Rheumatoid Factor Test Research Articles

Severity Indices in Rheumatoid Arthritis: A Systematic Review

ObjectiveTo identify tools designed to evaluate the severity of patients with rheumatoid arthritis (RA) in order to use them in the investigation of prognostic markers in early arthritis. MethodsWe conducted a systematic review of studies that developed/validated an index for RA disease severity. They were analysed using the COSMIN checklist to assess their methodological quality. In addition, all the variables included were evaluated for their clarity of definition, feasibility and probability of being present in each outcome during the first 2 years of the disease course. To estimate redundancy, variables were grouped by domains. ResultsAfter reviewing 3519 articles, 3 studies were included. The first study, the PAS, assessed whether current and lifetime treatment with disease-modifying antirheumatic drugs and/or biologics accurately predicted RA severity, as measured by the patient-reported PAS. Treatment variables did not fully distinguish patients in the highest and lowest quartiles of PAS scores. Another severity index, the Claims-Based Index for RA Severity (CIRAS), included the variables age, sex, Felty's syndrome, number of rehabilitation and rheumatology visits, test for inflammatory markers, number of chemistry panels/platelet counts ordered and rheumatoid factor test. The correlation was low (r=0.56) with an index previously validated by the same research group, the RA medical records-based index of severity (RARBIS), with Disease Activity Score-C-reactive protein (DAS28-PCR) (r=0.07) and Multidimensional Health Assessment Questionnaire (MD-HAQ) (r=0.008). Finally, the RARBIS, used to validate the CIRAS, was devised as an RA severity index based on medical records. It includes as domains surgery, radiology, extra-articular manifestations, clinical and laboratory variables, previously chosen by an expert panel. RARBIS had a weak correlation with treatment intensity (r=0.35) and with DAS28 (r=0.41). ConclusionThere is no index to assess the severity of RA based on the course of the first 2 years of follow-up that is adapted to the current strategy of therapeutic management of this disease. Therefore, we believe it is reasonable to develop a new ad hoc severity index for patients with early arthritis.

Case report of primary Sjögren Syndrome with simple trigeminal lesion as initial symptom

PurposeIt will provide a reference for early detection, early diagnosis and early treatment of atypical primary Sjogren syndrome with neurological impairment as the first symptom. MethodsCase report and Literature review. ResultsHere we report a 30-year-old woman diagnosed with trigeminal damage secondary to pSS who presented atypical trigeminal neuralgia of numbness of the right head and face and persistent prickling-like pain not associated with eating, talking or tooth-brushing, and had no “trigger point”. The patient further received rheumatoid immune factor tests, ophthalmic examinations, salivary gland emissioncomputed tomography(ECT) and lip biopsy, and found positive antinuclear antibodies (1:320), atypical xerophthalmia, impaired intake and excretion of bilateral salivary glands and degree II of lip biopsy. The patient received methylprednisolone and antiviral therapy, which showed very good outcome. ConclusionsClinically primary Sjögren Syndrome (pSS) combined with trigeminal lesion is common, but cases of pSS with trigeminal involvement as initial symptom have rarely been reported, which is easy to misdiagnose. This case suggested that the signs of simple trigeminal lesion, especially those with atypical manifestations, could be the early manifestation of other systemic diseases. Attention should be paid to identification of the pathogeny of the primary disease to achieve early identification, diagnosis and treatment.

SEROPREVALENCE OF ANTI-MANNOSE BINDING LECTIN AUTOANTIBODIES IN PATIENTS WITH RHEUMATOID ARTHRITIS IN SANA'A CITY- YEMEN

Objective: Rheumatoid arthritis (RA) characterized by synovial inflammation and destruction of cartilage and bone. Until now there is no single test that diagnoses RA, however, several blood tests may suggest the presence of this disease. RA is associated with the presence of a number of autoantibodies as such as rheumatoid factor (RF), anti-cyclic citrullinated peptide (ACPA) and anti-mannose binding lectin (anti-MBL). This study aimed firstly to investigate the presence of anti-MBL autoantibodies in the sera of RA patients and healthy controls and secondly to determine the diagnostic value of this marker in comparison with the classical RF, C- reactive protein (CRP) and ACPA among RA cases. Methods: This case-control study was conducted at four health establishments; two public (Al-Thawra Modern General Hospital and National Center of Central Public Health Laboratories) and two private (University of Science and Technology Hospital and Aulqi Specialized Medical Laboratories) in Sana'a city. Ninety-four individuals were enrolled in this study. Forty-seven persons were clinically diagnosed to have RA by a rheumatologist and 47 healthy subjects without RA were used as controls. Sera were separated and tested for presence of serum anti-MBL autoantibodies, ACPA, RF and CRP by a commercially available enzyme linked immunosorbent assay (ELISA) and latex agglutination technique. Results: Study results showed that the mean±SD for the levels of serum anti-MBL autoantibodies among RA cases were 394±243 ng/ml which were significantly higher than that recorded among healthy controls (217±173 ng/ml). The levels of serum anti-MBL autoantibodies were associated with positive RF and CRP tests (p=.02 and .007 respectively), but not with positive ACPA test (p=.42). Conclusion: The result of this study showed higher levels of serum anti-MBL autoantibodies among RA cases comparing with the healthy controls and reveal an association with positive results for RF and CRP, but not with ACPA. Therefore, the anti-MBL antibody levels may associated with systemic autoimmune diseases and might not exclusive to RA. Peer Review History: Received 8 May 2018; Revised 12 May; Accepted 14 May, Available online 15 May 2018 UJPR follows the most transparent and toughest ‘Advanced OPEN peer review’ system. The identity of the authors and, reviewers will be known to each other. This transparent process will help to eradicate any possible malicious/purposeful interference by any person (publishing staff, reviewer, editor, author, etc) during peer review. As a result of this unique system, all reviewers will get their due recognition and respect, once their names are published in the papers. We expect that, by publishing peer review reports with published papers, will be helpful to many authors for drafting their article according to the specifications. Auhors will remove any error of their article and they will improve their article(s) according to the previous reports displayed with published article(s). The main of it is ‘to improve the quality of a candidate manuscript’. Our reviewers check the ‘strength and weakness of a manuscript honestly’. There will increase in the perfection, and transparency. Received file: Reviewer's Comments: Average Peer review marks at initial stage: 6.5/10 Average Peer review marks at publication stage: 8.0/10 Reviewer(s) detail: Dr. Ahmad Abdelsattar El-Ebiary, Tanta University Hospitals, Tanta, Egypt, a.ebiary@med.tanta.edu.eg Dr. Anthony C. C. Egbuonu, Michael Okpara University of Agriculture, Nigeria, tonycemalukegbuonu@yahoo.com Similar Articles: PREVALENCE OF DYSLIPIDEMIA AND ITS ASSOCIATION WITH DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS IN SULAIMANI GOVERNORATE THE ASSOCIATION OF EPSTEIN-BARR VIRUS ANTIBODIES WITH RHEUMATOID ARTHRITIS AMONG YEMENI PATIENTS IN SANA’A CITY INTERLEUKIN-22 SERUM LEVELS IN PATIENTS WITH RHEUMATOID ARTHRITIS IN SANA'A CITY, YEMEN

Annals for Educators - 20 March 2018.

Annals for Educators - 20 March 2018.

Rheumatoid factor testing in Spanish primary care: A population-based cohort study including 4.8 million subjects and almost half a million measurements.

Rheumatoid factor (RF) testing is used in primary care in the diagnosis of rheumatoid arthritis (RA); however a positive RF may occur without RA. Incorrect use of RF testing may lead to increased costs and delayed diagnoses. The aim was to assess the performance of RF as a test for RA and to estimate the costs associated with its use in a primary care setting. A retrospective cohort study using the Information System for the Development of Research in Primary Care database (contains primary care records and laboratory results of >80% of the Catalonian population, Spain). Participants were patients ≥18 years with ≥1 RF test performed between 01/01/2006 and 31/12/2011, without a pre-existing diagnosis of RA. Outcome measures were an incident diagnosis of RA within 1 year of testing, and the cost of testing per case of RA. 495,434/4,796,498 (10.3%) patients were tested at least once. 107,362 (21.7%) of those tested were sero-positive of which 2768 (2.6%) were diagnosed with RA within 1 year as were 1141/388,072 (0.3%) sero-negative participants. The sensitivity of RF was 70.8% (95% CI 69.4-72.2), specificity 78.7% (78.6-78.8), and positive and negative predictive values 2.6% (2.5-2.7) and 99.7% (99.6-99.7) respectively. Approximately €3,963,472 was spent, with a cost of €1432 per true positive case. Although 10% of patients were tested for RF, most did not have RA. Limiting testing to patients with a higher pre-test probability would significantly reduce the cost of testing.

Biochemical and genetic characteristics of the largest worldwide Fabry cohort reported to present

To systematically analyze literature with the aim of examining whether rheumatoid factor (RF) is a predictor of response to tumor necrosis factor (TNF) antagonists in rheumatoid arthritis (RA).A systematic review and meta-analysis of observational studies were conducted. All studies on the association of baseline RF (titer and/or status) and response to any TNF antagonists, or with enough information to estimate this association were included. Qualitative analysis and meta-analysis using random-effects approach by type of outcome response and RF test was performed. Risk of publication bias was also evaluated.The systematic review included 18 studies of 4163 identified articles, involving 5703 patients with homogeneous baseline characteristics. The most common outcome to assess response was European League Against Rheumatism (EULAR) response criteria, normally merging good and moderate categories as response. The weighted mean difference (WMD) of baseline IgM RF titer in meta-analysis was higher in the non-responders group [−101.58 (95% CI −156.58,−46.59) I2 = 0.0]. Combined odds ratios (ORs) of positive IgM RF, positive IgA RF, and positive IgG RF to achieve good/moderate response were 1.08 (0.80, 1.47), I2 = 40.9%; 0.83 (0.39, 1.73), I2 = 39.8%, and 1.30 (0.48, 3.51), I2 = 62.9%, respectively. We did not find an association between a positive IgM RF and EULAR good response or remission.This meta-analysis does not support baseline IgM RF titer as a predictor of response to TNF antagonists in RA. However, this conclusion is hampered by high heterogeneity in the studies included in this meta-analysis.

Pulmonary arterial hypertension in a patient treated with dasatinib: a case report

BackgroundThere have been several reports on dasatinib-induced reversible pulmonary hypertension. This is the first reported case in Latvia; the patient did not discontinue the drug after the first adverse effects in the form of pleural effusions, which we speculate led only to partial reversion of the disease.Case presentationA 67-year-old white man with chronic myelogenous leukemia was treated with the dual Src and BCR-ABL tyrosine kinase inhibitor dasatinib. After treatment with dasatinib he had multiple pleural effusions which were suspected to be caused by congestive heart failure. Later a transthoracic Doppler echocardiography and right-sided heart catheterization revealed severe pulmonary hypertension with pulmonary vascular resistance of 12 Wood units and mean pulmonary artery pressure of 53 mmHg. Computed tomography ruled out a possible pulmonary embolism; laboratory specific tests for human immunodeficiency virus, rheumatoid factor, and anti-nuclear antibodies were negative, and dasatinib-induced pulmonary arterial hypertension was diagnosed.A follow-up right-sided heart catheterization and 6-minute walk test done a month after the discontinuation of dasatinib showed significant improvement: mean pulmonary artery pressure of 34 mmHg and pulmonary vascular resistance of 4 Wood units.ConclusionsPatients should always be closely monitored when using dasatinib for a prolonged time. Dasatinib-induced pulmonary hypertension may be fully reversible after the therapy is suspended, but the key factors involved are still unclear and need to be further studied.

Drug-induced Rowell syndrome, a rare and difficult to manage disease: A case report.

Rowell syndrome is defined as the association between lupus erythematosus, erythema multiforme-like lesions and characteristic immunological changes including positive tests for rheumatoid factor, speckled antinuclear antibody, positive anti-Ro or anti-La antibodies. The present report presents the case of a 45-year-old female patient who was previously diagnosed in January 2010 with terbinafine-induced subacute cutaneous lupus erythematosus and was admitted for a skin eruption consisting of erythematous-papular erythema multiforme-like lesions, primarily on the trunk and limbs. The associated symptoms consisted of fatigability, myalgia and gonalgia. In October 2015, the illness reoccurred ~1 week after the initiation of Helicobacter pylori eradication treatment. Anti-Ro antibodies, rheumatoid factor and antinuclear antibody tests were positive. Given the patient's medical history, clinical manifestations, and laboratory, histopathological and immunofluorescence microscopy findings, a diagnosis of Rowell syndrome was made. Systemic corticosteroids (methylprednisolone; 0.5 mg/kg/day) and immunomodulatory therapy (azathioprine; 50 mg/day) were administered with the associated medication (omeprazole, 20 mg/day; KCl, 1 g/day) and topical dermocorticoids (fluticasone propionate 0.05% cream; 1 application/day), with a favorable outcome. The major diagnostic criteria for Rowell syndrome are the presence of lupus erythematosus (acute, subacute or systemic), erythema multiforme-like lesions and positive testing for antinuclear antibodies. The minor diagnostic criteria for Rowell syndrome are chilblains, the presence of anti-Ro antibodies and positive testing for rheumatoid factor. A diagnosis of Rowell syndrome is made if the patient exhibits all major criteria and at least one minor criterion. The present case met all diagnostic criteria, excluding the presence of chilblains. Notably, in this case there was a co-occurrence of subacute lupus erythematosus and Rowell syndrome lesions, which was drug-induced.

A young female presenting with unilateral sacroiliitis following dengue virus infection: a case report

BackgroundDengue is a common arthropod-borne viral infection in Sri Lanka which is spread by the mosquitos of the genus Aedes. The clinical features of dengue include high-grade fever associated with arthralgia and myalgia. However, dengue virus is not considered an arthritogenic virus. We report a case of a previously healthy young female who presented with imaging-confirmed right-sided sacroiliitis 10 days after developing dengue fever. This is the first reported case that shows a possible link between dengue infection and development of arthritis.Case presentationA 14-year-old Sri Lankan female presented to our medical unit with right buttock and hip pain of 3 weeks’ duration. She had serologically confirmed dengue infection 10 days prior to the onset of buttock pain. A clinical examination revealed features of right sacroiliitis. An X-ray of her sacroiliac joint showed joint space widening and reactive bone changes. Magnetic resonance imaging of her pelvis and sacroiliac joint confirmed the diagnosis of acute sacroiliitis. She had an erythrocyte sedimentation rate of 110 mm first hour with a normal C-reactive protein. Her human leukocyte antigen-B27, rheumatoid factor, antinuclear antibody, chikungunya antibody, hepatitis serology, Brucella serology, and tuberculin skin test were negative. She was treated with nonsteroidal anti-inflammatory drugs and showed gradual improvement.ConclusionsAfter excluding possible causes for sacroiliitis, we postulated that sacroiliitis in the index case could have been caused or triggered by dengue virus infection. However there is a possibility that the sacroiliitis merely coincided with the dengue virus infection. This case illustrates the possibility that dengue virus could have a link with the development of arthritis in the same manner as other arthritogenic viruses; possible mechanisms for this include direct invasion of the synovium and the joint tissue by the virus, immune complex formation and deposition in the joint tissue, and immune dysregulation. Further studies are needed in this field to gain more knowledge, as dengue infection is highly prevalent in Sri Lanka.

Determining early referral criteria for patients with suspected inflammatory arthritis presenting to primary care physicians: a cross-sectional study.

ObjectiveEarly diagnosis and initiation of treatment for inflammatory arthritis can greatly improve patient outcome. We aimed to provide standardized and validated criteria for use by primary care physicians (PCPs) in the identification of individuals requiring referral to a rheumatologist.Patients and methodsWe analyzed the predictive value of a wide variety of demographic variables, patient-reported complaints, physical examination results, and biomarkers in order to identify the most useful factors for indicating a requirement for referral. Patients for this cross-sectional study were enrolled from various centers of the city of Jeddah, Saudi Arabia, if they were ≥18 years of age and presented to a PCP with small joint pain that had been present for more than 6 weeks. A total of 203 patients were enrolled, as indicated by the sample size calculation. Each patient underwent a standardized physical examination, which was subsequently compared to ultrasound findings. Biomarker analysis and a patient interview were also carried out. Results were then correlated with the final diagnosis made by a rheumatologist.ResultsA total of 9 variables were identified as having high specificity and good predictive value: loss of appetite, swelling of metacarpophalangeal joint 2 or 5, swelling of proximal inter-phalangeal joint 2 or 3, wrist swelling, wrist tenderness, a positive test for rheumatoid factor, and a positive test for anti-citrullinated protein antibodies.ConclusionNine variables should be the basis of early referral criteria. It should aid PCPs in making appropriate early referrals of patients with suspected inflammatory arthritis, accelerating diagnosis and initiation of treatment.

Phenome-Wide Association Study of Rheumatoid Arthritis Subgroups Identifies Association Between Seronegative Disease and Fibromyalgia.

The differences between seronegative and seropositive rheumatoid arthritis (RA) have not been widely reported. We performed electronic health record (EHR)-based phenome-wide association studies (PheWAS) to identify disease associations in seropositive and seronegative RA. A validated algorithm identified RA subjects from the de-identified version of the Vanderbilt University Medical Center EHR. Serotypes were determined by rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) values. We tested EHR-derived phenotypes using PheWAS comparing seropositive RA and seronegative RA, yielding disease associations. PheWAS was also performed in RF-positive versus RF-negative subjects and ACPA-positive versus ACPA-negative subjects. Following PheWAS, select phenotypes were then manually reviewed, and fibromyalgia was specifically evaluated using a validated algorithm. A total of 2,199 RA individuals with either RF or ACPA testing were identified. Of these, 1,382 patients (63%) were classified as seropositive. Seronegative RA was associated with myalgia and myositis (odds ratio [OR] 2.1, P = 3.7 × 10-10 ) and back pain. A manual review of the health record showed that among subjects coded for Myalgia and Myositis, ∼80% had fibromyalgia. Follow-up with a specific EHR algorithm for fibromyalgia confirmed that seronegative RA was associated with fibromyalgia (OR 1.8, P = 4.0 × 10-6 ). Seropositive RA was associated with chronic airway obstruction (OR 2.2, P = 1.4 × 10-4 ) and tobacco use (OR 2.2, P = 7.0 × 10-4 ). This PheWAS of RA patients identifies a strong association between seronegativity and fibromyalgia. It also affirms relationships between seropositivity and chronic airway obstruction and between seropositivity and tobacco use. These findings demonstrate the utility of the PheWAS approach to discover novel phenotype associations within different subgroups of a disease.

Potency of Enzymes from Renal Tubules as Biotracers in Rheumatoid Arthritis Patients Treat With Most Used Antirheumatic Drugs

Aim: To estimate the effect of initial therapy with Paracetamol and Ketoprofen on glomerular and tubular integrity in patients with Rheumatoid arthritis (RA), to quantify the toxicity of these drugs through measurements of the enzyme excretion that correlates with the damage degree on the tubular epithelium. Microalbuminuria is used as a marker for glomerular damage, and the urinary excretion of N-Acetyl-?-D-glucozaminidase (NAG) as an indicator of proximal tubular damage. To determine if there is a change in the clinical indicators of renal function (serum urea and creatinine, urine urea and creatinine, glomerular filtration rate - GFR) in the course of disease and if that change correlates with the dynamics of the quantity of excreted enzymes in urine, reactants of the acute pfase and index of disease activity (DAS28). Methods: Using the colorimetric method for the determination of NAG, as well as immunoturbidimetric immunoturbidimetric assay for detection of microalbuminuria, we examined samples of 70 participants (35 RA pts treated only with Paracetamol, 35 RA pts treated with Ketoprofen), followed up in five time intervals in the course of 24 weeks. Rheumatoid factor (RF) is determined by the agglutination test (Lateks RF test) in the same participants. Results: there is a weak correlation between NAG and microalbuminuria (r=0.16) in the group of patients treated with Paracetamol, while in the group treated with Ketoprofen there is a moderate correlation (r=0.28). NAG Arch Clin Biomed Res 2016; 1 (1): 20-31 21 enzymuria in range, in number of examined patients and in the time of appearance is greater and appears earlier in the group with Ketoprofen compared with the group of Paracetamol. Conclusions: Ketoprofen is a more potent NAG inductor and triggers greater tubular enzymuria than Parcetamol.

Rheumatoid arthritis: Autoantibody testing to predict response to therapy in RA.

New research shows that an extended autoantibody repertoire is associated with adverse clinical outcomes in patients with rheumatoid arthritis. Testing for rheumatoid factor and antibodies against citrullinated proteins is now routine in the evaluation of patients with rheumatoid arthritis; should this testing be extended to include other classes of autoantibody?

Determination of Specificity and Sensitivity of Rheumatoid Factor and Anti CCP Tests in Patients with RA in Private Clinic in Tehran, Iran

Introduction Rheumatoid Arthritis (RA) is a common systemic autoimmune disease that 1% of the world's population is suffering from it [1]. The disease, in addition to reducing the average life expectancy of patients, is associated with significant morbidity. So that 50% of RA patients are no

Evaluation of the Involvement of the Tempromandibular Joint in Patients with Psoriasis using Computed Tomography for Detection of Psoriatic Arthritis Changes

Background: Tempromandibular disorders is a collective term, embracing several clinical roblems involving the muscles of mastica- tion, temporomandibular joint (TMJ), or both . Tempromandibular disorders is a symptom complex rather than a single condition. TMDs form a cluster of related disorders with common symptoms which include localized pain, limited or asymmetric movement, and clicks or grating on opening . Psoriatic arthritis is a chronic inflammatory arthropathy that affects patients with psoriasis . The clinical findings for Tempromandibular PSA are pain, tenderness, limitation of movement , joint stiffness, clicking as the jaw is opened or closed, difficulty in opening the mouth, locking of the jaw,and crepitations. These findings are essentially the same as for myofascial pain/dysfunction (3) . The objective of the study were to determine the extent of tempromandibular joint involve- ment in patients with psoriatic arthritis and to evaluate the correlation between clinical findings and radiographic finding. Materials and method: In this study 98 patients were selected ,50 male and 48 female, their age ranged between(18-68)years. They were collected at Al –yarmook teaching hospital/department of.They were diagnosed as having psoriatic arthritis by a derma- tologist according to (Moll and Wright diagnostic criteria 1973) (11) . These patients were subjected to rheumatoid factor test RF to exclude the presence of rheumatoid arthritic disease, then the patients were exposed to CT scanning for the Tempromandibular joint in Al-Yarmook teaching hospital for screening the involvement of TMJ with psoriatic arthritis by the presence of any radio- graphic changes such as erosion, flattening,osteophyte and sclerosis in the condylar head. Results: The result of the study showed that the mean age of psoriatic arthritic patients in TMJ was (44.2) years, and female per- centage was (48.4%) and male was(51.6%). Psoriatic arthritis in TMJ showed high significance in the unilateral side complaining (100%) and itwas significant in the positive family history (54.8%), and non significant in the right/left ratio (41.9%). Oligo type was found in twenty six patients (83.9%) with significant p-value. Clinically: all symptoms including clicking, tenderness and temproma- dibular joint pain were highly significant, limitation showed (54.8%), TMJ pain showed (64.5%) and tenderness showed (54.8%). Radiologically: CT scan showed sensitivity for erosion in TMJ (54.8%), for osteophyte (32.3%), for condylar flattening (16.1%) and for sclerosis (9.7%) while specificity for all were (100%). Association between clinical and radiological changes showed non significant correlation. Conclusions: Psoriatic arthritis of TMJ is unilateral (oligo type).Female/ male ratio is about 1:1. About 50% of patients have lim- itation in mouth opening. Most of the patients have positive family history. Duration of the disease is related to the development of psoriatic arthritis in TMJ. Plaque psoriasis is the most associated type with the psoriatic arthritis in TMJ. Most of patients with psoriatic arthritis show psoriatic nail changes. The most radiographic findings found in patients with psoritic arthritis was erosion in the condylar head. There is association between clinical and radiologic findings for psoriatic arthritis in TMJ.

Whipple's arthritis

Whipple's disease is a chronic systemic infection that is due to the bacterial agent Tropheryma whipplei and can be cured by appropriate antibiotic therapy. The typical patient is a middle-aged man. Rheumatologists are in a prime position to handle Whipple's disease. The classical presentation combines weight loss and diarrhea, preceded in three-quarters of patients by a distinctive pattern of joint manifestations that run an intermittent course, at least initially. The mean time from joint symptom onset to the diagnosis of Whipple's disease is 6 years. Either oligoarthritis or chronic polyarthritis with negative tests for rheumatoid factors (RFs) develops. If the diagnosis is missed, progression to chronic septic destructive polyarthritis may occur. Spondyloarthritis has also been reported, as well as a few cases of diskitis or, even more rarely, of hypertrophic osteoarthropathy. In most patients with the classical form of Whipple's disease, periodic acid-Schiff (PAS) staining of duodenal and jejunal biopsies shows macrophagic inclusions that contain bacteria. However, the involvement of the bowel may be undetectable clinically or, less often, histologically, and even PCR testing of bowel biopsies may be negative. Therefore, when nothing points to bowel disease, rheumatologists should consider T. whipplei infection in middle-aged men with unexplained intermittent oligoarthritis. PCR testing allows the detection of T. whipplei genetic material in joint fluid, saliva, and feces. This test is now a first-line diagnostic investigation, although T. whipplei is a rare cause of unexplained RF-negative oligoarthritis or polyarthritis in males. PCR testing can provide an early diagnosis before the development of severe systemic complications, which are still fatal in some cases.

Novel immunodiagnostics for inflammatory arthritis

Immunodiagnostics play an important role in the differential diagnostics of arthritis but the test results must be interpreted with respect to the clinical context. The detection of antibodies against citrullinated proteins has significantly improved the immunodiagnostics of arthritis, whereas the importance of testing for rheumatoid factor has decreased due to the low specificity. Antibodies against carbamylated or oxidized proteins will expand the immunodiagnostics of arthritis (especially rheumatoid arthritis) in the future. In contrast, the determination of cytokine concentrations in plasma or synovial fluid plays a subordinate role in the differential diagnostics of arthritis. Indirect immunofluorescence continues to be the gold standard in the detection of antinuclear antibodies (ANA) and in the case of positive results further testing for antigen specificity should be carried out. The presence of ANA is not necessarily associated with autoimmune diseases. An example of a non-pathogenic ANA is anti-DFS70 antibodies.

Phenotypic Characterization of Juvenile Idiopathic Arthritis in African American Children.

Juvenile idiopathic arthritis (JIA) affects children of all races. Prior studies suggest that phenotypic features of JIA in African American (AA) children differ from those of non-Hispanic white (NHW) children. We evaluated the phenotypic differences at presentation between AA and NHW children enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry, and replicated the findings in a JIA cohort from a large center in the southeastern United States. Children with JIA enrolled in the multicenter CARRA Registry and from Emory University formed the study and replication cohorts. Phenotypic data on non-Hispanic AA children were compared with NHW children with JIA using the chi-square test, Fisher's exact test, and the Wilcoxon signed-rank test. In all, 4177 NHW and 292 AA JIA cases from the CARRA Registry and 212 NHW and 71 AA cases from Emory were analyzed. AA subjects more often had rheumatoid factor (RF)-positive polyarthritis in both the CARRA (13.4% vs 4.7%, p = 5.3 × 10(-7)) and the Emory (26.8% vs 6.1%, p = 1.1 × 10(-5)) cohorts. AA children had positive tests for RF and cyclic citrullinated peptide antibodies (CCP) more frequently, but oligoarticular or early onset antinuclear antibody (ANA)-positive JIA less frequently in both cohorts. AA children were older at onset in both cohorts and this difference persisted after excluding RF-positive polyarthritis in the CARRA Registry (median age 8.5 vs 5.0 yrs, p = 1.4 × 10(-8)). Compared with NHW children, AA children with JIA are more likely to have RF/CCP-positive polyarthritis, are older at disease onset, and less likely to have oligoarticular or ANA-positive, early-onset JIA, suggesting that the JIA phenotype is different in AA children.

Carbimazole-induced agranulocytosis

A 47 year old lady with hyperthyroidism for past 1½ years was initially on Carbimazole 20 mg orally then changed to 30 mg (during Hysterectomy) but was taking 10 mg for last 1 year. She had intermittent fever with severe B/L bifrontal headache since 3 weeks. Routine investigations showed anaemia, neutropenia, leucopenia and CRP elevation. Peripheral smear showed normocytic normochromic anaemia with Rouleaux formation, leucopenia with 2% atypical cells and mild thrombocytosis. Widal test, RA factor (Rheumatoid factor) test, Ig M (Immunoglobulin M) dengue, Ig M Lepto, TORCH infections (Toxoplasmosis, Other (Syphilis, varicella-zoster, parvovirus B19), Cytomegalovirus and Herpes infections), ANA (Antinuclear antibody) screen cANCA (Cytoplasmic antineutrophil cytoplasmic antibodies) and pANCA (Perinuclear Anti-Neutrophil Cytoplasmic Antibodies) tests were negative. Bone marrow aspiration showed normo to hypercellular marrow with 15% atypical cells and plasma cells. Multiple myeloma workup was done. Carbimazole was withheld. Conclusion: Drug induced agranulocytosis occurs with in 1-2 months of taking the antithyroid medication but onset delayed by 1½ year. De-challenge resulted normalization of blood parameters.

Rheumatoid Arthritis Serology in Macedonian Patients with Rheumatoid Arthritis: Rheumatoid Factor, Anti-Cyclic Citrulinated Peptide Antibodies or both?

Introduction : In the last 70 years, Rheumatoid Factor (RF) was considered the most useful laboratory marker in patients with rheumatoid arthritis (RA). The next very important milestone for the RA diagnosis was the discovery of anti-citrullinated peptide/protein antibodies (ACPA). The detection of ACPA is usually done with the CCP test of the second generation, CCP2. Objective : To evaluate the performances of RF and CCP2 tests and to see whether or not the performance of both tests together is better then the performances of either of the tests alone. Materials and Methods : We performed a cross-sectional study with 380 participants of which 155 RA patients who fulfilled the American College of Rheumatology (ACR) 1987 classification criteria for RA, 120 patients with inflammatory and other connective tissue diseases (Non-RA) and 105 healthy controls (HC), at the Rheumatology Clinic in Skopje, Macedonia. The patients and controls were tested for RF and ACPA. Results : The mean age of the RA patients was 50 years, and 87 % of the patients were female. The average duration of the disease has been 6 years. In this group of patients, CCP2 test showed identical sensitivity of 0,69 and better specificity than RF (0,95 vs. 0,87 respectively). For the patients who tested positive for both tests, the sensitivity was lower 0,60 and for the patients who were either ACPA or RF positive, sensitivity was slightly higher 0,73. The specificity of 0,88 for both or either of the tests was identical with that of RF. The positive likelihood ratio was 13,8 for the CCP2 test, 5,3 for RF and 5,1 for both tests done together. Ninety four out of 155 RA patients were positive for both ACPA and RF, 20 patients were positive for either one of the antibodies of which 7 (4,5%) RA patients were only anti-CCP positive and 13 (8,3%) patients were only RF positive. Conclusion : The results from our study showed that the sensitivity and specificity of both tests, done in parallel, does not differ much from the sensitivity of either of the tests alone and from the specificity of RF, respectfully. Still, CCP2 test showed the highest specificity and positive likelihood ratio as was expected. The results from our study support the idea that in countries like Macedonia, which can not afford enough CCP2 antibody kits, we may use RF first, especially in patients who are not likely to meet any clinical criteria for RA. In patients with early undifferentiated arthritis or early RA we may use both antibodies in order to select the patients who will need more aggressive treatment.