Inflammatory Low Back Pain Research Articles

Inflammatory low back pain-associated malignancies mimicking spondylarthritis.

Inflammatory low back pain (IBP) is a typical feature of spondylarthritis (SpA). IBP can be caused by infections, drugs, and different malignancies. Among cancers, hematologic malignancies and solid tumors can cause IBD either paraneoplastically or through metastasis. In this study, we aimed to present the demographic and clinical characteristics of our patients who presented with IBP in the last 10years and whose final diagnosis was malignancy. Thirty-four patients who presented with inflammatory low back pain in the last 10years and were diagnosed with malignancy as the final diagnosis were included in the study. Thirty-six patients, diagnosed as axial SpA, with similar age-sex ratio of 1:1 from each center were included as the control group. Hematologic malignancies were multiple myeloma, acute leukemia, and lymphoma in descending order. Solid tumors were breast cancer, lung cancer, bone tumors, prostate, colon, embryonal carcinoma, and malignancy of unknown primary. In malignancy-related low back pain, the hematologic/solid ratio was similar (18/16), the interval between symptom and diagnosis was shorter, and biomarkers' results such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum lactate dehydrogenase (LDH) levels were significantly higher than the control group. Malignancy-related low back pain differs from SpA patients with a more severe clinical picture, higher acute phase reactants levels, and higher LDH values. Malignancies must be kept in mind in the differential diagnosis, and in order to validate our findings, the results of larger case series are needed, especially in terms of causative malignancies. Key Points • In malignancy-related inflammatory low back pain, the hematologic/solid ratio was similar, the interval between symptom and diagnosis was shorter, and acute phase reactant levels and LDH levels were significantly higher. • Malignancy-related inflammatory low back pain differs from axial SpA patients with a more severe clinical picture, higher acute phase reactants levels, and higher LDH values. • Malignancies must be kept in mind in the differential diagnosis of axial SpA.

Rotation or change of biotherapy after TNF blocker treatment failure for axial spondyloarthritis: the ROC-SpA study, a randomised controlled study protocol

IntroductionAxial spondyloarthritis (axSpA) is a chronic inflammatory disease characterised by inflammatory low back pain. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as a first treatment in axSpA. In case of inadequate...

Exploring causal correlations between blood inflammatory cytokines and low back pain: a Mendelian randomization

PurposeLow back pain (LBP) is a common and recurring public health problem that affects sufferers both physically and mentally and warrants further research. A succession of studies have suggested a plausible role for inflammatory cytokines in the pathogenesis of LBP. To date, there is no conclusive mechanism explaining how inflammatory cytokines affects LBP.MethodsA bidirectional two-sample Mendelian randomization (MR) investigation was undertaken in two stages. The initial phase encompassed 41 inflammatory cytokines as the exposure, with LBP as the outcome, and the subsequent phase adopted the inverse approach. A total of 41 blood inflammatory cytokines were extracted from the genome-wide association study meta-analysis database, encompassing 8,293 individuals. Data pertaining to LBP were acquired from the Finnish biobank. Primary findings were computed using inverse-variance weighting (IVW), while sensitivity analyses accounting for pleiotropy and invalid instruments were conducted utilizing the weighted-median estimator, MR-Egger, and MR Pleiotropy RESidual Sum and Outlier.ResultsOur results suggest that higher levels of Macrophage migration inhibitory factor (MIF) as well as lower levels of C-C motif chemokine ligand 3 (CCL3) are associated with an increased risk of LBP (odds ratio [OR] = 1.134, 95% confidence interval [CI ]= 1.032–1.245, P = 0.009; OR = 0.887, 95% CI = 0.803–0.980, P = 0.018). Moreover, there was no heterogeneity and horizontal pleiotropy observed in the sensitivity analysis. In contrast, in studies of the effect of LBP on inflammatory cytokines, genetically determined LBP had no causal effect on 41 inflammatory cytokines (IVW P > 0.05).ConclusionsOur study confirms that the levels of circulating MIF and CCL3 may be regarded as valuable circulating inflammatory biomarkers for the management of LBP in clinical practice and as potential molecules for future mechanistic investigation and drug target identification.

Case of gout with inflammatory low back pain

Case of gout with inflammatory low back pain

E033 Beyond the surface: artful imitation of Hodgkin’s lymphoma as axial spondyloarthritis

Abstract Background/Aims Rheumatic conditions may be associated with different neoplastic-diseases. Sacroiliitis is not defined as a paraneoplastic syndrome in the literature and considered as the direct involvement of the sacral/iliac bones or sacroiliac joints. There are only few reported cases of back pain and sacroiliac bones/joint involvement as an initial presentation of Hodgkin’s lymphoma. Methods An 18 year boy presented with low back pain of 18 months duration. He had significant morning stiffness and reported good response with non-steroidal anti-inflammatory drugs. He also complained of intermittent fever, insignificant weight loss and occasional dry cough. He denied peripheral joint pain, skin lesions, urethritis, conjunctivitis, uveitis and gastrointestinal disease. The family history was negative for spondyloarthritis (SpA) and neoplastic diseases. He was given empirical anti-tubercular drugs for 6 months with no significant improvement. He was evaluated by physician and rheumatologist elsewhere and treated as SpA in view of inflammatory low back pain, very high inflammatory markers and sacroiliac bones/joint involvement on MRI. The patient tested negative for HLA-B27 (PCR). He was initially started on sulfasalazine, however there was no induction of remission and later switched to tofacitinib since last 4 months. General examination was unremarkable. Bilateral sacroiliac compression and FABER tests were the only positive findings on systemic examination. Results There was leukocytosis (14,100/mm3) with predominant polymorphs, hemoglobin was 9.8g/dl, thrombocytosis (5.4 lakhs/mm3), serum CRP was markedly raised (123mg/L) and ESR was 57mm/hr. His workup for infectious diseases and rheumatic diseases were unremarkable. Repeat MRI according to SpA protocol showed altered marrow signal intensity in lumbar and sacral vertebral bodies and enhancing lytic lesion in right iliac bone till sacroiliac joint. PET-CT revealed multifocal FDG avid mixed lytic sclerotic lesions disseminated in the axial as well as appendicular skeleton with FDG avid sub-centimetric bilateral neck, supraclavicular, axillary, mediastinal and bilateral external/internal iliac and inguinal lymph nodes. Excision biopsy of right supra-clavicular node showed classical Hodgkin lymphoma (CD15 and CD30+ve). He was referred to the haematology clinic for further management. Bone marrow examination was suggestive of tumour infiltration. He received chemotherapy according to the protocol. He is under haematologist care and on a regular follow up with significant improvement in symptoms along with normal inflammatory markers. Conclusion There may be involvement of sacral/ iliac bones and sacroiliac joints by various malignancies including Hodgkin’s lymphoma. Morning stiffness, good response to NSAIDs and MRI findings may delay the diagnosis of primary malignancy, however we should keep a differential of lymphoproliferative disorders as in the aforementioned case and perform other diagnostic modalities. When the expected clinical response is not achieved, the physician must think of a malignancy in cases with persistently high inflammatory markers and marked constitutional symptoms. Disclosure P. Khatri: None. J. Yadavalli: None. K. Shivam: None. R. Gupta: None.

Race-specific associations: inflammatory mediators and chronic low back pain.

Chronic low back pain (cLBP) is a global health crisis that disproportionately burdens non-Hispanic Black (NHB) individuals, compared with those who identify as non-Hispanic White (NHW). Despite the growing personal and societal impact of cLBP, its biological underpinnings remain poorly understood. To elucidate the biological factors that underlie the racial disparities in cLBP, this study sought to determine whether inflammatory mediators associated with pain interference (PI), pain at rest (PAR), and movement-evoked pain (MEP) differ as a function of racial identity. Blood samples were collected from 156 individuals with cLBP (n = 98 NHB participants, n = 58 NHW participants). Enzyme-linked immunosorbent assay and multiplex assays were used to quantify concentrations of proinflammatory (fibrinogen, C-reactive protein [CRP], serum amyloid A, tumor necrosis factor α [TNF-α], and interleukin [IL]-1α, IL-1β, and IL-6) and anti-inflammatory markers (IL-4 and IL-13). Spearman rho correlations were used to assess associations among markers of inflammation and PI, PAR, and MEP using the Brief Pain Inventory-Short Form. Analyses revealed that for NHW patients, CRP, serum amyloid A, and IL-6 were positively associated with cLBP outcomes and IL-4 was inversely associated with PAR and MEP. However, for NHB patients, only IL-1α was positively associated with PAR. Our findings suggest that, while there are associations between inflammation and cLBP outcomes, the biomarkers that underlie the inflammation could very well differ as a function of racialized minority group. However, more research with racially inclusive samples is needed to elucidate the mechanisms that may contribute to racial disparities in cLBP.

P401 The diagnostic efficacy of the DETAIL questionnaire as a screening tool for spondyloarthritis in Korean patients with Inflammatory Bowel Disease

Abstract Background The DETection of Arthritis in Inflammatory boweL diseases (DETAIL) is a very simple questionnaire consisting of six items. Developed in Italy as a screening tool for spondyloarthritis (SpA) in patients with inflammatory bowel diseases (IBD), it has not been validated in Asian patients with IBD. This study aims to assess whether the DETAIL questionnaire demonstrates appropriate screening properties in Korean patients with IBD. Methods Adult patients with IBD experiencing musculoskeletal symptoms were prospectively enrolled. An IBD specialist assessed them using a Korean-translated version of the DETAIL questionnaire, and referred them to a rheumatologist. The diagnosis of SpA was made based on the Assessment of SpondyloArthritis international Society classification criteria. The performance of the DETAIL questionnaire was evaluated using a Bayesian analysis model, with results graphically represented using Fagan’s nomogram. Results Eighty-seven patients with IBD (58 with ulcerative colitis and 29 with Crohn’s disease) completed the DETAIL questionnaire. Male was 50.1%, and the mean age of the patients was 39.1±12.1 years. Among these patients, 30 (34.5%) were diagnosed with SpA (20 peripheral, 10 axial). In the DETAIL questionnaire, items 1 (exploring peripheral synovitis), 2 (exploring dactylitis), and 3 (exploring Achilles enthesitis), which assess peripheral SpA, demonstrated good performance, especially with the highest positive likelihood ratio (LR+) found in item 2 (LR+ 3.26). Meanwhile, questions about inflammatory low back pain (items 4, 5, and 6), exhibited poorer performance, with LR+ values near or below 1. In subgroup analysis, the DETAIL questionnaire exhibited superior performance in younger IBD patients (< 40 years old) across three items for peripheral SpA, compared to older IBD patients (≥ 40 years old). An affirmative response to at least two questions about peripheral arthritis yielded a posttest probability of SpA of 85% or more. Conclusion The DETAIL questionnaire demonstrates effective screening properties for detecting SpA in young Korean IBD patients.

J-2156, a small molecule somatostatin type 4 receptor agonist, alleviated hindpaw hypersensitivity in the streptozotocin-induced rat model of painful diabetic neuropathy but with a 2-fold decrease in potency at an advanced stage in the model, mimicking morphine.

There is a large unmet need for novel pain-killers to improve relief of painful diabetic neuropathy (PDN). Herein, we assessed the efficacy of the somatostatin type 4 (SST4) receptor agonist, J-2156, for relief of PDN in rats. Diabetes was induced with streptozotocin (STZ; 70mg/kg) and bilateral hindpaw hypersensitivity was fully developed by 8-week post-STZ. In the intervals, 8-12-weeks (morphine-sensitive phase; Phase 1) and 16-18-weeks (morphine-hyposensitive phase; Phase 2) post-STZ, rats received a single dose of intraperitoneal (i.p.) J-2156 (10, 20, 30mg/kg), gabapentin (100mg/kg i.p.), subcutaneous morphine (1mg/kg) or vehicle. Hindpaw withdrawal thresholds (PWTs) were assessed using von Frey filaments pre-dose and at regular intervals over 3-h post-dose. In Phase 1, J-2156at 30mg/kg evoked significant anti-allodynia in the hindpaws with maximal effect at 1.5h compared with 1h for gabapentin and morphine. The durations of action for all three compounds were greater than 3h. The corresponding mean (±SEM) extent and duration of anti-allodynia (ΔPWT AUC) for gabapentin did not differ significantly from that for J-2156 (30mg/kg) or morphine. However, in Phase 2, the ΔPWT AUC for morphine was reduced to approximately 25% of that in Phase 1, mirroring our previous work. Similarly, the mean (±SEM) ΔPWT AUC for J-2156 (30mg/kg) in Phase 2 was approximately 45% of that for Phase 1 whereas for gabapentin the mean (±SEM) ΔPWT AUCs did not differ significantly (p > 0.05) between the two phases. Our findings further describe the preclinical pain relief profile of J-2156 and complement previous work in rat models of inflammatory pain, neuropathic pain and low back pain. SST4 receptor agonists hold promise as novel therapeutics for the relief of PDN, a type of peripheral neuropathic pain that is often intractable to relief with clinically used drug treatment options.

Precision medicine in axial spondyloarthritis: current opportunities and future perspectives.

Axial spondyloarthritis (axSpA) is a complex disease characterized by a diverse range of clinical presentations. The primary manifestation is inflammatory lower back pain, often accompanied by other clinical manifestations such as peripheral arthritis, enthesitis, uveitis, psoriasis, and inflammatory bowel disease. However, the presentation of axSpA can vary widely among patients. Despite extensive research, the precise pathogenesis of axSpA remains largely unknown. The lack of complete understanding poses challenges in subgrouping the disease, developing specific treatment approaches, and predicting treatment response. In this review, we will explore the limitations in diagnosing and treating axSpA. In addition, we will examine the current knowledge and potential opportunities provided by various omics and technological advancements in enhancing the diagnosis and personalized treatment of axSpA.

The effect of polypharmacy on rheumatoid and psoriatic arthritis treatment: retrospective study.

Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are chronic, progressive inflammatory diseases that can be accompanied by other diseases. In recent years, with the increase in the lifespan of individuals, the concept of polypharmacy has become more prominent. We aimed to show the prevalence of polypharmacy and the effects of polypharmacy on disease activity in RA and PsA. This study included PsA patients who had peripheral joint involvement and, RA patients. Since PsA has a heterogeneous clinical picture, only patients with peripheral joint involvement were included in the study and patients with inflammatory low back pain or radiological sacroiliitis or spondylitis, dactylitis or enthesitis were not included in the study due to homogeneity concerns. The numbers of medications used by the patients at the onset of their treatment and at sixth months into their treatment were recorded. Polypharmacy was accepted as the simultaneous use of at least five medications by the person. The Disease Activity Score 28 joints C-Reactive Protein (DAS-28 CRP) was used to assess disease activity for both disease. The modified Charlson Comorbidity Index (CCI) scores of the patients were calculated based on their chronic diseases. The sample of the study included 232 RA and 73 PsA patients. Polypharmacy was present at the treatment onset in 115 (49.6%) of the RA patients and 28 (38.4%) of the PsA patients. At the sixth month of treatment, polypharmacy was present in the sixth month of the treatment in 217 (93.5%) RA and 61 (83.6%) PsA patients. The mean ages of the RA and PsA patients who were receiving polypharmacy treatment at the beginning were significantly older than the mean ages of those who were not receiving polypharmacy treatment. In both the RA and PSA groups, the patients with polypharmacy at the beginning had statistically significantly higher DAS-28 CRP scores at six months of treatment than those without polypharmacy at the beginning (p<0.001). Polypharmacy was present both at the time of diagnosis and in the treatment process in the RA and PsA patients, and the presence of polypharmacy at the beginning of the treatment was among the factors that affected the treatment of these patients by significantly affecting their 6th-month DAS-28 CRP values.

What is the best referral strategy for axial spondyloarthritis? A prospective multicenter study in patients with suspicious chronic low back pain.

To assess the value of referral strategies for axial spondyloarthritis (axSpA) in patients with suspicious chronic inflammatory low back pain (LBP), to estimate the value of inflammatory back pain (IBP) for referral, and to identify the predictive factors of the final diagnosis of axSpA in Middle Eastern Arab countries. The study was multicentric, prospective, and conducted in LBP first-line clinics (rheumatology, internal, family medicine, orthopedic surgery, neurosurgery, and neurology). Consecutive adult patients aged under 45years were included in case of LBP suspicious of inflammatory nature according to the first-line physician. The rheumatologist's final diagnosis was the gold standard. The diagnostic properties of ten referral strategies (Brandt I, II, III, Hermann, RADAR, RADAR 2/3, MASTER, Braun, CAFASPA, and ASAS) and of IBP were calculated. A multivariable logistic regression identified the clinical predictive factors of axSpA. In 515 referred patients, axSpA was confirmed in 48%, refuted in 43%, and diagnosis remained inconclusive in 9%. The optimal referral strategy was the MASTER (PLR 3.3), which comprises IBP, good response to NSAIDs, positive HLA-B27, and SpA family history. Considering strategies without HLA-B27, the RADAR 2/3 had a PLR of 2.9 (IBP, good response to NSAIDs, any extra-musculoskeletal manifestation). The predictive factors for axSpA were MRI sacroiliitis, positive HLA-B27, high CRP, psoriasis, IBP, and longer symptom duration. Of all patients, 35% were self-referred, 16% were referred by primary care physicians, and 15% by neuro/orthopedic surgeons. Optimizing physicians' awareness of these clinical features may enhance referral in axSpA.

Serum Progranulin Levels and Disease Activity in Patients with Axial Spondyloarthritis

Abstract Background Axial spondyloarthritides (ax-SpA) are a group of chronic systemic diseases of unknown aetiology, affecting mostly young men, with common features such as inflammatory low back pain, axial skeletal involvement, sacroiliitis, and association with HLA-B27. Inflammatory cytokines, mainly TNF-α, play a role in its aetiopathogenesis. Progranulin (PGRN) is thought to be an anti-inflammatory molecule that acts through the TNF-α pathway. In our study, we aimed to investigate the relationship between serum PGRN levels and disease activity in patients with AS. Material and Methods Forty-five patients between the ages of 18 and 65 who were classified as having ax-SpA according to ASAS classification criteria were included in our study. Forty-five individuals between the ages of 18 and 65 who did not have pregnancy or lactation status, no acute or chronic infection and no malignancy or rheumatic disease were included as the healthy control group. In addition, BASDAI, BASFI, BASMI, ASDAS-CRP, ESR and CRP levels were recorded in the patient group to determine the laboratory and clinical findings of patients with ax-SpA. Results Mean serum progranulin levels were higher in axial SpA patients compared with the control group (5156.72±1274.34 vs. 4836.50±1422.10), but this result was not statistically significant (p=0.275). Serum progranulin levels were negatively correlated with ESR (p=0.031) but ASDAS-CRP (p=0.407) and BASDAI (p=0.297) values were not correlated with the progranulin levels. Conclusion Although we found a negative correlation between progranulin and ESR, we did not find any association between progranulin and disease activity in patients with axSpA. There is a need for new and larger studies to be conducted with a higher number of participants in this patient group and to measure serum PGRN levels as well as antibodies against PGRN.

Assessing the causal relationship between genetically determined inflammatory biomarkers and low back pain risk: a bidirectional two-sample Mendelian randomization study.

Observational studies have suggested an association between inflammatory markers and low back pain (LBP), but the causal relationship between these factors remains uncertain. We conducted a bidirectional two-sample Mendelian randomization analysis (MR) study to investigate whether there is a causal relationship between inflammatory markers and low back pain. We obtained genetic data for CRP, along with its upstream inflammatory markers IL-6, IL-8, and IL-10, as well as low back pain from publicly available genome-wide association studies (GWAS). We applied several MR methods, including inverse variance weighting, weighted median, MR-Egger, Wald Ratio, and MR-PRESSO, to test for causal relationships. Sensitivity analyses were also conducted to assess the robustness of the results. Our analyses utilizing the Inverse Variance Weighted (IVW) method, the MR-Egger method, and the weighted median method indicated that IL-6 may be associated with an increased risk of LBP (Effect Size: -0.009, 95% Confidence Interval: -0.013-0.006, p = 9.16e-08); however, in the reverse direction, there was no significant causal effect of LBP on inflammatory markers. Our study used a Mendelian randomization approach and found that elevated IL-6 levels may reduce the risk of LBP.

Automatic Image Segmentation and Grading Diagnosis of Sacroiliitis Associated with AS Using a Deep Convolutional Neural Network on CT Images.

Ankylosing spondylitis (AS) is a chronic inflammatory disease that causes inflammatory low back pain and may even limit activity. The grading diagnosis of sacroiliitis on imaging plays a central role in diagnosing AS. However, the grading diagnosis of sacroiliitis on computed tomography (CT) images is viewer-dependent and may vary between radiologists and medical institutions. In this study, we aimed to develop a fully automatic method to segment sacroiliac joint (SIJ) and further grading diagnose sacroiliitis associated with AS on CT. We studied 435 CT examinations from patients with AS and control at two hospitals. No-new-UNet (nnU-Net) was used to segment the SIJ, and a 3D convolutional neural network (CNN) was used to grade sacroiliitis with a three-class method, using the grading results of three veteran musculoskeletal radiologists as the ground truth. We defined grades 0-I as class 0, grade II as class 1, and grades III-IV as class 2 according to modified New York criteria. nnU-Net segmentation of SIJ achieved Dice, Jaccard, and relative volume difference (RVD) coefficients of 0.915, 0.851, and 0.040 with the validation set, respectively, and 0.889, 0.812, and 0.098 with the test set, respectively. The areas under the curves (AUCs) of classes 0, 1, and 2 using the 3D CNN were 0.91, 0.80, and 0.96 with the validation set, respectively, and 0.94, 0.82, and 0.93 with the test set, respectively. 3D CNN was superior to the junior and senior radiologists in the grading of class 1 for the validation set and inferior to expert for the test set (P < 0.05). The fully automatic method constructed in this study based on a convolutional neural network could be used for SIJ segmentation and then accurately grading and diagnosis of sacroiliitis associated with AS on CT images, especially for class 0 and class 2. The method for class 1 was less effective but still more accurate than that of the senior radiologist.

Survey on rheumatic disease symptom recognition by the general population

Introduction/ObjectivesTo assess people's level of recognition of rheumatic disease symptoms and their awareness that the rheumatologist is the main effector when it comes to these disorders. Materials and methodsSurvey performed in 8 towns in the Buenos Aires Province. Every town had at least one rheumatologist. Three clinical cases were presented: (1) inflammatory low back pain, (2) systemic disease, and (3) chronic polyarthritis. The population was asked whether (a) a physician should be immediately consulted, or (b) they could wait. They were asked whether they would advocate any initial treatment. They were also asked which physician should be consulted. ResultsOut of 150 surveys, 68% were female, the average age was 51.7 years old. Most people asserted that treatment with anti-inflammatory drugs should come first: 83% in inflammatory low back pain, 70% in systemic disease, and 70% in chronic polyarthritis (p=0.02). The number of men that suggested waiting was higher (47% vs. 28% of women; p=0.04). A rheumatologist was recommended by 51% for chronic polyarthritis, 15% for systemic disease, and 8% for inflammatory low back pain (p<0.0001). Thirty-eight percent of those who never considered consulting a rheumatologist had elementary education vs. 19% of those who considered consulting a rheumatologist for one of the 3 cases (p=0.01) ConclusionsChronic polyarthritis was the disease people identified best as within the rheumatologist's field of expertise. Men tended to delay consultation more than women. Consultation is less likely when the level of education is lower.

Tenascin-C and Interleukin-17 Up-regulation in Axial Spondyloarthritis Patients

Background: Axial spondyloarthritis (axSpA) is an inflammatory, systemic rheumatic condition that mostly affects the axial skeleton. Tenascin-C (TN-C) is a hexameric glycoprotein of considerable size, upregulated in many inflammatory conditions, while Interleukin-17 (IL-17) a cytokine that plays an important role in SpA symptoms. Objective: to investigate the upregulation between the serum levels of TN-C and IL-17 in Iraqi axSpA patients and the disease characteristics. Patients and Methods: Seventy-four axSpA patients and 28 matched controls were studied. Fifty-four patients received a tumor necrosis factor inhibitor (TNFi) and 20 did not. Serum TN-C and IL-17 concentrations were determined using the ELISA technique. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was assessed. For statistical tests, Chi Square, Mann Whitney, Independent Samples T, and Pearson's correlation tests are used. Results: Patients mean age was 35.6±0.9 years, 65 males and 9 females, and disease duration was 5.18±0.6 years. 47.4% were smokers, 47% had inflammatory low back pain, and HLA-B27 was present in 91%. BASDAI mean was 6.1±0.4 in non-TNFi and 2.6±0.3 in those on TNFi. The serum TN-C concentration was significantly increased in patients, especially those on non-TNFi (79±9.6 pg/mL) compared to those on TNFi (69.1±3.2 pg/mL) and control (53±3.9 pg/mL) (p=0.003). Serum IL-17 was significantly elevated in those receiving TNFi (877.9±257 pg/mL) compared to non-TNFi (487.2±234 pg/mL) and control (182.4±36.6 pg/mL) (p=0.033). The TN-C significantly correlated with erythrocyte sedimentation rate (r=0.27, p=0.02) and with hemoglobin (Hb) concentration (r=0.26, p=0.02). TN-C and IL-17 were non-significantly related (r=0.14, p=0.2). Conclusions: axSpA Patients demonstrated high levels of serum TN-C, particularly in those not receiving TNFi, and high IL-17 levels in those receiving TNFi, suggesting that there is an association with tissue injury from the disease and stimulation of immunological and resident tissue cells. Patients who had not received TNFi showed significantly higher disease activity than others.

Does post-COVID reactive arthritis exist? Experience of a tertiary care centre with a review of the literature

BackgroundRheumatological manifestations following COVID-19 are various, including Reactive Arthritis (ReA), which is a form of asymmetric oligoarthritis mainly involving the lower limbs, with or without extra-articular features. The current case series describes the clinical profile and treatment outcome of 23 patients with post-COVID-19 ReA. MethodsA retrospective, observational study of patients with post-COVID-19 arthritis over one year was conducted at a tertiary care centre in India. Patients (n=23) with either a positive polymerase chain reaction test for SARS-CoV2 or an anti-COVID-19 antibody test were included. Available demographic details, musculoskeletal symptoms, inflammatory markers, and treatment given were documented. ResultsSixteen out of 23 patients were female. The mean age of the patients was 42.8 years. Nineteen patients had had symptomatic COVID-19 infection in the past. The duration between onset of COVID-19 symptoms and arthritis ranged from 5 to 52 days with a mean of 25.9 days. The knee was the most involved joint (16 out of 23 cases). Seven patients had inflammatory lower back pain and nine had enthesitis. Most patients were treated with non-steroidal anti-inflammatory drugs (NSAIDs) and steroids – either depot injection or a short oral course. Three patients required treatment with hydroxychloroquine and methotrexate which were eventually stopped. No relapse was reported in any of the patients. ConclusionOn combining our data with 21 other case reports of ReA, a lower limb predominant, oligoarticular, asymmetric pattern of arthritis was seen with a female preponderance. The mean number of joints involved was 2.8. Axial symptoms and enthesitis were often coexistent. Treatment with NSAIDs and intra-articular steroids was effective. However, whether COVID-19 was the definitive aetiology of the arthritis is yet to be proven.

Characteristics of Ankylosing spondylitis patients in Kurdistan region of Iraq

Background: Ankylosing spondylitis (AS) affects predominantly the axial skeleton and causes inflammatory low back pain. Aims and Objectives: We aimed to explore clinical characteristics of AS patients in Iraqi Kurdistan. Materials and Methods: In this cross-sectional study, the patients who attended a rheumatic disease center in Kurdistan Region of Iraq in 2022 were screened for the diagnosis of AS. Results: The mean age of the patients was 38.31 (17–65 years old) and most were Middle age and males (93.07%; male: female ratio: 13.43:1). The patients were normal sleepers (61.39%), short sleepers (28.71%), and long sleepers (9.90%). The patients were most physically active through walking. The age at symptoms onset of patients was 22.61 years (7–56 years). The patient’s disease was diagnosed at the mean value of 29.56 years. The median gap of diagnosis was 5 years. The patients had different characteristics; peripheral arthritis (56.44%), sacroiliitis (bilateral: 91.09%), tenosynovitis (14.85%), plantar fasciitis (45.54%), achilles tendinitis (17.82%), anterior uveitis (23.76%), positive human leukocyte antigen-B27 (88.40%), and spinal involvement (94.06%). Most patients received treatment (89.11%) including received biological treatment (53.47%) followed by multiple treatments (29.70%) and non-steroidal (4.95%) and only 0.99% (one patient) used physical therapy. The patients with normal sleepers and physically active and without extra-articular manifestations of AS had better disease severity and function compared to short sleepers and nonphysically active. Conclusion: A AS patients have escalating disease severity and function patients in this region. The disease severity and function were associated with healthy lifestyles such as sleeping and physical activity.

Ultrasound guided corticosteroids sacroiliac joint injections (SIJIs) in the management of active sacroiliitis: a real-life prospective experience.

Active sacroiliitis represents the hallmark of axial spondyloarthritis (axSpA) and manifests as inflammatory low back pain associated with morning stiffness (MS). Sometimes, the combination of non-steroidal anti-inflammatory drugs (NSAIDs) and biological disease modifying drugs (bDMARDs) proves unsatisfactory in achieving a remission. We enrolled patients affected with active sacroiliitis confirmed via magnetic resonance imaging (MRI) and treated with a corticosteroid sacroiliac joint injection (SIJI) via ultrasound guidance. After SIJI, we evaluated visual-analogue scale (VAS) and MS pain changes. As controls, we selected axSpA patients starting bDMARDs. We enrolled 26 patients (mean age 55 ± 14years; 25 females and 1 male; > 95% treated with NSAIDs; 46% on bDMARDs; 75.82 ± 123months) and examined a total of 47 treated joints. We detected a 48% reduction in VAS pain after 24h. Moreover, we observed a significant reduction (p < 0.0001) of VAS pain between the baseline and every subsequent follow-up visit. Further, a significant difference in VAS pain compared to the baseline in the controls was observed starting from week 12. There was a significant reduction in MS after 1week due to SIJIs, while in the controls the first significant change from the baseline in MS was detected after 12weeks. The efficacy of infiltrative therapy lasted up to 6months: persistent VAS as well as MS pain reduction was observed. US-guided SIJI represents an effective and safe technique for patients who have active sacroiliitis yet are ineligible for biologic treatment or who experience unsatisfactory disease control despite receiving therapy.

Validation of screening criteria for spondyloarthritis in patients with inflammatory bowel disease in routine clinical practice.

Spondyloarthritis (SpA) is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). Diagnostic delay must be avoided. We assessed the validity of SpA screening criteria (any of the following characteristics: chronic low back pain with onset before 45 years of age; inflammatory lower back pain or alternating buttock pain; arthritis; heel enthesitis; dacylitis; HLA-B27 positivity; sacroiliitis on imaging). This was a multicenter cross-sectional observational study in IBD patients aged ≥18 years. After evaluating the SpA screening criteria, the gastroenterologists referred the participants to the rheumatologists, who determined whether the patient fulfilled the screening criteria and carried out the necessary tests for SpA diagnosis. 35 (11.7%) out of 300 patients were diagnosed with SpA. The combination with the best balance between sensitivity and specificity (91.4% and 72.1%, respectively, when applied by the rheumatologists; 80% and 78.9%, when applied by the gastroenterologists) for SpA screening, was fulfillment of any of the following: chronic low back pain with onset before age 45 years, inflammatory low back pain or alternating buttock pain, arthritis, or dactylitis. This is one of the first studies to validate SpA screening criteria in IBD patients in routine clinical practice.