Polyarticular Involvement Research Articles

Musculoskeletal Disorders due to Chikungunya Virus: A Real Experience in a Rheumatology Department in Neiva, Huila.

Chikungunya (CHIKV), is an endemic RNA virus in some regions of Asia and Africa. In Colombia in 2014, its spread starts explosively and quickly. The presentation of CHIKV is a febrile condition, with musculoskeletal symptoms, which can progress to erosive arthropathy and polyarticular deformity. The purpose of this study is to evaluate in patients suffering from CHIKV infection in Neiva, Huila who attend the Rheumatology clinic, the symptomatic and serological behavior, and to describe comorbidities associated to the chronic phase of the disease. An observational, longitudinal and retrospective analysis of data collected in 410 patients afflicted with the CHIKV virus, with symptoms lasting more than 3 months, who persisted with musculoskeletal and joint symptoms. The patients were classified according to their commitment in post-viral arthralgias, polyarthritis post viral, Rheumatoid Arthritis (RA) post CHIKV, Spondyloarthritis postCHIKV, and soft tissue rheumatism. The statistical analysis was performed using SPSS software (version 24). A descriptive analysis was carried out to evaluate quantitative variables such as the mean (standard deviation), and categorical variables such as frequency (%). The categorical variables were compared using the Chi-square equation. As a statistical significance, a p less than .05 was considered. Of the 410 patients, 89.23% were women, with polyarticular involvement in 92.26% of the cases. Of the patients, 49.83% had osteoarthritis. At the time of the evaluation in the Rheumatology clinic, 46.3% of the cases presented persistent non-inflammatory arthralgias, and 53.7% of the patients underwent arthritis on physical examination, of which, remarkably, 20.3% met the criteria for rheumatoid arthritis postCHIKV. The development of musculoskeletal symptoms after CHIKV infection is a very serious public health problem, with persistent complications and long-term morbidity risk in real life. The presence of net postviral arthritis is noteworthy, however the development of postCHIKV rheumatoid arthritis usually requires more advanced pharmacological measures, including, in some cases, transition to biological therapy. The presence of symptoms of venous insufficiency in the lower limbs that developed with CHIKV infection was an incidental finding that requires a more precise study.

Rare case of fungal arthritis of knee joint in non-immunocompromised patient

Fungal septic arthritis is a rare medical and surgical problem in orthopaedics. It mainly occurs in immunocompromised state. However our patient was not immunodeficient. The knee is most common site involved. Sometimes polyarticular involvement is also seen. Our case had monoarticular left knee joint involvement. Debridement and Antifungal therapy are the main stay of the treatment. Few cases of fungal septic arthritis are reported in literature. Our Patient showed good result with our treatment. Keywords: Amphotericin B, Debridement of joint, Orthopaedic management and Poor prognosis.

Tapering of Biological Agents in Juvenile ERA Patients in Daily Clinical Practice.

Objectives: We aim to evaluate the proportion and characteristics of enthesitis-related arthritis (ERA) patients in whom medications can be withdrawn in daily practice and to analyze the factors associated with flare-ups during medication tapering of these patients.Methods: We retrospectively reviewed records of patients under 16 years old diagnosed with ERA from April 2001 to March 2020 in one tertiary medical center in Taiwan. Patients were categorized by different medication uses: conventional disease modifying anti-rheumatic drugs (cDMARDs) only and cDMARDs plus biologics. Demographics, laboratory data, presence of uveitis, and medication withdrawal rate were analyzed. Subgroup analysis was performed in the patients with cDMARDs plus biologics to identify factors associated with flare-ups during medication tapering of these patients. Statistical analysis was performed using R (v3.6.0).Results: There were 75 juvenile ERA patients with a median onset age of 10.28 years old. Nineteen (25.3%) patients used cDMARDs for disease control; 56 (74.7%) patients depended on cDMARDs plus biologics. Poly-articular involvement was noted in 29 (38.7%) patients, and it occurred more frequently in the cDMARDs plus biologics subgroup (cDMARDs only, 5.3%; cDMARDs plus biologics, 53.6%; P = 0.0001). ANA positivity was observed in 18 (24.0%) patients, and it occurred more frequently in the cDMARDs plus biologics subgroup (cDMARDs, 0%; cDMARDs plus biologics, 32.1%; P = 0.0038). The overall medication withdrawal rate was 34.7%, and it occurred more frequently in patients with cDMARDs only (cDMARDs only, 84.2%; cDMARDs plus biologics, 17.9%; P < 0.001). In the subgroup analysis of patients with cDMARDs plus biologics, patients on biologics tapering with flare-up had a significantly longer time interval between disease onset and initiation of cDMARDs (biologics tapering without flare-up: 0.27 (0.11–0.73) years; biologics tapering with flare-up: 1.14 (0.39–2.02) years; ever withdrawing biologics: 0.26 (0.18–0.42) years, P = 0.0104).Conclusion: Juvenile ERA patients with polyarticular involvement had a higher risk of developing cDMARDs refractory and progressing to biologics use. Patients with a long time interval between disease onset and initiation of cDMARDs were prone to experience flare-up during tapering of biologics.

Drug Therapeutic in the Subacute and Chronic Phase of Chikungunya Virus Infection

Background: Chikungunya fever is an infectious disease that can evolve to a subacute or chronic condition, with changes in the daily activities of patients. Drugs that aim to reduce these symptoms are used, such as corticoids (acute phase) and disease-modifying anti-rheumatic drugs (chronic phase). Objective: To evaluate the clinical response to drug therapy in the subacute and chronic phase of infection by the Chikungunya virus. Methodology: A prospective and a retrospective study with patients with subacute and chronic Chikungunya infection, out at the infection and autoimmunity outpatient clinic at the Nucleus of Tropical Medicine, from January 2016 to December 2019, in the morning of Thursdays. The patient was observed in the Baseline, first and second return, and drugs were introduced according to the stage of the disease with subsequent reassessment. The Visual Analogue Scale (VAS) was applied to all evaluation moments. Results: 101 patients were evaluated, and arthralgia was the predominant symptom in the three evaluated moments. According to the VAS, moderate baseline pain was observed in 58.1% and 58.6% of subacute and chronic cases, respectively. On the first return, moderate pain still predominated in 46.2% in subacute cases and 43% in chronic cases. In the second visit, all patients were in the chronic phase of the disease, 43.8% had VAS with no pain. Regarding the number of compromised joints in the Baseline, polyarticular involvement predominated in both subacute (79%) and chronic (74.1%) cases, in the first return, oligoarticular involvement predominated in 53.8% of subacute cases and 54.7% in chronic cases and, the second return, 40.6% of the patients had oligoarticular involvement and 43.8% had no joint involvement. As for the use of medications in the Baseline, 33.4% of subacute cases used antiinflammatory drugs, and 40% of chronic cases used corticosteroids. At the first visit, 25% of chronic patients were already using combined corticosteroids and methotrexate and 15% were using only methotrexate. In the second return, 35.1% used combined methotrexate and corticosteroids, and 64.9% used only methotrexate. Safety in the use of methotrexate was observed in the context of CHIKV treatment, as the number of adverse reactions was minimal (three patients) and the medication was well tolerated. Conclusion: It was observed that with the adjustment of the medications, there was a reduction in joint impairment, VAS showed mild pain indexes and in some cases with no pain, showing the benefit of using therapy in subacute and chronic cases and improving quality of life of these users.

Potential Differences in Clinical Features, Disease Activity, Function and Impact of Disease Between Oligo and Polyarticular Psoriatic Arthritis

Objective: The primary aim of the study was to assess the potential differences in clinical features, disease activity, function and impact of disease between Psoriatic Arthritis (PsA) patients with oligoarticular and polyarticular involvement. Methods: Consecutive PsA patients attending our unit were divided into 2 groups: 1) Oligoarticular (&lt;5 involved joints with or without enthesitic/axial manifestations) and 2) Polyarticular (≥5 joints with or without enthesitic/axial manifestations). A full clinical examination with the assessment of disease characteristics, disease activity (DAPSA, MDA), function (HAQ-DI) and impact of disease (PsAID-12) was performed. Furthermore, a 6-month follow-up evaluation was carried out in order to assess disease differences at baseline and at follow-up. Results: Of the 102 enrolled patients, oligoarticular subset was present in 63 (61.7%), while 39 (38.3%) patients had polyarticular involvement. Patients with oligoarticular subset showed, at baseline evaluation, lower values of global disease activity assessed by physician, HAQ-DI and DAPSA compared to patients with polyarticular pattern. No differences in the impact of disease (PsAID), patient global assessment of disease activity or pain were found. At 6-month follow-up, no significant changes in each group occurred. Conclusion: Our study showed some differences in patients with oligoarticular and polyarticular involvement in terms of disease activity and HAQ-DI, while the overall impact of the disease and the presence of enthesitis, dactylitis and axial disease seem to be similar, with no substantial changes after 6-month follow-up. These results could mean that clinical phenotype might not be responsible for the impact of the disease perceived by the patient.

Musculoskeletal disorders due to chikungunya virus: A real experience in a rheumatology department in Neiva, Huila

Introducción:Chikungunya (CHIKV) es un virus RNA endémico en algunas regiones de Asia y África. En Colombia en el año 2014 inicia su dispersión de manera explosiva y rápida. La presentación del CHIKV es una condición febril con síntomas musculoesqueléticos que pueden progresar a artropatía erosiva y deformidad poliarticular. El propósito de este estudio es evaluar en pacientes aquejados por la infección por CHIKV en Neiva, Huila que acuden a la consulta de Reumatología, el comportamiento sintomático y serológico, y describir comorbilidades asociadas a la fase crónica de la enfermedad. MétodosSe realizó un análisis observacional, longitudinal y retrospectivo, de datos recolectados en 410 pacientes aquejados por el virus CHIKV con síntomas de más de tres meses de duración que persistían con afecciones musculoesquelíticas y articulares. Los pacientes fueron clasificados según su compromiso en: artralgias postvirales, poliartritis postviral, artritis reumatoide (AR) postCHIKV, espondiloartritis postCHIKV y reumatismo de tejidos blandos. El análisis estadístico fue realizado usando SPSS software (versión 24). Se llevó a cabo análisis descriptivo para evaluar variables cuantitativas como la media (desviación estándar) y variables categóricas como la frecuencia (%). Las variables categóricas fueron comparadas usando la ecuación X2. Como significancia estadística se consideró una p<0,05. ResultadosDe los 410 pacientes, 89,23% fueron mujeres, con compromiso poliarticular en 92,26% de los casos. El 49,83% de los pacientes presentaban de base osteoartritis. Al momento de la evaluación en la consulta de Reumatología, 46,3% de los pacientes cursaron con artralgias no inflamatorias persistentes y 53,7% de los casos presentaban artritis al examen físico, de los cuales, de manera remarcable 20,3% cumplieron criterios para AR postCHIKV. ConclusionesEl desarrollo de síntomas musculoesquelíticos luego de la infección por CHIKV es un problema de salud pública bastante serio, con complicaciones persistentes y riesgo de morbilidad a largo plazo en la vida real. La presencia de artritis postviral neta es de resaltar, sin embargo, el desarrollo de AR postCHIKV requiere usualmente medidas de índole farmacológico más avanzadas, incluso, en algunos casos es necesario referir a los pacientes a terapia biológica. La presencia de síntomas de insuficiencia venosa en miembros inferiores desarrollados con la infección por CHIKV, fue un hallazgo incidental que requiere de un estudio más preciso.

Progressive Rash In A High School Basketball Athlete

HISTORY: A 16 year old female high school basketball player presented to the athletic training room with a rash on the bilateral lower extremities. It was first noticed 1 week prior to presentation and had progressed from the feet and ankles proximally to the upper thighs. She stated that she initially had right ankle pain but at presentation felt her left knee was particularly swollen and painful. She denied any significant itching related to the rash but felt her legs were swollen and heavy. She denied any specific joint trauma and had been participating in her usual physical activities. She endorsed that she was currently recovering from an upper respiratory viral illness that occurred prior to the appearance of the rash. She had tried taking oral diphenhydramine for the rash which did not help. PHYSICAL EXAMINATION: She was in no acute distress. Nasal congestion and cough were noted. The legs were diffusely swollen from the ankles to the proximal third of the thighs bilaterally with scattered, non-blanching and non-tender purpuric lesions. There was non-specific tenderness to palpation about the left knee without warmth. It was difficult to assess for a knee effusion as there was significant soft tissue swelling. Knee flexion range of motion was 0 to 150 degrees, pain-free and flexion and extension strength was 5/5. Ligamentous structures of the knees were intact. Sensation to light touch of the bilateral lower extremities was intact. She reported pain in the left knee with gait but was not observed as having a limp. Balance was intact. DIFFERENTIAL DIAGNOSIS: 1)Septic arthritis 2)Transient synovitis 3)Lyme disease 4)IgA Vasculitis (formerly known as Henoch-Schnolein Purpura) 5)Coagulopathy 6)Dermatologic hypersensitivity TESTS AND RESULTS: The patient was sent to the emergency department for further evaluation. Blood pressure was 116/69, pulse was 90, respiration rate was 19 breaths per minute with 100% oxygen saturation, and temperature was 97.5oF. A complete blood count showed normal platelets and no leukocytosis, while a basic metabolic panel showed normal renal function. A urinalysis showed trace blood and left lower extremity vascular ultrasound was negative for DVT. Musculoskeletal ultrasound did not show any intra-articular effusion in the left knee. FINAL/WORKING DIAGNOSIS: IgA Vasculitis (formerly known as Henoch-Schnolein Purpura) with polyarticular involvement. TREATMENT AND OUTCOMES: Our patient was managed conservatively with symptom management as needed. Although there was concern for septic arthropathy, she remained afebrile with no clinical signs of sepsis. The rash and arthralgias resolved within 4 weeks.

THU0419 BIOLOGICS IN THE TREATMENT OF CALCIUM PYROPHOSPHATE DEPOSITION DISEASE. A SYSTEMATIC LITERATURE REVIEW

Background:Only few case reports and case series have analysed the efficacy of IL-1 inhibitors in the treatment of calcium pyrophosphate deposition disease (CPPD), reporting conflicting results.Objectives:The main aim of this systematic literature review (SLR) was to summarize the evidence in the use of biological therapies in CPPD.Methods:PRISMA-IPD guidelines were used for this review. Published articles reporting the use of TNFα and/or IL-1 inhibitors in the treatment of CPPD were reviewed. We performed a SLR using PubMed, Embase and Cochrane databases. The search resulted in 83 articles; 11 were further evaluated in the SLR.Results:Seventy-six patients were included: 2 received infliximab, whereas 74 anakinra. The main data of included studies are reported in table 1.Table 1.Studies evaluating biological therapies in patients with CPPD.AuthorsYear of publicationPopulation of interestNumber of CPPD patientsDiagnostic criteriaClinical presentationMcGonagle D. et al.2008CPPD1SFAChronicAnnoun N. et al.2009CPPD1SFAAcuteCouderc M. et al.2012CPPD3ImagingAcute and chronicDiamantopoulos A.P. et al.2012CPPD1SFAChronicMoltó A. et al.2012CPPD5SFAAcute and chronicOttaviani S. et al.2013CPPD16SFA and/or imagingAcuteVerhoeven F. et al.2013G and CPPD2NRAcute and chronicBruges-Armas J. et al.2014CPPD2NRChronicAouba A. et al.2015G, CPPD and HADD1ImagingAcuteDesmarais J. et al.2018G, CPPD11SFA and/or imagingAcuteThomas M. et al.2018CPPD32SFA and/or imagingAcuteLegend.G: gout,HADD: hydroxyapatite deposition disease,NR: not reported,SFA: synovial fluid analysisTable 2.Efficacy of anakinra in the treatment of CPPDAcute CPPD (n=67)Chronic CPPD (n=7)Clinical efficacy (%)54 (80.6)3 (42.9)Pre TJC6.3±2.43.8±2.4Post TJC1.2±0.61.3±1.5Mean reduction5.1±2.3*2.5±1.9+Pre SJC4.8±2.23.8±2.4Post SJC1.1±0.61.3±1.5Mean reduction3.7±2.2*2.5±1.9+Pre VAS pain (0-100 mm)68.5±9.5/Post VAS pain (0-100 mm)24.2±10.4/Mean reduction44.2±10.9*/Pre CRP (mg/l)40.9±50.950.0±66.5Post CRP (mg/l)22.2±8.63.2±2.5Mean reduction18.6±54.1*46.7±64.0+Legend. CRP: C-reactive protein,SJC: swollen joint count,TJC: tender joint count,VAS: visual analogue scale.+p values were not calculated because of a too small sample size. * p values were &lt;0.01Sixty-seven (88.2%) patients presented with an acute CPPD (mean disease duration: 2.7±6.9 months; polyarticular involvement in 61.2%, oligoarticular in 31.3% and monoarticular in 7.5%), whereas 9 (11.8%) patients with a chronic CPPD (mean disease duration: 130.1±133.6 months; polyarticular involvement in 66.7% and oligoarticular in 33.3%).Anakinra was used in refractory disease (85.1%) or in patients with contraindications to standard treatments such as colchicine, oral glucocorticoids and/or non-steroidal anti-inflammatory drugs (23.0%). Clinical response to anakinra was reported in table 2.Duration of anakinra treatment prior to complete resolution of symptoms was associated with the clinical phenotype of chronic CPPD (Rpb: 0.67, p&lt;0.01) and with disease duration (R: 0.49, p&lt;0.01). In 47 out of 57 (82.5%) responders, complete resolution of symptoms was observed within 4 days after the first injection of anakinra. Adverse events were reported in 4.1% of the cases: local skin reaction at the injection site, skin rash on the back and bacterial pneumonia.Conclusion:This SLR provides evidence in favour of the use of anakinra as a therapeutic option in patients with CPPD, especially in acute refractory CPPD or when standard treatments are contraindicated.Disclosure of Interests: :Edoardo Cipolletta: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Anna Scanu: None declared, Martina Isidori: None declared, Jacopo Di Battista: None declared, Leonardo Punzi: None declared, Walter Grassi Speakers bureau: Prof. Grassi reports personal fees from AbbVie, personal fees from Celgene, personal fees from Grünenthal, personal fees from Pfizer, personal fees from Union Chimique Belge Pharma, outside the submitted work., Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work.

Long-term effectiveness and safety of secukinumab for treatment of refractory mucosal and articular Behçet’s phenotype: a multicentre study

ObjectiveTo evaluate the effectiveness and safety of secukinumab in patients with a mucosal and articular Behçet’s phenotype resistant to conventional and biologic treatment.MethodsA multicentre retrospective study was performed on 15...

Juvenile idiopathic arthritis in infants with Harlequin Ichthyosis: two cases report and literature review

BackgroundHarlequin Ichthyosis is the most severe variant of congenital autosomal recessive ichthyosis, associated with severe morbidity and potentially lethal in early life. At birth, patients present thick and plaque-like scales all over the body, with consequent cutaneous and extra-cutaneous complications, such as poor thermoregulation, recurrent infections, pain, electrolytes imbalance and joint contractures. Juvenile Idiopathic Arthritis usually manifests before the age of 16 years and persists for more than 6 weeks. The association between these two pathologies has been described in the literature as a very rare event, which creates diagnostic and therapeutic challenge.Case presentationWe describe two patients affected by Harlequin Ichthyosis who early developed Juvenile Idiopathic Arthritis. Both patients were treated with retinoids, ibuprofen and long-acting intra-articular glucocorticoids; due to polyarticular involvement, one child was also treated with weekly oral methotrexate.ConclusionsThe association between Harlequin Ichthyosis and Juvenile Idiopathic Arthritis is rare and the pathophysiological mechanism that binds them is still unknown. Nonetheless caregivers should be aware of the possible occurrence of Juvenile Idiopathic Arthritis at very early ages in children affected by Harlequin Ichthyosis.

Total Hip Replacement in a Systemic Lupus Erythematosus Patient

Patients with systemic lupus erythematosus (SLE) going for surgery have put challenges to the treating surgeon, anaesthetist and physician as the patients can present with various medical complications perioperatively. It can be associated with polyarticular involvement especially avascular necrosis of the head of femur. The patients may present young with severe clinical findings and abnormal radiological features. The surgery in young SLE patients revolves on the longevity of the prosthesis used.We report a case of a 26-year-old lady with SLE going for right total hip replacement for her avascular necrosis of right hip.&#x0D; Bangladesh Journal of Medical Science Vol.19(2) 2020 p.322-325

Pharmacologic Management of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune, systemic inflammatory disease whose hallmark is symmetrical, polyarticular joint involvement. There is characteristic synovial membrane inflammation and proliferation with potential joint and periarticular structure destruction resulting in pain, joint destruction, deformity, and loss of function. Systemic symptoms can occur in RA; they can sometimes antedate evident joint manifestations and include fatigue, weakness, low-grade fever, and generalized malaise. RA occurs predominantly in women, with a peak onset between the fourth and sixth decades of life. All ethnic groups can be affected, although Native American populations tend to have higher rates of prevalence while Asian populations seem to have lower rates. The prevalence of RA in the United States has been estimated at around 1% [1]. RA results in increased morbidity and mortality. The increased morbidity includes significantly increased rates of myocardial infarction, stroke, infection, and lymphoma. It has also been estimated that RA results in mortality rates up to 27% higher than in the general population [2]. Life expectancy can be significantly reduced in patients with RA, although estimates vary widely [3]. The medical and societal costs of RAin the United States have been estimated at $9 billion per year [4]. These estimates fail to account for intangible costs, such as impact on the family as daily life is modified to accommodate the needs of the person with RA. The lifetime costs for a patient with RA have been said to rival those of entities such as stroke or cardiovascular disease [5].

Quality of life in Ecuadorian patients with established rheumatoid arthritis.

PurposeTo evaluate quality of life in patients with established rheumatoid arthritis (RA) and identify the factors that negatively affect it.MethodsThis was a cross-sectional study with patients with established RA from a rheumatology center in Ecuador. The RA Quality of Life (RAQoL) questionnaire was used to assess QoL and the Health Assessment Questionnaire — disability index (HAQ-DI) questionnaire for functional capacity. In addition, demographics, clinical characteristics, and markers of disease activity were included. Data were analyzed using SPSS 22.ResultsOf 186 patients, 89.8% were women, with a mean age of 51 years, 86.6% had symmetrical polyarticular involvement, 40.3% erosions, 46.8% morning stiffness, 46.8% xerophthalmia, and 39.2% fatigue. Depression was the most frequent comorbidity — 42.5%. The mean HAQ-DI score was 0.8, and 26.9% had functional disability. The mean RAQoL score was 7.2. Xerophthalmia, xerostomia, fatigue, morning stiffness, and depression were related to higher scores in the RAQoL (p<0.05). The mean RAQoL was higher in patients with more disease activity and comorbidities (p<0.05). Likewise, patients with functional disability had a mean RAQoL score of 15.6 versus 4.1 in patients without disability (p<0.05). There were positive correlations between RAQoL and ESR, CRP, painful-joint count, swollen-joint count, VAS of pain, and physician assessment (p<0.05).ConclusionQoL is severely affected in patients with RA. Depression, fatigue, morning stiffness, pain, high disease activity, and disability have a negative effect on QoL in RA. Likewise, patients with more comorbidities and extraarticular manifestations show worse QoL.

Musculoskeletal ultrasound in monitoring response to apremilast in psoriatic arthritis patients: results from a longitudinal study.

Apremilast, PDE4 competitive inhibitor, has been recently introduced in the treatment of adult psoriatic arthritis (PsA) patients, but only preliminary data are available on imaging evaluation. Thus, we evaluated the response to apremilast in PsA patients by ultrasonographic (US) assessment. Thirty-four patients (M/F 7/27; median age 61years, IQR 15; median disease duration 10years, IQR 13) treated for polyarticular involvement were longitudinally evaluated. All the patients were assessed at baseline (T0), and after 6 (T1), 12 (T2), and 24weeks (T3) by DAS28, CDAI, SDAI, and DAPSA. At the same time-points, US assessment was performed in 22 sites (wrists, MCPs, PIPs): synovial effusion/hypertrophy and power Doppler were scored with a semi-quantitative scale (0-3). A total score, corresponding to patient's inflammatory status, was obtained by their sum (0-198). We assessed also the presence of tenosynovitis of flexor tendons of hands' fingers bilaterally, registering the number of involved tendons (US-tenosynovitis score 0-10). We found a significant reduction in the US inflammatory score values after 6weeks (T0, median 15 (IQR 11.2); T1, 6 (10.0); P = 0.0002), confirmed at T2 (4.0 (4.0), P = 0.0002) and T3 (4.0 (6.0); P = 0.0003). Finally, US-detected tenosynovitis was observed in 44.1% of patients: a significant improvement in tenosynovitis score was identified at 6weeks (T0, median 4 (IQR 4); T1, 1 (2); P < 0.0001) and maintained at T2 (0 (IQR 1); P < 0.0001) and T3 ((IQR 1.25); P < 0.0001). Apremilast is able to induce an early and sustained improvement of ultrasonographic inflammatory status at articular and peri-articular level. Key points •Apremilast induces a significant, early, and sustained improvement of inflammatory joint status in psoriatic arthritis patients. •Ultrasonographic assessment is able to monitor articular and peri-articular response to apremilast.

Prevalence and characteristics of arthritis in Kawasaki disease: a Chinese cohort study.

Arthritis is a major complication of Kawasaki disease (KD). The aims of this study were to define the frequency and the clinical characteristics of arthritis in KD in China and to analyze the relation between arthritis and coronary outcome in KD. We included 1420 KD patients followed at Jiangxi Children's Hospital from January 2014 to December 2017. Demographic, clinical and laboratory features of KD were analyzed. Among the 1420 patients enrolled, 151 had arthritis. The median age of KD patients with arthritis was 29months and older than those without arthritis (20months). Of the 151 patients developed arthritis, 101 patients (66.9%) had oligoarticular involvement and 50 patients (33.1%) had polyarticular involvement. Early-onset and late-onset arthritis were, respectively, observed in 123 (81.45%) and 28 (18.54%) patients. The KD patients with arthritis had significantly increased levels of inflammatory markers, and we observed a higher incidence rate of coronary artery aneurysms among those with arthritis (7.28%) compared to those without arthritis (2.75%) (p = 0.003), but the prevalence of coronary artery lesions (CALs) was similar in the two groups. The arthritis in KD was self-limited, left no sequelae and did not require additional medications. KD patients with arthritis were more likely to get coronary artery aneurysms than the patients without arthritis, so examination of joints in KD was necessary.

Musculoskeletal Tuberculosis: A Multifaceted Foe

AbstractTuberculosis (TB) still remains a global epidemic, and India accounts for one-fourth of the world's TB burden. The incidence of extrapulmonary TB has relatively remained constant, but with the introduction of antitumor necrosis factor, there has been a surge in pulmonary and extrapulmonary TB cases presenting to rheumatologists. Musculoskeletal TB accounts for 10 to 30% of all cases of extrapulmonary TB, with spondylitis (Pott's spine) being the most common manifestation. Manifestations mimicking autoimmune spondylitis are seen in 10% of cases. Tubercular arthritis most commonly presents with large joint monoarthritis, but oligo- or polyarticular involvement is also seen. Poncet's disease is a form of reactive arthritis occurring in patients with pulmonary or extrapulmonary TB, which is rarely seen with good response to antitubercular treatment. Quite often, there is delay in the diagnosis of musculoskeletal TB due to absence of constitutional symptoms. Treatment of musculoskeletal TB involves prolonged course of antitubercular treatment, and surgical interventions are limited to special cases.

Tuberculous rheumatism: A great mimic of juvenile idiopathic arthritis

Tuberculosis (TB) is an underreported epidemic. Musculoskeletal TB is a relatively rare extrapulmonary complication of Mycobacterium tuberculosis involving just 1%–3% of patients. It commonly affects the spine and osteoarticular joints such as hip and knee, and it is mostly monoarticular. Oligo and polyarticular involvement, also called tuberculous rheumatism or Poncet's disease (PD), is an extremely rare occurrence due to a vigorous immune response to mycobacteria which contributes to the arthritic process. Here, we report a case of PD in a 3-year-old girl, who presented with complaints of insidious onset polyarthritis, mimicking juvenile arthritis. Cervical lymph node aspirate isolated acid-fast bacilli. The child was diagnosed as a case of PD, and after starting antituberculous therapy, her symptoms dramatically resolved. This patient illustrates the need to consider the possibility of TB in high-risk pediatric populations in countries like India as one of the causes of nonresolving chronic arthritis.

Systemic onset juvenile idiopathic arthritis: a single center experience.

Sağ E, Uzunoğlu B, Bal F, Sönmez HE, Demir S, Bilginer Y, Özen S. Systemic onset juvenile idiopathic arthritis: a single center experience. Turk J Pediatr 2019; 61: 852-858. Systemic juvenile idiopathic arthritis (sJIA) presents with prolonged fever and systemic features such as arthritis, rash, lymphadenopathy, hepatosplenomegaly and serositis. In this study, we aimed to evaluate the clinical and laboratory findings, and outcomes of sJIA patients from a tertiary rheumatology center. Between 2010-2017, patients who had been diagnosed with sJIA, participated in the study. The demographics, clinical and laboratory features, and outcomes, were evaluated retrospectively. Seventy-five sJIA (%56 male) patients were enrolled. The mean age at diagnosis was 6,45±4,80 years. At the time of diagnosis, the most common findings were fever (%100) followed by arthritis (78,7%), and rash (66,2%). Twenty-four percent of the patients present with macrophage activation syndrome (MAS) at the time of diagnosis. Totally, 36% of the patients had at least one MAS attack during the course of the disease. 46% of the patients had polyphasic course while 54% had one attack (26% monophasic, 28% persistant). All of the patients were treated with non-steroid anti-inflammatory drugs (NSAID) and/or corticosteroids at the beginning of the disease. Twenty percent of the patients reached remission with corticosteroid or disease-modifying anti-rheumatic drugs (DMARDs) however the rest of the patients needed at least one biologic agent. Anakinra was the most common first-line biologic treatment choice (n=45). Fourteen (18,7%) of the patients had polyarticular joint involvement during the disease course, and 5 of them achieved remission with tocilizumab. Systemic JIA is an important disease with high risk of morbidity and mortality. As our center is one of the most important tertiary referral rheumatology centers in the country, we had a high MAS incidence. Eighty percent of the patients achieved remission with a biological agent. Anti-IL1 drugs are mostly preferred for ongoing systemic inflammation. Anti-IL-6 agents are very efficient in patients with a polyarticular course.

The necessity, efficacy and safety of biologics in juvenile idiopathic arthritis.

OBJECTIVE:Juvenile idiopathic arthritis (JIA) is the most common cause of chronic arthritis in children. Biologics have changed the faith of children with rheumatic diseases. The main objective of this study was to demonstrate the rate of usage, efficacy and safety of biologics in JIA subtypes.METHODS:This retrospective observational cohort study was conducted between May 2010 and September 2017. All children with the diagnosis of JIA and children under a biological agent treatment were recorded into the local registry system. Age, gender, JIA subtype, medications used, the clinical status of the patient, tuberculosis screening results, and side effects observed under biologics were retrieved from the registry.RESULTS:There were 405 patients with the diagnosis of JIA in the cohort. Biologics were used in 123 (30.3%) JIA patients. Subtype frequencies of JIA patients were as follows: persistent oligoarticular JIA (33.6%), enthesitis-related arthritis (29.2%), systemic JIA (13%), rheumatoid factor (RF)-negative polyarticular JIA (13%), extended oligoarticular JIA (4.2%), RF-positive polyarticular JIA (3.4%), psoriatic arthritis (1.8%) and unclassified arthritis (1.8%). The rate of biologic use was high in extended oligoarticular JIA (64.7% of the cases), RF-positive polyarticular JIA (57.1%), psoriatic arthritis (57.1%), RF-negative polyarticular JIA (41.5%), and in systemic JIA (39.6%). Enthesitis-related arthritis (27.1%), persistent oligoarticular JIA (17.6%) and unclassified arthritis (16.6%) patients were the cases that needed a biologic agent in the last order. At the last control, 78.9% of the cases were in remission, while 21.1% of them were active despite biologic treatment. Isoniazid prophylaxis was used in 30.8% of the patients. None of the patients developed active tuberculosis infection under prophylaxis. Adverse events were observed in 18.6% of patients under biologics as recurrent uncomplicated upper respiratory tract infections being the most common.CONCLUSION:Biologics are safe and effective treatment options in children with JIA. Most of the JIA patients with polyarticular involvement require biologics earlier in the disease course. The risk of tuberculosis infection seems not to be increased after appropriate screening and prophylaxis.

Gout — does it looks like Rheumatoid Arthritis?

Characteristically in gout the feet and hands are commonly involved with a very asymmetric (random) polyarticular joint involvement. Radiographs shows varying densities due to calcium precipitation with the urate crystals. Erosions can occur in a very sporadic asymmetric distribution. Borders can be sclerotic because of the indolence of the process, creating a punched-out or “mouse bitten” appearance, overhanging edges, bony enlargement, and irregular spicules at the sites of tendon and ligament attachments can also be present. Joint spaces are preserved until late and there is no osteopenia. Some patients with advanced gout have such large deposits of urate crystals in periarticular tissues and bone, causing erosion and destruction that may resemble a lytic tumor on radiographs. Usually, soft-tissue swelling, and other signs readily establish the diagnosis. The authors report several cases of arthritic hand caused by gout to describe the typical radiographic findings. Complementary studies as well as a review of the literature are presented to report the differences between gout and AR. All the patients presented with painful, swollen, hot and tender several hand joints, usually in both hands. Some deposits of urate crystals were found but no skin ulceration. Treatment began with resting the joint and applying ice, NSAIDS, corticosteroids and colchicine. Healthy diet low in purines (from alcohol, meat, fish) was recommended. Serial clinical reevaluations and plain radiographs were done. The radiographic studies showed asymmetric and polyarticular joint involvement. Varying densities were seen on radiographs due to calcium precipitation with the urate crystals. Erosions, sclerotic borders and a “mouse bitten” appearance were, also, found. Joint spaces were preserved even with the joints partially destroyed. Despite multiple erosions, there is no osteopenia evident in the patients. These patient's hands characteristically had an asymmetric polyarticular joint involvement. Urate crystals deposits and erosions were seen, also with asymmetric distribution. The “mouse bitten” appearance, sclerotic borders and erosion was seen in the older patients. Joint spaces were well preserved in the youngers. In contrast to rheumatoid arthritis, mineralization was maintained and there was no predominant periarticular osteopenia. There are several differences between gout and AR-asymmetric polyarticular joint involvement, Urate deposits and “mouse bitten” appearance, irregular spicules at the sites of tendon and ligament attachments and no osteopenia.