. However, the results of these studies are contradictory. The present study was conducted to evaluate biochemical, serological, and immunological tests for the diagnosis of COVID-19 patients. This study was presented in accordance with the PRISMA protocol. This protocol is registered with the code CRD42019145410 in PROSPERO. We conducted a comprehensive literature search in databases, including Web of Science, PubMed/Medline, CINAHL Scopus, Cochrane Library, EMBASE, Science Direct, and EBSCO to find citations from the beginning of January 2019 until the beginning of April 2020 without any restrictions. Finally, 51 studies, including 5,490 COVID-19 patients, were included in the present metaanalysis. The prevalence of different factors observed in laboratory findings was as follows: the prevalence of lymphopenia in patients with COVID-19 accounted for 51.6% (95% CI: 44.0-59.1), elevated C-reactive protein (CRP) was 63.6% (95% CI: 57.0-69.8), elevated erythrocyte sedimentation rate (ESR) was 62.5% (95% CI: 50.1-73.5), elevated tumor necrosis factor alpha (TNFα) was 28.7% (95% CI: 9.0-62.1), elevated serum amyloid-A level was 74.7% (95% CI: 50.0-89.7), elevated procalcitonin level was 72.6% (95% CI: 58.1-83.5), elevated interleukin-6 level was 59.9% (95% CI: 48.2-70.5), reduced CD3 level was 68.3% (95% CI: 50.1-82.2), reduced CD4 level was 62.0% (95% CI: 51.1- 71.6), elevated lactate dehydrogenase (LDH) level accounted for 53.1% (95% CI: 43.6-62.4), elevated brain natriuretic peptide (BNP) accounted for 48.9% (95% CI: 30.4-67.7), reduced albumin and reduced pre-albumin levels in patients with COVID-19 were estimated to be 54.7% (95% CI: 38.1-70.2) and 49.0% (95% CI: 26.6-71.8), and D-dimer level was 44.9% (95% CI: 31.0-59.6). The results show lymphopenia, elevated ESR level, elevated CRP level, elevated serum amyloid-A, elevated TNFα, elevated procalcitonin level, elevated interleukin-6 level, reduced CD3, reduced CD4, elevated BNP, elevated LDH, reduced albumin, reduced pre-albumin, and elevated Ddimer levels as the most common findings at the time of admission.

High inflammatory burden predicts cardiovascular events in patients with axial spondyloarthritis: a long-term follow-up study.

Background:Axial spondyloarthritis (axSpA) patients are at higher risk of cardiovascular (CV) disease (CVD) than the general population, partly due to consequences of inflammation or its treatment. But relationship between inflammation in axSpA and cardiovascular events (CVE) is unknown.Objectives:To examine whether inflammatory burden over time can predict CVE independent of baseline CV risk factors in axSpA patients.Design:A cohort analysis was performed in patients who had been recruited since January 2001. The primary outcome was a first CVE occurring between January 2001 and December 2020.Methods:Three CVD risk scores were computed at baseline. The performance of the original and modified (*1.5 multiplication factor) CV risk algorithms were assessed. Time-varying Cox proportional hazard models and Kaplan–Meier survival analysis were used to assess whether inflammatory burden (Bath ankylosing spondylitis disease activity index [BASDAI] and inflammatory markers), nonsteroidal anti-inflammatory drugs (NSAIDs) and disease modifying antirheumatic drugs (DMARDs) can predict the development of first CVE.Results:463 patients (35 [26–45] years, male: 360 [77.8%]) were recruited. After a median follow-up of 12 (7–19) years, 61 patients (13.2%) experienced a first CVE. Traditional/modified CV risk scores underestimated CV risk. Erythrocyte sedimentation rate (ESR) ⩾ 20 mm/h was associated with a significantly higher risk of CVE during follow-up (HR: 2.07, 95%CI [1.10, 3.98], p = 0.008). Active disease as indicated by a rising BASDAI also showed positive trend towards a higher risk of developing CVE over time. After adjusting for CV risk scores in the multivariable models, high ESR level (ESR ⩾ 20 mm/h) over time remained significantly associated with a higher risk of developing CV events.Conclusion:Increased inflammatory burden as reflected by elevated ESR levels (ESR ⩾ 20) was associated with increased risk of CVE, while the use of NSAIDs and DMARDs were not.

Elevated ESR and CRP Prior to Second-Stage Reimplantation Knee Revision Surgery for Periprosthetic Joint Infection Are Associated with Increased Reinfection Rates.

Although two-stage revision surgery is considered as the most effective treatment for managing chronic periprosthetic joint infection (PJI), there is no current consensus on the predictors of optimal timing to second-stage reimplantation. This study aimed to compare clinical outcomes between patients with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) prior to second-stage reimplantation and those with normalized ESR and CRP prior to second-stage reimplantation. We retrospectively reviewed 198 patients treated with two-stage revision total knee arthroplasty for chronic PJI. Cohorts included patients with: (1) normal level of serum ESR and CRP (n = 96) and (2) elevated level of serum ESR and CRP prior to second-stage reimplantation (n = 102). Outcomes including reinfection rates and readmission rates were compared between both cohorts. At a mean follow-up of 4.4 years (2.8-6.5 years), the elevated ESR and CRP cohort demonstrated significantly higher reinfection rates compared with patients with normalized ESR and CRP prior to second-stage reimplantation (33.3% vs. 14.5%, p < 0.01). Patients with both elevated ESR and CRP demonstrated significantly higher reinfection rates, when compared with patients with elevated ESR and normalized CRP (33.3% vs. 27.6%, p = 0.02) as well as normalized ESR and elevated CRP (33.3% vs. 26.3%, p < 0.01). This study demonstrates that elevated serum ESR and/or CRP levels prior to reimplantation in two-stage knee revision surgery for chronic PJI are associated with increased reinfection rate after surgery. Elevation of both ESR and CRP were associated with a higher risk of reinfection compared with elevation of either ESR or CRP, suggesting the potential benefits of normalizing ESR and CRP prior to reimplantation in treatment of chronic PJI.

Persistence with Early-Line Abatacept versus Tumor Necrosis Factor-Inhibitors for Rheumatoid Arthritis Complicated by Poor Prognostic Factors.

Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by joint swelling and destruction that leads to severe disability. There are no clear guidelines regarding the order of therapies. Gathering data on treatment patterns outside of a clinical trial setting can provide useful context for clinicians.Objectives: To assess real-world treatment persistence in early-line abatacept versus tumor necrosis factor-inhibitors (TNFi) treated patients with RA complicated by poor prognostic factors (including anti-cyclic citrullinated peptide antibodies [ACPA] and rheumatoid factor [RF] seropositivity).Methods: We performed a multi-center retrospective medical record review. Adult patients with RA complicated by poor prognostic factors were treated with either abatacept or TNFis as the first biologic treatment at the clinic. Poor prognostic factors included ACPA+, RF+, increased C-reactive protein levels, elevated erythrocyte sedimentation rate levels, or presence of joint erosions. We report 12-month treatment persistence, time to discontinuation, reasons for discontinuation, and risk of discontinuation between patients on abatacept versus TNFi. Select results among the subgroup of ACPA+ and/or RF+ patients are presented.Results: Data on 265 patients (100 abatacept, 165 TNFis) were collected. At 12 months, 83% of abatacept patients were persistent versus 66.1% of TNFi patients (P=0.003). Median time to discontinuation was 1423 days for abatacept versus 690 days for TNFis (P=0.014). In adjusted analyses, abatacept patients had a lower risk of discontinuing index treatment due to disease progression (0.3 [95% confidence interval (CI): 0.1-0.6], P=0.001). Among the subgroup of ACPA+ and/or RF+ patients (55 abatacept, 108 TNFis), unadjusted 12-month treatment persistence was greater (83.6% versus 64.8%, P=0.012) and median time to discontinuation was longer (961 days versus 581 days, P=0.048) in abatacept versus TNFi patients.Discussion: Patients with RA complicated by poor prognostic factors taking abatacept, including the subgroup of patients with ACPA and RF seropositivity, had statistically significantly higher 12-month treatment persistence and a longer time to discontinuation than patients on TNFis.Conclusions: In a real-world setting, RA patients treated with abatacept were more likely to stay on treatment longer and had a lower risk of discontinuation than patients treated with TNFis.

Persistence with Early-Line Abatacept versus Tumor Necrosis Factor-Inhibitors for Rheumatoid Arthritis Complicated by Poor Prognostic Factors

Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by joint swelling and destruction that leads to severe disability. There are no clear guidelines regarding the order of therapies. Gathering data on treatment patterns outside of a clinical trial setting can provide useful context for clinicians. Objectives: To assess real-world treatment persistence in early-line abatacept versus tumor necrosis factor-inhibitors (TNFi) treated patients with RA complicated by poor prognostic factors (including anti-cyclic citrullinated peptide antibodies [ACPA] and rheumatoid factor [RF] seropositivity). Methods: We performed a multi-center retrospective medical record review. Adult patients with RA complicated by poor prognostic factors were treated with either abatacept or TNFis as the first biologic treatment at the clinic. Poor prognostic factors included ACPA+, RF+, increased C-reactive protein levels, elevated erythrocyte sedimentation rate levels, or presence of joint erosions. We report 12-month treatment persistence, time to discontinuation, reasons for discontinuation, and risk of discontinuation between patients on abatacept versus TNFi. Select results among the subgroup of ACPA+ and/or RF+ patients are presented. Results: Data on 265 patients (100 abatacept, 165 TNFis) were collected. At 12 months, 83% of abatacept patients were persistent versus 66.1% of TNFi patients (P=0.003). Median time to discontinuation was 1423 days for abatacept versus 690 days for TNFis (P=0.014). In adjusted analyses, abatacept patients had a lower risk of discontinuing index treatment due to disease progression (0.3 [95% confidence interval (CI): 0.1-0.6], P=0.001). Among the subgroup of ACPA+ and/or RF+ patients (55 abatacept, 108 TNFis), unadjusted 12-month treatment persistence was greater (83.6% versus 64.8%, P=0.012) and median time to discontinuation was longer (961 days versus 581 days, P=0.048) in abatacept versus TNFi patients. Discussion: Patients with RA complicated by poor prognostic factors taking abatacept, including the subgroup of patients with ACPA and RF seropositivity, had statistically significantly higher 12-month treatment persistence and a longer time to discontinuation than patients on TNFis. Conclusions: In a real-world setting, RA patients treated with abatacept were more likely to stay on treatment longer and had a lower risk of discontinuation than patients treated with TNFis.

Polymyalgia rheumatica: A case series from Colombia and analysis of Latin America

ObjectivePolymyalgia rheumatica (PMR) is the most common inflammatory disease in patients over 50 years. Information about the disease in Latin America (LATAM) is scarce. We aimed to evaluate a group of Colombian patients with PMR and to conduct a systematic review of PMR in LATAM. MethodsA multicentric retrospective study was performed. Medical records of 256 PMR patients were evaluated. Patients were divided into two groups, those fulfilling the 2012 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria for PMR and those who did not (i.e., clinical diagnosis). A systematic literature review and meta regression was performed comparing Colombian vs LATAM patients. ResultsFrom 256 patients, 145 (56.6%) fulfilled the 2012 EULAR/ACR criteria, and 111 (43.3%) were classified by clinical diagnosis. Inflammatory bilateral shoulder pain, pelvic girdle aching, morning stiffness >45 min, elevated erythrocyte sedimentation rate (ESR), and C-reactive protein (CPR), and Methotrexate (MTX) prescription were more common in the 2012 EULAR/ACR group. None of the included patients presented overt polyautoimmunity (PolyA), whereas up to 24% exhibited latent PolyA. In addition, these patients showed high frequency of malignancy (7.59%). In the meta regression analysis, Colombian patients exhibited lower ESR levels, and were less likely to develop giant cell arteritis (GCA) as compared to the rest of LATAM data. ConclusionPatients with PMR in LATAM exhibit similar phenotypes from other cohorts worldwide. Malignancy, GCA and latent PolyA should be considered in the routine clinical follow-up of patients with PMR.

Risk Factors of Bone Loss in Spondyloarthritis

We aimed to determine the bone mineral status in patients with spondyloarthritis (SA), and to assess the impact of parameters associated with bone loss on bone mineral density (BMD). Seventy-five patients (62 men) with SA fulfilling the modified New York criteria were included in a cross-sectional study during one year. BMD was assessed in all patients using dual-energy X-ray absorptiometry. The patient’s average age was 36.8 years. Sixty-five patients (86.6%) had bone loss. The lumbar spine was the site most affected by osteoporosis (37%). Bone loss was significantly associated with low BMI, peripheral joint involvement, active disease (high ASDASESR and BASDAI), vitamin D insufficiency, elevated erythrocyte sedimentation rate (ESR) and c-reactive protein, as well as high BASRI, high BASMI, and with the use of csDMARDs or anti-TNF alpha therapy. The disease activity, biologic inflammation, low vitamin D level, peripheral joint involvement, and structural damage were the major factors that induce bone loss in SA patients. Multivariate analysis showed that only high ESR level (AOR 19.9, 95% CI) and peripheral arthritis (AOR 14.5, 95% IC) were independent risk factors of bone loss. Our study shows that bone loss was a multifactorial complication of SA.

Factors associated with blood loss in ankylosing spondylitis patients with hip involvement undergoing primary total hip arthroplasty: a cross-sectional retrospective study of 243 patients

BackgroundTotal hip arthroplasty (THA) can cause considerable blood loss and perioperative transfusion in ankylosing spondylitis (AS) patients. This study aimed to identify the factors related to blood loss in AS patients with hip involvement undergoing THA.MethodsWe analyzed 243 AS patients with advanced hip involvement undergoing primary THA from 2012 to 2017. Bilateral THA was performed by a one-stage operation during one general anesthesia session. The patients were divided into three groups according to the grade of blood loss, as determined by the Advanced Trauma Life Support hypovolemic shock classification system. Ordinal logistic regression was used to identify factors associated with blood loss in the patients.ResultsThe proportion of patients who were male, underwent bilateral THA, had a hip range of motion (ROM) = 0°, had a BASRI-hip score of 4, underwent iliopsoas and adductor release, and underwent autologous or allogenic transfusion increased significantly with the grade of blood loss, while that of the patients who received tranexamic acid (TXA) decreased significantly (P < 0.05). The preoperative hemoglobin (Hb) level, hematocrit level, and operating time also increased significantly with the grade of blood loss (P < 0.05). The ordinal logistic regression results identified the factors related to blood loss during THA in AS patients with hip involvement to be the male sex (odds ratio [OR] = 3.287; 95% confidence interval [CI] 1.022, 10.567), bilateral THA (OR = 13.896; 95% CI 4.950, 39.011), hip ROM = 0° (OR = 2.513; 95% CI 1.277, 4.946), an elevated erythrocyte sedimentation rate (ESR) level (OR = 3.042; 95% CI 1.320, 7.014), an elevated preoperative Hb level (OR = 1.043; 95% CI 1.017, 1.070), a long operating time (OR = 1.009; 95% CI 1.003, 1.016), and the administration of TXA (OR = 0.252; 95% CI 0.134, 0.472).ConclusionsThe male sex, bilateral THA, a hip ROM = 0°, an elevated ESR level, a high preoperative Hb level, and a long operating time are risk factors associated with blood loss in AS patients with hip involvement undergoing THA, while the administration of TXA is a protective factor. These results might help determine the risk of bleeding in the perioperative assessment and develop more efficient blood management strategies for THA in AS patients with hip involvement.

Retrospective study of the differential diagnosis between cryptogenic multifocal ulcerous stenosing enteritis and small bowel Crohn\u2019s disease

BackgroundBeing a rare disease, cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is easily misdiagnosed as small bowel Crohn’s disease (SBCD).AimsThis study was aimed to compare clinical features of CMUSE to SBCD.MethodsFourteen patients with CMUSE and 61 patients with SBCD were retrospectively analyzed.ResultsHematochezia was more frequent in CMUSE patients (10, 71.4% vs 23, 37.7%, P = 0.022), while diarrhea was more common in SBCD patients (23, 37.7% vs 0, 0.0%, P = 0.015). More patients with CMUSE developed intestinal stenosis than with SBCD (14, 100% vs 37, 60.7%, P = 0.011). 30 (50.0%) SBCD patients and none CMUSE patients had an elevated erythrocyte sedimentation rate level (P = 0.001). Extra-enteric findings found by computed tomography enterography were significantly more prevalent in SBCD patients than in CMUSE patients (25,71.4% vs 3,25%, P = 0.013). Longitudinal ulcers found by endoscopy were more common in SBCD patients (16, 37.2% vs 0, 0.0%, P = 0.041), while circumferential ulcers were more common in CMUSE patients (6, 54.6% vs 8, 18.6%, P = 0.041). All ulcers observed in CMUSE patients were within mucosal and submucosal layers, but 8 (44.4%) SBCD patients had deep ulcers that reached beyond submucosal layers (P = 0.003). Ulcers were located at strictures in 9 (90.0%) CMUSE patients but only in 1 (5.6%) SBCD patient (P = 0.000).ConclusionsGastrointestinal symptoms, erythrocyte sedimentation rate levels, radiologic, endoscopic and pathologic features help to distinguish CMUSE from SBCD.

Erythrocyte sedimentation rate as an independent prognostic marker for mortality: a prospective population-based cohort study.

A very high erythrocyte sedimentation rate (ESR) is usually an indication of underlying pathology. Additionally, a moderately elevated ESRmay also be attributable to biological ageing. Whether the ESR is a prognostic factor for mortality, regardless of age, has been scarcely investigated. Therefore, the objective was to analyse the association between elevated ESR levels and the risk of mortality in a prospective cohort of the general population. We studied data from the Rotterdam Study (1990-2014). ESR levels were measured at baseline and individuals were followed until death or end of study. Associations between moderately (20-50mmh-1 ) and markedly (>50mmh-1 ) elevated ESR levels and all-cause mortality were assessed using multivariate Cox proportional hazard models. In total, 5226 participants were included, and the mean age was 70.3years. During a median follow-up time of 14.9years, 3749 participants died (71.7%). After adjustment, both a moderately elevated ESR and a markedly elevated ESR were associated with a significantly higher risk of overall mortality [hazard ratio (HR) 1.23, 95% confidence interval (CI) 1.12-1.35 and HR 1.89, 95% CI 1.38-2.60, respectively]. Although the ESR becomes higher with age, in a group aged above 75years, without any comorbidities, an ESR>20mmh-1 remained associated with a significantly increased risk of mortality (HR 1.29, 95%CI 1.01-1.64). An elevated ESR is an independent prognostic factor for mortality. Despite the fact that ESR increases with age, it remains associated with an increased risk of mortality and warrants close follow-up.

Elevated erythrocyte sedimentation rate is associated with metastatic disease and worse survival in patients with cutaneous malignant melanoma.

Elevated erythrocyte sedimentation rate (ESR) is common in cancer patients and it may affect survival. However, its clinical role and prognostic significance remain unknown in melanoma patients. The objective of the present study was to determine the clinical significance of the ESR levels in cutaneous melanoma patients. A total of 139 cutaneous melanoma patients were enrolled in this study and were retrospectively investigated. The median age of the patients was 52 years (range, 16-88 years). The median ESR was 22 mm/h (range, 2-122 mm/h). Significant differences in ESR were found to be associated with sex, histology, blood hemoglobin level, lactate dehydrogenase (LDH) and metastatic disease. Female patients (P=0.006) and those with nodular histology (P=0.005), low hemoglobin concentration (P<0.001), higher LDH levels (P=0.003) and metastatic disease (P<0.001) were more likely to have elevated ESR levels. However, ESR was not found to be significantly associated with age, site of lesion, or pathological indicators, including Clark's level of invasion, Breslow's depth, mitotic rate, ulceration, vertical growth phase, tumor-infiltrating lymphocytes, regression, neurotropism, lymphovascular invasion and BRAF (V600E) mutation (P>0.05). ESR was also not associated with lymph node involvement (P=0.188) or responsiveness to chemotherapy (P=0.390). However, ESR was found to be significantly associated with outcome; patients with increased ESR had worse survival compared with those with normal values (hazard ratio=2.033; 95% confidence interval: 1.156-3.577; P=0.012). In conclusion, elevated ESR was found to be associated with metastatic disease and was also found to be a prognostic factor adversely affecting survival in patients with cutaneous melanoma.

The predictive value of C-reactive protein and erythrocyte sedimentation rate for 18F-FDG PET/CT outcome in patients with fever and inflammation of unknown origin.

The objective of this study was to determine the predictive value of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to a positive fluorine-18 fluorodeoxyglucose ((18)F-FDG) PET/computed tomography (CT) result in patients with inflammation of unknown origin and fever of unknown origin. Individual data of 498 patients were retrieved from three retrospective studies. Receiver operating characteristic derived areas under the curve were used to assess (18)F-FDG PET/CT versus age, CRP, and ESR. The discriminative value of age, CRP, and ESR related to (18)F-FDG PET/CT was examined using the net reclassification improvement (NRI). A diagnosis was established in 331 patients; (18)F-FDG PET/CT had a diagnostic accuracy of 89%. (18)F-FDG PET/CT had the highest area under the curve (0.89, P<0.001). The addition of (18)F-FDG PET/CT to a diagnosis prediction model including age, CRP, and ESR resulted in an NRI of 42% (P<0.001). In the same model with CRP values below 20 mg/l or ESR values below 20 mm/h, the NRI was 64% (P<0.001) and 29% (P=0.059), respectively. In 30 of 91 patients with CRP less than 10 mg/l, a diagnosis could be established; (18)F-FDG PET/CT was 100% true negative only in patients with CRP levels less than 5 mg/l. In patients with fever of unknown origin or inflammation of unknown origin, compared with elevated ESR levels, elevated CRP levels more often indicate a true positive (18)F-FDG PET/CT outcome.In addition, (18)F-FDG PET/CT, compared with CRP and ESR, shows the highest discrimination of patients with possible disabling disease.

Systematic review of the literature and a case report informing biopsy-proven giant cell arteritis (GCA) with normal C-reactive protein

Giant cell arteritis (GCA) is a vasculitis of large- vessels. A markedly elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are characteristics of GCA, although temporal artery biopsy remains the gold standard for the diagnosis. We describe a case of biopsy-proven GCA showing a heavy infiltration of CD68 macrophages and CD3 T cells and with normal ESR and CRP levels at diagnosis. Key points (1) GCA may occur with normal ESR in a percentage of about 4 to 15 % (although the American College of Rheumatology classification criteria for giant cell arteritis include an ESR of 50 mm/h or more), while it can occur with normal ESR and normal CRP in a percentage of about 0.8 %. So, the clinical suspicion must be confirmed with a positive biopsy. (2) GCA patients with ESR >40 mm/h are characterized by higher incidence of headache and jaw claudication compared to patients with normal ESR. In our case, it occurred with normal ESR. (3) Color duplex ultrasonography is a noninvasive, easy, and inexpensive method for supporting a diagnosis of TA, with a high sensitivity and specificity. It can predict which patient will need TAB.

Hip pain in children with normal radiographs

Abstract: Introduction:An acutely painful hip in a child can be the presenting symptom in a number of conditions. One of the most important conditions of which is septic arthritis of the hip for which early diagnosis and treatment is essential. The focus of management in acute hip pain in a child is to rule out septic arthritis as the penalty for missing a diagnosis of septic arthritis of the hip in a child has serious consequences .The purpose of our study is to add to the available pool of data on hip pain, validate the predictive values published by preceding authors. We also hope that by presenting the breadth and scope of patients presenting with an acutely painful hip with normal radiographs, we can assist the physician in decision-making when confronted with this common diagnostic challenge. Methods: Retrospective review of all the patients who were admitted to our tertiary referral pediatric hospital with complains of hip pain and pain referable to the hip between January 1997 and December 2003. A total of 207 patients 162 patients with normal x-ray were reviewed retrospectively with evaluation of history, physical examination, laboratory studies. Patients whose diagnoses were defined as transient synovitis were made by the attending physician based on result of a combination of some or all of the Laboratory tests.( presence of fever, full blood count, Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) levels, negative blood culture, and effusion on ultrasound, and clinical picture of early resolution. Patients whose diagnoses were defined as septic arthritis or probable septic arthritis were made based on the findings of elevated ESR, CRP, positive blood culture or hip aspiration culture. Results: The 162 patients included 42 females and 120 males, with an age range from 6 months to 14 years. Of our cohort of patients admitted for hip pain, 111 patients were diagnosed as transient synovitis. 56 patients who were diagnosed as transient synovitis underwent ultrasound examination of the affected hip. 89.3% (50/56) had an effusion with a mean joint space thickness of 6.6mm. 10.7% (6/56) of the patients who underwent ultrasound examination had no demonstrable effusion. Conclusions: In patients with septic with hip pain and normal radiograph, the commonest diagnosis was transient synovitis comprising 67.9% of patients.Septic arthritis is the most important diagnosis to exclude and should be suspected if there is fever, inability weight bear and highly elevated levels of ESR and CRP needed

Identification of Independent Predictive Factors for Atherosclerosis in Rheumatoid Arthritis: Based on KARRA Cohort Study

Objective. This study sought to investigate independent predictive factors for subclinical atherosclerosis in Korean patients with rheumatoid arthritis (RA). Methods. We used high-resolution B-mode ultrasonography to measure the carotid artery intima-media thickness (IMT) and carotid plaque in 367 patients with RA. Detailed information on the demographic characteristics, cardiovascular (CV) risk factors, and RA disease characteristics were collected on all subjects. The relationship of the carotid artery IMT and carotid plaque to relevant clinical and laboratory variables were examined. Results. Old age and male sex had the most significant association with increased IMT and presence of plaque than other factors. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and mKHAQ (Korean version of modified health assessment questionnaire) were significantly associated with both increased IMT and presence of plaque after univariate analysis adjusting for age and sex. A multivariable logistic regression analysis revealed that ESR and TJC68 were independent factors associated with the presence of plaque (p<0.001 and p=0.019, respectively). There was a significant linear correlation between the number of plaques and ESR (p<0.001 and R =0.07). Conclusion. Our results indicated that markers of systemic inflammation contributed significantly to subclinical atherosclerosis in patients with RA. We emphasize the need for aggressive control of RA disease activity in patients who persistently demonstrate highly elevated ESR levels.

Bilateral arteritic anterior ischemic optic neuropathy

Background Arteritic anterior ischemic optic neuropathy (AION) is a disease of the optic nerve head seen in patients over the age of 50 and more commonly over the age of 70. With few exceptions, arteritic AION is caused by giant cell arteritis. Early diagnosis and prompt treatment with corticosteroids are essential for preventing potentially devastating visual loss from this disease. Case Report A 63-year-old white man presented with the complaints of blurred vision of the right eye and visual field loss of the left eye. Ocular examination found bilateral swollen optic nerve heads. Visual field testing showed altitudinal defects in each eye. Laboratory testing was significant for elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. The patient was treated with oral prednisone for arteritic AION and referred to a rheumatologist. At follow-up, the patient’s ESR and CRP levels showed significant improvement. The optic nerve head of the left eye showed a reduction in swelling, and the visual field finding was stable. Conclusion Arteritic AION is an ocular emergency. Optometrists need to be able to recognize and diagnose this condition quickly to initiate critical corticosteroid treatment.

Factors Contributing to Hospitalization for Gastroparesis Exacerbations

The clinical course of patients with gastroparesis is characterized by symptomatic exacerbations often necessitating hospitalization. To investigate precipitating factors leading to hospitalization for exacerbation of symptoms in patients with gastroparesis. This was a retrospective review of 103 admissions (63 patients) for gastroparesis exacerbation. Etiologic categories for gastroparetic patients were diabetic (43%), idiopathic (39%), and post surgical (8%). Poor glycemic control was present in 36%, infection in 19% (12 urinary tract infections and two bacteremia), and noncompliance with or intolerance of, medications in six and 5% of patients, respectively. Fasting morning cortisol concentrations were \3 mcg/dl in 9%. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were seen in 34 of 65 (52%) and 11 of 50 patients (22%), respectively. No identifiable infection was found in 74 and 45% of patients with elevated ESR and elevated CRP, respectively. ESR and CRP were higher when patients were symptomatic necessitating hospitalization (26.2 +/- 6.6 mm/h and 1.6 +/- 1.0 mg/l) compared with when they were seen in outpatient follow-up and less symptomatic (10.3 +/- 2.9 mm/h and 0.3 +/- 0.1 mg/l; P = 0.0001 and P = 0.211, respectively). Poor glycemic control, infection, noncompliance with/intolerance of medications, and, perhaps, adrenal insufficiency were contributory factors leading to hospitalizations of gastroparetic patients. Hospitalized patients with gastroparesis exacerbations had elevated ESR and CRP levels. Although many patients with elevated inflammatory markers had evidence of infection, some did not. Assessment of inflammatory markers may help indicate those gastroparetic patients in whom a search for infection should be undertaken.

NEITHER CLINICAL NOR BIOLOGICAL DATA CAN PREDICT RENAL INVOLVEMENT IN INFANTS WITH FEBRILE URINARY TRACT INFECTION

INTRODUCTION: 99m Tc-dimercaptosuccinic acid (DMSA) scintigraphy is accepted as the gold standard in the diagnosis of acute pyelonephritis. OBJECTIVE: In an attempt to reduce the number of investigations after urinary tract infections (UTIs), with this prospective study we aimed to evaluate the diagnostic value of acute-phase reactants in identifying renal involvement in infants with febrile UTI. METHODS: Fifty-four infants (36 male, 18 female) aged 1 to 12 months were studied. For all infants, clinical findings such as duration and height of fever before antibiotic administration and laboratory parameters such as leukocytosis (white blood cell count of &amp;gt;15.000/μL), elevated erythrocyte sedimentation rate (ESR) (&amp;gt;20 mm/hour), and high levels of C-reactive protein (&amp;gt;10 mg/mL) were compared with the results of the DMSA scan obtained within 72 hours after referral. RESULTS: Regarding microbial agents, Escherichia coli was identified in 42 (78%) of the 54 infants, and 16 (29.5%) of the 54 of infants were febrile for &amp;gt;2 days before diagnosis of UTI. Leukocytosis, elevated ESR, and high levels of C-reactive protein were present in 14 (26%), 41 (76%), and 38 (70%) infants, respectively. Acute-phase DMSA showed renal involvement in 10 (18.5%) infants. Vesicoureteral reflux was found in 16 (29.5%) infants. Gender, duration of fever before antibiotic administration, leukocytosis, elevated ESR, and high levels of C-reactive protein were not related to the severity of renal damage, as shown by DMSA. Only fever of &amp;gt;39°C was slightly correlated with an abnormal DMSA scan result (r = 0.3; P = .032). CONCLUSIONS: Acute-phase DMSA scintigraphy remains superior to clinical and laboratory data for predicting renal involvement in infants with febrile UTIs.