Manifestations In Rheumatoid Arthritis Patients Research Articles

Rheumatoid Arthritis and Associated Lung Diseases: A Comprehensive Review

Rheumatoid arthritis (RA) is a prevalent autoimmune disorder affecting 0.5-1% of the population in North America and Europe. Pulmonary manifestations in rheumatoid arthritis patients result in significant morbidity and mortality. Management of these pulmonary manifestations in RA patients causes various challenges for the physicians. This review article has discussed the current state of knowledge of these pulmonary manifestations, including interstitial lung diseases, airway-related diseases, pulmonary vasculature, and pleural involvement in RA patients. This review article has also explored various pharmacological options, including steroids, disease-modifying antirheumatic drugs (DMARDs), immunosuppressive drugs, and biologic agents. Non-pharmacological options include conservative treatment, supplemental oxygen, pulmonary rehabilitation, smoking cessation, and lung transplantation.

English

BACKGROUND The prevalence of rheumatoid arthritis (RA) in India is 0.28% to 0.7%, 15-45% of patients with RA develop ocular manifestations. Ocular disabilities can be reduced with timely interference by an ophthalmologist. Keratoconjunctivitis sicca (Sjogren’s syndrome) is the most common ocular association of RA. This study was done to find out various ocular manifestations in rheumatoid arthritis patients. METHODS A cross sectional study was conducted among the patients attending the rheumatology clinic at Government Medical College, Trivandrum. Patients in the age group of 18-60 years were screened and further evaluated at regional institute of ophthalmology, Trivandrum. Screening for RA was done using the American Rheumatism Association criteria. A complete ophthalmic examination was done for those who satisfied the criteria. The various ocular manifestations in RA are described and presented as proportions. RESULTS Ocular manifestation was found in 38% of total patients attending the rheumatology clinic. There were 54 females (80.5%) and 13 males (19.4%). Age group mainly affected were in 46-50 yr (17.9%). The duration of rheumatoid arthritis ranged from few months to 25 years. Keratoconjunctivitis sicca was the commonest manifestation found, detected in 22(84%) patients, episcleritis was noted in two patients (7.6%), scleritis in 1 patient (3.8%) and marginal furrowing in 1 patient (3.8%). CONCLUSIONS In this clinic-based study there was a high proportion (38%) of ocular involvement in RA and hence it is essential to include ophthalmic evaluation as a routine in RA patients. The most common manifestation was keratoconjunctivitis sicca followed by episcleritis, diffuse anterior scleritis and marginal corneal furrowing. KEY WORDS Rheumatoid Arthritis, Keratoconjunctivitis Sicca, Ocular Manifestations, Scleritis, Episcleritis

Variability of clinical manifestations in rheumatoid arthritis patients with COVID-19 infection

ObjectiveThe authors conducted the present retrospective study to assess the epidemiological, clinical, laboratory, and radiological characteristics in coronavirus disease-2019 (COVID-19) associated with rheumatoid arthritis (RA). As known, COVID-19 can cause fatal respiratory infection and may be accompanied with multiorgan affection, including the kidney and heart. The morbidity and mortality may be higher in patients with the immune-deficiency condition.Patients and methodsThe present study is a retrospective cohort study that retrieved the data of 307 patients with and/or without RA evaluated in Rheumatology Department in Mataria Teaching Hospital, who were previously infected with SARS-CoV-2. Patients' medical record IDs were reviewed between April and May, following the peak of SARS-CoV-2 infection. Selected patients were classified into two groups: the first group included 257 RA patients infected with COVID-19 versus 52 control groups infected with COVID-19. RA cases with confirmed COVID-19 through the period of April 2020 and May 2021. The diagnosis of COVID-19 was based on positive RT–PCR.ResultsThe number of RA patients infected with COVID was 257 (83.7%). Fever (56.0%), fatigue (78.2%), myalgia (37.0%), and arthralgia (9.7%). Some patients developed shortness of breath (29.6%), chest pain that was found in 32.8% of patients. Ground-glass opacities were present in 31.3% and 18.7% presented with consolidation, 30% of rheumatoid patients developed respiratory failure. RA patients receiving conventional synthetic disease-modifying antirheumatic drugs were 96.8%.ConclusionMost rheumatic disorders, including RA, were likely to develop COVID-19 infection, but there was no evidence of a worse prognosis or poor outcome, despite immunosuppressive therapy.

Frequency of extra-articular manifestations in cohort of Pakistani patients presented with RA at Independent University Hospital Faisalabad.

Objective: To determine the frequency of extra articular manifestations in Rheumatoid Arthritis patients at independent university hospital Faisalabad. Study Design: Cross Sectional study. Setting: Rheumatology Division of Internal Medicine Independent University Hospital Faisalabad. Period: January 2019 to December 2019. Material & Methods: Consecutive Three hundred and twenty-three adult patients of either sex, of age between 20-60 years with baseline RA fulfilling the 2010 criteria of American College of Rheumatology. Extra articular manifestations were assessed. Chi square test was used to compare the frequency of extra articular manifestations among different disease duration, age groups, seropositivity and disease score. A p-value ≤ 0.05 was considered statistically significant. Results: 323 patients with RA were assessed in this study. Extra articular manifestations were assessed according to clinical presentation. 15.2% (49) patients were found to have lung involvement with predominant interstitial lung disease. Rheumatoid nodules were found in 9.9% (32) patients. 3rd most common extra-articular manifestation was sicca syndrome, seen in 3.7% (12) patients followed by neurological 2.2% and cardiac was 1.5%. Other extra-articular manifestations were seen in 2.8% of patients. Conclusion: it is very important to assess the extra articular manifestations in rheumatoid arthritis. Early assessment and early intervention can decrease the disease morbidity and mortality.

Association Between Adiponectin and Clinical Manifestations in Rheumatoid Arthritis.

Adiponectin (APN) belongs to adipokines. Previous studies showed contradictory results that have both proinflammatory and anti-inflammatory effects in rheumatoid arthritis (RA). We set out to detect the levels of APN and the correlations between APN and the clinical manifestations in RA patients. Sera of 60 newly diagnosed patients with RA and 29 age- and gender-matched healthy subjects were collected. Clinical parameters, including C-reactive protein (CRP), erythrocyte sedimentation rate, rheumatoid factor (RF), antibodies to cyclic citrullinated peptide, disease activity score 28, and bone erosion conditions, were collected. The serum levels of total APN and high-molecular-weight APN (HMW-APN) were detected by enzyme-linked immunosorbent assay. As a result, total APN and HMW-APN levels were all lower in patients with RA compared with healthy controls. The levels of APN and HMW-APN were all positively correlated with CRP levels. There was also positive correlation between HMW-APN levels and RF levels. Moreover, patients with higher disease activities had higher HMW-APN levels; patients with more severe synovial thickening had higher APN and HMW-APN levels. Therefore, APN, especially HMW-APN, may play a regulatory role in RA.

Neglected extra-articular manifestations in rheumatoid arthritis patients with normal body mass index: reduced skeletal muscle overlapping overfat.

Background:Chronic inflammation in rheumatoid arthritis (RA) can induce reduced muscle mass (myopenia) and ectopic fat deposition probably showing normal body mass index (BMI). We aimed to investigate their body composition (BC) characteristics and clinical significance.Methods:BMI and BC were collected in consecutive RA patients and control subjects. Myopenia was defined by appendicular skeletal muscle mass index (ASMI) ⩽7.0 kg/m2 in men and ⩽5.7 kg/m2 in women. Overfat was defined by body fat percentage (BF%) as ⩾25% for men and ⩾35% for women.Results:There were 620 RA patients (57.6% with normal BMI) and 2537 control subjects (62.5% with normal BMI) recruited. After 1:1 age and sex matching with control subjects, RA patients with normal BMI (n = 240) showed significantly higher prevalence of myopenia (43.3% versus 22.1%) and overfat (19.2% versus 7.1%) as well as myopenia overlapping overfat (17.1% versus 3.3%). In all RA patients with normal BMI (n = 357), there were 18.2% patients with myopenia overlapping overfat who had the worst radiographic scores and highest rates of previous glucocorticoid treatment and hypertension. Compared with those without, normal BMI RA patients with previous glucocorticoid treatment (24.4% versus 10.3%) or hypertension (27.8% versus 13.6%) had a higher rate of myopenia overlapping overfat. Previous glucocorticoid treatment [odds ratio (OR) = 2.844, 95% confidence interval (CI) 1.441–5.614] and hypertension (OR = 2.452, 95% CI 1.283–4.685) were potential associated factors of myopenia overlapping overfat in RA patients with normal BMI.Conclusion:Myopenia overlapping overfat is an important extra-articular manifestation which should not be ignored in RA patients with normal BMI, especially with glucocorticoid treatment and hypertension.

SLC22A5 polymorphism associated with risk of extra-articular manifestations in rheumatoid arthritis patients.

ObjectivesRheumatoid arthritis (RA), the most common autoimmune disease, is thought to be a complex disease in which a combination of risk alleles from different susceptibility genes predisposes to development of the disease, following exposure to as yet unknown environmental factors. An important component of the carnitine system is the plasma membrane carnitine transporters, also called organic cation transporters, i.e. OCTN1 and OCTN2 encoded by the SLC22A4 and SLC22A5 genes, respectively. The aim of this study was to investigate the association between SLC22A5 polymorphism and RA.Material and methodsThe study was carried out on 404 patients diagnosed with RA according to the criteria of the American College of Rheumatology and 560 healthy subjects. The single nucleotide polymorphism (SNP) within the SLC22A5 gene – 207C>G (rs 2631367) was genotyped using pre-validated TaqMan genotyping assays.ResultsThe distribution of SLC22A5 genotypes and alleles in RA patients did not differ significantly from that in healthy controls. Moreover, there were no significant associations between SLC22A5 genotypes and age at time of disease diagnosis, rheumatoid factor, erosive disease and response to treatment with methotrexate. Extra-articular manifestations were diagnosed in 16.7% of SLC22A5 GG homozygous patients, in 9.4% with the GC genotype and in 7.2% of homozygous CC patients. The frequency of extra-articular manifestations was two-fold greater in homozygous GG patients as compared with carriers of the C allele (GG vs. GC + CC), OR = 2.06 (95% CI: 1.11–3.85, p = 0.022).ConclusionsThe results of the present study suggest that the SLC22A5 polymorphism may be associated with the development of extra-articular manifestations of RA but the distribution of SLC22A5 genotypes and alleles in studied RA patients did not significantly differ from healthy subjects.

Prevalence and characteristics of eye involvement in patients with rheumatoid arthritis

Background and objective: Rheumatoid arthritis is a systemic inflammatory disease. Ocular manifestations involved with rheumatoid arthritis are keratoconjunctivitis sicca, episcleritis, scleritis, anterior and posterior uveitis, dry eyes and ulcerative keratitis. This study aimed to detect the prevalence of ocular manifestations in rheumatoid arthritis patients, find out the relation between the effects of disease modifying anti-rheumatic drugs, biological agents and ocular complications in rheumatoid arthritis patients and explore role of anti-cyclic citrullinated peptide antibodies. Methods: This is a cross-sectional clinical study of 60 rheumatoid arthritis patients who have attended Rizgary Teaching Hospital in Erbil. A data information about symptoms of ocular manifestations and history of ocular complications before starting disease modifying anti-rheumatic drugs and/or biological agents were taken. Musculoskeletal examination, serum Anti-CCP antibodies test were done. Ocular examination by ophthalmologist was done. Results: This study was conducted from April to November 2015 and involved 60 patients; 55 females and five males with a mean± SD age of 46 ± 11.46 years. Thirty nine (65%) patients had ocular manifestations of rheumatoid arthritis. The most frequent manifestation was dry eyes 30 (50.0%). There was no relation between severity of the rheumatoid arthritis disease and ocular manifestation (P = 0.529). There was a relationship between the Anti-CCP antibodies titer and presence of ocular manifestations in rheumatoid arthritis patients (P = 0.006). There were no curable effects of the disease modifying anti-rheumatic drugs, biological agents on ocular manifestations in rheumatoid arthritis patients (P = 0.787). Conclusion: Dry eye was the most common ocular manifestation, anti-CCP antibodies are a sensitive marker for ocular manifestations. Disease modifying anti-rheumatic drugs and biological therapies provide no significant efficacy in treatment or prevent the occurrence of ocular manifestations in rheumatoid arthritis patients.

Ocular involvement and its manifestations in rheumatoid arthritis patients

Background Rheumatoid arthritis (RA) is a systemic inflammatory disease associated with a number of extra-articular organ manifestations. Ocular manifestations involved with RA are keratoconjunctivitis sicca (KCS), episcleritis, scleritis, keratitis, and retinal vasculitis. The etiopathogenesis of this autoimmune disorder is still debated. The aim of the current study was to present different ocular manifestations of RA and their frequency. Patients and methods A total of 180 patients with RA participated in this cross-sectional survey. All patients were subjected to general and specific examinations, ophthalmological examinations, and rheumatologic examinations in addition to blood investigations for rheumatoid factor and anti-cyclic citrullinated peptide. Results Of the 180 examined patients, 61 (33.9%) patients had ocular manifestations. There were 52 (85.3%) patients with KCS, three (4.9%) patients with episcleritis, three (4.9%) patients with scleritis, and three (4.9%) patients with keratitis. Patients with longer disease duration were much more likely to have ocular manifestations (odds ratio=7.13, P Conclusion Ocular manifestations involved with RA are significant. The most common manifestation of ocular involvement was KCS. Ocular manifestations were more common among patients with longer disease duration.

Value of High-frequency Ultrasound in the Diagnosis of Peripheral Nerve Compression in Rheumatoid Arthritis Patients.

Objective To evaluate the value of high-frequency ultrasound (HFUS) in diagnosing peripheral nerve compression in patients with rheumatoid arthritis (RA). Methods The upper limb nerves were evaluated by HFUS in 80 RA patients (RA group) and 60 non-RA patients (control group),then the incidence of peripheral nerve compression was recorded respectively. RA patients with/without neurological symptoms were compared in terms of age,disease course,Health Assessment Questionnaire Disability Index (HAQ-DI) score,and clinical disease activity index (CDAI). Results The incidence of upper limb nerve compression in RA group was significantly higher than that in control group(15.0% vs. 3.3%,P=0.046).The patients with nerve compression was older [(60.2±11.4)y vs.(49.2±7.9)y;t=2.343,P=0.039] and had longer disease course [(9.50±5.99) y vs. (5.88±3.87)y;t=2.639,P=0.023] and higher HAQ-DI score (1.58±0.75 vs.0.85±0.67;t=2.490,P=0.030). These two groups had no statistical differences in CDAI (14.50±11.68 vs.16.62±9.24;t=1.141,P=0.278).Conclusions Peripheral neuropathies are common extra-articular manifestations in RA patients. HFUS can be valuable in patients suspected of RA.

Interstitial Lung Disease and Rheumatoid Arthritis: A Review

Interstitial lung diseases (ILDs) are a group of diffuse parenchymal lung disorders that are classified according to different clinical, radiological and histopathological features. Interstitial lung disease can be primary or it can be due to a secondary cause, such as an underlying connective tissue disease (CTD). Rheumatoid arthritis (RA) is the most common CTD, and ILD can be found in a quarter of RA patients. Interstitial lung disease has a significant impact on RA patients in terms of their burden of disease and quality of life. Despite this it remains largely understudied and pathogenesis is unclear. Newer imaging techniques include ultrasound and 18F-FDG PET/CT. Therapeutics that show promise include mycophenolate mofetil and rituximab. Paradoxically, some of the agents that are good in treating articular manifestations in RA patients can result in the worsening or development of ILD.

Cutaneous manifestations of rheumatoid arthritis

Rheumatoid arthritis (RA) is a multisystem autoimmune disease, affecting the joints predominantly, and extra-articular sites like skin, lungs, heart etc. The American College of Rheumatology (ACR) in collaboration with the European League Against Rheumatism (EULAR) in 2010, revised the 1987 ACR classification criteria for RA. The criteria covered four areas (joint involvement, serodiagnosis, acute phase reactants, duration of arthritis) and established a point value on a scale of 0 to 10. Patients with a value of 6 or higher are classified as having RA. Although there are a number of studies on each of these factors, there is a paucity of studies on the cutaneous manifestations in RA patients. The present study explores cutaneous manifestations in RF-positive, predominantly female patients in their fourth decade of age. Drug-induced and other miscellaneous side effects accounted for majority of the lesions. A significant correlation of nevi and striae with RA has been observed in this population.

PMS2 - The Impact of Commodities and Extra-Articular Manifestations in Rheumatoid Arthritis Patients

PMS2 - The Impact of Commodities and Extra-Articular Manifestations in Rheumatoid Arthritis Patients

English

Introduction Rheumatoid arthritis is caused by a complex mechanism involving synoviocytes, osteoclasts and immune cells that are interconnected via cytokines and other signalling molecules. Effective medical treatment for joint destruction in rheumatoid arthritis is lacking because the molecular mechanisms leading to joint destruction are incompletely understood. However, it is known that cytokinemediated immunity and perturbations in the balance of effector cells at the disease site play a crucial role in rheumatoid arthritis pathogenesis. Cellular and cytokine inhibitors have been used for treatment purposes. Increasing evidence has revealed the importance of IL-17, an activated T cell-derived inflammatory cytokine, and IL-23 in the pathogenesis of rheumatoid arthritis. The role of IL-17 has been of particular interest, as IL-17 affects the differentiation and activation of pathogenic osteoclasts. Cellularly, the key features of rheumatoid arthritis include disturbance of the Th17/Treg balance and plasticity, deregulated Th17 responses and the reduction or absences of Treg cells. Recent developments in the area of CD4 + T-cell differentiation, together with experimental and preclinical findings on inhibitors of the IL-17 pathway and the use of Treg cell-based therapy, indicate that CD4 + effector cells, TH17 and Treg, could be effective targets for restoring immune tolerance. In this critical review, we summarise the progress in our understanding of the role of IL-23, IL-17 and CD4 + T-cell differentiation into specialised effectors, focusing on Th17 and Treg cells, in the pathogenesis of rheumatoid arthritis. Conclusion Pathogenesis of rheumatoid arthritis is slow and complex. Cytokines and cell-mediated immunity are involved in irreversible bone and cartilage destruction. Cytokine levels and the Treg/Th17 balance might be relevant for the diversity of clinical manifestations in rheumatoid arthritis patients and might be critical for the development of improved treatment methods.

Immunoglobulin subtypes predict therapy response to the biologics in patients with rheumatoid arthritis

To analyze the effectiveness of rituximab (RTX) versus alternative TNF antagonists (aTNFs) on rheumatoid arthritis (RA) disease activity in different subgroups of patients and relation with extraarticular manifestations of RA and to assess that RF-subsets have potential as predictors of clinical response to RTX. Patients with RA (n = 40, M/F: 3/37) who received aTNFs at least 6 months with good response (group I; n = 20) or discontinued at least one aTNFs because of the ineffectiveness and subsequently received RTX at least one course (group II; n = 20) were retrospectively evaluated. IgM-, IgA-, IgG-rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) levels were measured by ELISA technique. Extraarticular manifestations and radiological scores were also recorded. The mean (SD) age was 51.7 ± 6.5 years in group I and 52.1 ± 6.1 years in group II patients (p > 0.05). The median disease durations were higher in group II than group I [8.0 (2-30) vs. 13 (3-35) years, respectively, p = 0.04]. Presence of RF [13(61.9 %) vs. 20(100 %) p = 0.001] and extraarticular involvement [5(25 %) vs. 13(65 %) p = 0.01] were higher in group II patients. When Ig-RF subgroups analyzed, all subgroup (IgA, IgM, IgG) levels were higher in group II (p = 0.001, p = 0.05, p = 0.001). IgA-RF levels were significantly high in patients with extraarticular involvement (p = 0.04). Association between high RF levels and having extraarticular manifestations in RA patients may largely be attributed to the IgA isotype.

Accelerated Pulmonary Nodulosis and Sterile Pleural Effusion in a Patient With Psoriatic Arthropathy During Methotrexate Therapy

Pulmonary nodulosis and sterile pleural exudates are well-known extra-articular manifestations in rheumatoid arthritis patients with a positive rheumatoid factor. In some patients, treatment with methotrexate has been postulated as the trigger of these complications. We report a patient with psoriatic arthropathy, negative RF, negative anticyclic citrulinated peptide antibodies but positive antibodies to cardiolipin who developed massive sterile pleural empyema and multiple cavitary pulmonary nodules during methotrexate treatment. We suggest that awareness of methotrexate-induced lung and pleural complications should be extended to other than rheumatoid arthritis diseases, not necessarily accompanied by rheumatoid factor or anticyclic citrulinated peptide antibodies.

Pulmonary Manifestations of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic disease, characterized by symmetric joint involvement, but it can also affect other organ systems, including the lungs. The better-known pulmonary manifestations of RA are interstitial lung disease, rheumatoid nodules, and pleural effusions. Less common manifestations include bronchiolitis obliterans and crycoarytenoid arthritis. Management of these conditions involves, by and large, supportive pulmonary care and control of the underlying articular process. Other pulmonary manifestations in RA patients can ensue as a result of the treatments used for it, mainly methotrexate. This article discusses the most common pulmonary manifestations of RA and their treatment. A discussion about the increasing impact that cigarette smoking is having on RA is also provided.