Setting Of Rheumatoid Arthritis Research Articles

Cytomegalovirus chronic retinal necrosis with ganciclovir resistance: a case report.

Cytomegalovirus (CMV) chronic retinal necrosis (CRN) is a rare viral retinal infection that occurs in mildly immunocompromised people. It shares some features with both acute retinal necrosis and CMV retinitis. It is typically treated with combination intravitreal and systemic ganciclovir. We discuss the management of a case of CMV CRN with ganciclovir resistance. An 80-year-old female presented with one month of blurry vision in the left eye. She was being treated with abatacept, methotrexate, and prednisone for rheumatoid arthritis. Examination revealed anterior chamber and vitreous cell along with peripheral retinal whitening. Fluorescein angiogram showed diffuse retinal non-perfusion. Aqueous fluid PCR testing returned positive for CMV. The retinitis was initially controlled with oral and intravitreal ganciclovir, but then recurred and progressed despite these therapies. Ganciclovir resistance was suspected and the patient was switched to intravitreal foscarnet injections, along with oral letermovir and leflunomide, which lead to resolution of the retinitis. The patient has now continued with letermovir and leflunomide for approximately 2.5 years without reactivation of the retinitis or need for further intravitreal anti-viral injections and with adequate control of her rheumatoid arthritis. The incidence of CMV CRN may increase in the future as the use of non-cytotoxic immunosuppressive therapies that result in relatively mild immunosuppression also increases. Treatment with ganciclovir is effective but frequently leads to resistance, as in our case. In this situation, combination therapy with letermovir and leflunomide, particularly in the setting of rheumatoid arthritis where leflunomide can also have an anti-inflammatory effect, can be considered.

Rheumatoid Arthritis and Pericardial Effusion - A Unique Major Manifestation.

Pericardial effusion is common in the setting of rheumatoid arthritis (RA); however, it is rarely its first manifestation. An 82-year-old male presented with abdominal pain, vomiting and fever. Blood analysis revealed elevated systemic inflammatory markers, and an abdominal computed tomography scan revealed non-specific alveolar condensation of the right pulmonary base and pericardial effusion subsequently quantified as medium size by transthoracic echocardiography. A large aetiological panel was requested, with the autoimmunity study revealing high levels of rheumatoid factor (RF) and anti-citrullinated cyclic peptide (anti-CCP) antibodies. Since the patient did not present articular involvement, the initial hypothesis was pericardial effusion due to pneumonia and no specific treatment for RA was started. At follow-up, the pericardial effusion recurred and a pericardiocentesis was performed. The pericardial fluid analysis was sterile, and no malignant cells were identified. A new serological study confirmed high levels of RF and anti-CCP antibodies, and immunomodulatory treatment was initiated. After one year, the pericardial effusion recurred due to non-compliance with immunomodulatory therapy. A surgical pleuro-pericardial window was performed, and the cytological study of the pericardial patch revealed submesothelial thickening and foci of perivascular lymphocytic infiltrate. The patient remained asymptomatic. After exclusion of a large spectrum of infectious and non-infectious causes and the relapse after suspension of immunomodulatory treatment, the most probable aetiology for the pericardial effusion remains RA. Pericardial syndromes can be the first manifestation of AR even in the absence of articular symptoms and this disease must be considered in the aetiological investigation. The occurrence of pericardial effusion in the setting of rheumatoid arthritis (RA) is a usual finding but this form of extra-articular manifestation is possibly the first and only presentation of the disease.In the case of recurrent pericardial effusion, the diagnosis of RA must be considered in the aetiological investigation even in the absence of more common manifestations of the disease.

A Unique Interaction of Methotrexate and Nitrofurantoin Resulting in Irreversible Pulmonary Fibrosis

Pulmonary toxicity is the most well-known severe complication related to both methotrexate and nitrofurantoin, which can present as acute, subacute, and chronic. Rheumatoid arthritis is also known to cause pulmonary disease if left untreated. In this report, we present a unique case of a 94-year-old female being treated with methotrexate for several years and then treated with nitrofurantoin in the setting of rheumatoid arthritis and chronic urinary tract infections, resulting in irreversible pulmonary fibrosis, which can further cause more susceptibility to infections and pneumonia. Drug-drug interactions are common in polypharmacy and a patient's history should be analyzed thoroughly before prescribing any new medication that can cause more harm to the patient than good.

Analysis of a single-institution cohort of patients with Felty's syndrome and T-cell large granular lymphocytic leukemia in the setting of rheumatoid arthritis

T-cell large granular lymphocytic leukemia (T-LGLL) is a lymphoproliferative disorder characterized by a persistent increase in the number of large granular lymphocytes (LGLs), neutropenia, and splenomegaly. Clinical manifestations of T-LGLL in the setting of rheumatoid arthritis (RA) are often identical to those in which one would suspect Felty's syndrome (FS). These disorders are distinguished by the presence of T-cell clonality, which is present in T-LGLL but not in FS. Mutations in the signal transducer and activator of transcription 3 (STAT3) and 5b (STAT5b) genes can be used as molecular markers of T-LGLL, but their prevalence in FS is unknown.Eighty-one patients with RA and unexplained neutropenia or/and an increase in the number of LGLs above 2 × 109/L were stratified into RA-associated T-LGLL (N = 56) or FS (N = 25) groups based on the presence or absence of T-cell clonality. STAT3 and STAT5b gene mutations were assessed in each group by means of allele-specific polymerase chain reaction assays. Clinical, immunological, laboratory data and the results of immunophenotyping of blood and bone marrow lymphocytes were also evaluated.Mutations of the STAT3 gene and an increase in the number of LGLs above 2 × 109/L were detected in RA-associated T-LGLL, but not in FS (39% vs 0% and 21% vs 0%, respectively). Mutations in the STAT5b gene were not observed in either group. Expression of CD57, CD16, and CD5−/dim on CD3+CD8+ T-lymphocytes was observed in both RA-associated T-LGLL and FS.STAT3 gene mutations or LGL counts over 2 × 109/L in RA patients are indicative of T-LGLL.

Anatomic total shoulder arthroplasty in rheumatoid arthritis: A systematic review.

Given the poor soft-tissue quality in rheumatoid arthritis patients, many believe that rheumatoid arthritis should be treated with reverse total shoulder arthroplasty (rTSA). The purpose of this paper is to systematically assess outcomes of anatomic total shoulder arthroplasty (aTSA) in rheumatoid arthritis to determine if aTSA remains a viable option. A comprehensive literature search was conducted identifying articles relevant to aTSA in the setting of rheumatoid arthritis with intact rotator cuff. Outcomes include clinical outcomes and rates of complication and revision. Ten studies were included with a total of 279 shoulders with mean follow-up of 116 ± 69 months. The mean age was 68 ± 10 years. Survivorship was 97%, 97% and 89% at 5, 10 and 20 years, respectively. The overall complication rate was 9%. Radiolucency was present in 69% of patients, of which 34% were at risk of loosening at 79 months. The overall rate of revision was 8.4%. Studies generally reported clinically significant improvements in range of motion, Constant score and ASES score. aTSA in the rheumatoid patient results in improvements in range of motion and patient-reported outcomes. Rates of complications and survivorship are generally good in this population. However, it should be noted that there is significant heterogeneity in outcome reporting amongst the literature on this topic and that many studies fail to adequately report complication and revision rates. When compared to rTSA in patients with rheumatoid arthritis, evidence suggests that aTSA is still a viable treatment option despite the shift in utilization to rTSA.

P38 A rare case of rheumatoid arthritis with perforating collagenosis

Abstract Background Rheumatoid arthritis has multiple cutaneous manifestations with rheumatoid nodule being the commonest one. A maculopapular rash in setting of rheumatoid arthritis has a varied list of differentials including rheumatoid vasculitis, pyoderma gangrenosum, rheumatoid neutrophilic dermatosis, interstitial granulomatous dermatitis and palisaded neutrophilic granulomatous dermatitis. We present a rare case of patient with rheumatoid arthritis with perforating collagenosis. Methods A case report is presented in the results section. Results A 64 year old lady known to have seropositive rheumatoid arthritis for the past 6 years with poor compliance to treatment presented with maculopapular lesions on both her legs and abdomen. The lesions were itchy in nature and later became ulcerative. The lesions spread to various parts of the body over the next 4 weeks and patient was seen by a dermatologist who initially prescribed topical therapy and the patient came off her disease modifying anti rheumatic agents. She underwent a skin biopsy as initial investigations were otherwise unremarkable. Skin biopsy revealed a diagnosis of perforating collagenosis. She was given topical steroids and counselled regarding the need to take her disease modifying anti rheumatic drugs regularly. There was 95% resolution of skin lesions within 6 months. Conclusion Perforating collagenosis is a skin disorder characterised by transepithelial expulsion of dermal tissue which presents as a papulonodular rash with central keratin plugs. It is usually associated with diabetes mellitus and chronic kidney disease but rarely been reported in association with rheumatoid arthritis. Literature review revealed that there have been only 2 cases reported previously. The first case has been described in 2010 in a man from Singapore on treatment for RA for 2 years. Second case has been described by Ikeda et al in 2019 in a case of rheumatoid vasculitis. Clinically it presents as umbilicated, hyperkeratotic papules with a central white keratotic crust. Koebnerization may be seen and itching of surrounding regions may lead to papules to coalesce and form plaques. A biopsy will reveal features similar to those seen in the primary disease where perforating collagenosis shows cup shaped invagination of the epidermis filled with a plug consisting of keratin and cellular debris. There have been no trials and treatment is based on case reports. We believe that better compliance to her disease modifying anti rheumatic agent therapy, leading to improved treatment of the systemic cause had a significant role in resolving her skin lesions. Disclosures S. Deb None. S. Srirangan None.

Optimising low-dose methotrexate for rheumatoid arthritis-A review.

Methotrexate at low doses (5-25mg/week) is first-line therapy for rheumatoid arthritis. However, there is inter- and intrapatient variability in response, with contribution of variability in concentrations of active polyglutamate metabolites, associated with clinical efficacy and toxicity. Prescribing remains heterogeneous across population groups, disease states and regimens. This review examines current knowledge of dose-response of oral methotrexate in the setting of rheumatoid arthritis, and how this could help inform dosage regimens.

Outcomes of Minimally Invasive Oblique Lumbar Interbody Fusion in Patients with Lumbar Degenerative Disease with Rheumatoid Arthritis.

Standard treatment protocols for lumbar degenerative lesions in the setting of rheumatoid arthritis (RA) are lacking. The purpose of this study was to evaluate the clinical and radiologic outcomes of minimally invasive oblique lumbar interbody fusion (MI-OLIF) in RA patients having degenerative lumbar spine lesions. This was a retrospective hospital-based case series (evidence level 4). Eight patients with degenerative lumbar disease with significant back pain and neurologic claudication underwent MI-OLIFwith polyetheretherketone cage insertion and posterior pedicle screw instrumentation. The clinical outcomes were measured by the numerical rating scale (NRS) for back and leg pain and the Oswestry Disability Index (ODI), and radiologic outcomes were studied on radiographs, computed tomography, and magnetic resonance imaging. Minimum follow-up duration was 1 year. Mean NRS results for back and leg pain preoperatively were 6.3 and 7.1 that improved to 2.6 and 2 for back and leg pain, respectively, at last follow-up. The mean ODI scores preoperatively were 58.02 that improved to 39.06 at last follow-up. All patients had good functional outcomes, good fusion rates, and were able to continue their activities of daily living without much disability at last follow-up. MI-OLIF in patients with symptomatic lumbar spine degenerative lesions with RA seems to provide good short-term clinical and radiologic outcomes.

Thrombotic Microangiopathies with Rheumatologic Involvement.

Thrombotic microangiopathies are heterogeneous disorders characterized by microangiopathic hemolytic anemia with thrombocytopenia and renal injury. There are a variety of causes, including metabolic disorders, infections, medications, complement disorders, pregnancy, malignancy, and autoimmune disorders. This review focuses on renal thrombotic microangiopathy in the setting of rheumatologic diseases. Systemic lupus erythematosus is the most common autoimmune disease associated with thrombotic microangiopathy. Other etiologies include scleroderma renal crisis and antiphospholipid antibody syndrome, which can be primary or secondary to autoimmune diseases including systemic lupus erythematosus. There have also been case reports of thrombotic microangiopathy in the setting of rheumatoid arthritis and dermatomyositis.

Pelvic radiotherapy in the setting of rheumatoid arthritis: Refining the paradigm

PurposeConflicting results concerning the toxicity of radiotherapy in the setting of rheumatoid arthritis were reported in literature. This work describes the toxicity profiles of patients with rheumatoid arthritis undergoing pelvic radiotherapy for gynecologic malignancies at our institution. Patients and methodsCharts of patients with rheumatoid arthritis who underwent pelvic radiotherapy for cervical or endometrial cancer in a curative intent at the Gustave-Roussy Cancer Campus between 1990 and 2015 were reviewed for treatment-related toxicities. Acute and late effects were graded as per the Common Terminology Criteria for Adverse Events version 4.0 scoring system. ResultsEight patients with cervical cancer and three with endometrial cancer were identified. Median follow-up was 56 months. Median external beam radiotherapy dose was 45Gy. All patients received a brachytherapy boost using either pulse- or low-dose rate technique. Concomitant chemotherapy was used in seven cases. Median time from rheumatoid arthritis diagnosis to external beam radiation therapy was 5 years. No severe acute gastrointestinal or genitourinary toxicity was reported. One patient had grade 3 dermatitis. Any late toxicity occurred in 7 /11 patients, and one patient experienced severe late toxicities. One patient with overt systemic rheumatoid arthritis symptoms at the time of external beam radiation therapy experienced late grade 3 ureteral stenosis, enterocolitis and lumbar myelitis. ConclusionPelvic radiotherapy, in the setting of rheumatoid arthritis, appears to be feasible, with potentially slight increase in low grade late events compared to other anatomic sites. Patients with overt systemic rheumatoid arthritis manifestation at the time of radiotherapy might be at risk of potential severe toxicities.

Pyoderma gangrenosum et aortite neutrophilique précédant l’apparition d’une polyarthrite rhumatoïde

We report a case of pyoderma gangrenosum (PG) associated with a complication comprising ascending aortic dissection (neutrophilic aortitis) in a setting of rheumatoid arthritis (RA). A 79-year-old female patient was hospitalized in late 2009 for vegetating PG. Treatment with general steroids followed by colchicine and topical steroids resulted in complete healing of skin lesions. During hospitalization, the patient presented dissection of the ascending part of the aorta, for which emergency surgery proved effective. Histological examination of the excised tissue revealed diffuse neutrophilic aortitis. Diagnoses of Takayashu's disease and of lupus were ruled out. A chest CT scan showed interstitial lung disease with mild lymphocytosis in the bronchoalveolar fluid, but with no isolated pathogenic organisms. Relapse of skin lesions occurred 3 and 4 years later, associated with the development of RA, and worsening of the interstitial lung disease was noted in a scan carried out it in 2013, following which stabilization was observed in April 2014. There was no recurrence of the PG lesions. To our knowledge, no other cases involving association of neutrophilic aortitis with PG and RA has been published to date. The literature describes the emergence of the concept of systemic neutrophilic dermatoses, and this notion is reinforced by the presence of a cutaneous and aortic site of the neutrophilic disease in a single patient.

Distal humeral hemiarthroplasty: indications, results, and complications. A systematic review.

Distal humeral hemiarthroplasty (DHH) is a treatment option for unreconstructable intra-articular distal humerus fractures. DHH may also be used in the setting of rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis. DHH has specific advantages over other, more common, treatment modalities: total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF). DHH is especially a reasonable option in younger patients to preserve bone stock, avoid significant weight restrictions, and limit loosening. The literature was reviewed for all cases of DHH for fracture and non-fracture indications between 1947 and 2014. Two hundred thirty-six papers were identified; 4 studies including 17 patients met criteria for non-fracture indications and 13 studies including 116 patients were identified for fracture indications. A systematic review was generated; patient indications, outcomes, and complications were recorded. For non-fracture indications, good to excellent results were achieved in 76.5% of patients with a mean arc of motion of 62° at mean follow up of 46.3months. Half of the patients experienced a complication, most commonly stiffness. Loosening of the prosthesis was not noted in any patient. For fractures, good to excellent results were achieved in 67.4% of patients with a mean arc of motion of 98.3° at a mean follow up of 42.2months. One third of the patients experienced a complication but only 1.7% experienced loosening of the prosthesis. Here, we present the first review of the indications for DHH. DHH is a reasonable treatment option for older patients with unreconstructable intra-articular fractures of the distal humerus as well as younger patients with rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis.

The role of miR-155 in regulatory T cells and rheumatoid arthritis

Recently, various micro(mi)RNAs have been found deregulated in the setting of rheumatoid arthritis (RA), but their role in the pathogenesis of this disease remains a matter of debate. In the meanwhile, increasing evidence indicates a defective function of regulatory T cells (Tregs) in RA. This review discusses relevant studies addressing the function of Tregs and Cytotoxic T-Lymphocyte Antigen 4 in RA, provides recent data on the role of miRNAs for Tregs homeostasis, and focuses on the role of miR-155 in Tregs. In a final perspective section we discuss the potential impact of therapeutic miR-155 modulation in RA.

Overuse of Prescription and OTC Non-Steroidal Anti-Inflammatory Drugs in Patients with Rheumatoid Arthritis and Osteoarthritis

Non-steroidal anti-inflammatory drugs (NSAIDs) have been demonstrated to have significant cardiovascular and gastrointestinal toxicity; high dose of intake and concomitant use of multiple compounds or corticosteroids are factors that increase the risk of NSAID toxicity. In this paper we described our experience on NSAIDs misuse (both prescribing and OTC formulations), particularly relevant in the setting of rheumatoid arthritis (39.5 percent of patients) and osteoarthritis (47 percent of patients). We also evaluated causes underlying NSAIDs misuse (e.g. not satisfactory pain control, other painful conditions, etc).

Abatacept Therapy for Rheumatoid Arthritis in the Setting of Hepatitis C Infection

Chronic hepatitis C in the setting of rheumatoid arthritis may be an obstacle to optimal management because of potential hepatotoxicity and adverse effects from immune suppression in these patients with a chronic infection. There are no reports in the literature discussing the use of abatacept, a T-cell costimulatory blocker, in patients with chronic hepatitis C. This article is the first report to describe the use of abatacept in 2 patients with rheumatoid arthritis and concomitant hepatitis C with favorable outcome.

Dermatite granulomateuse interstitielle avec arthrites : quatre cas

Interstitial granulomatous dermatitis with arthritis, or Ackerman's syndrome, is characterized by inflammatory articular flares of potentially destructive outcome and cutaneous lesions of varied patterns: cord-like lesions on the flanks or violaceous plaques on the trunk and limbs. Histologically, the main features are histiocytes laminated between collagen fibres, sometimes organized in rosettes comprising tiny granulomas surrounding fibres of homogeneous aspect. Four patients fitting this description were investigated. Cutaneous lesions displayed various patterns: cord-like lesions (one patient), brown plaques on the flanks edged with papules (one patient), grossly annular violaceous plaques on the back (one patient), and infiltrated plaques on the palms and thighs (one patient). Joint symptoms were present in all cases (one seropositive rheumatoid arthritis and one seronegative rheumatoid arthritis, both already known; acute rheumatoid arthritis in two cases). The histological pattern was quite similar in all cases, with laminated histiocytes in palisading layers mixed with swollen collagen fibres; "rosette" figures were present in two cases. Autoimmune response was seen with antinuclear antibodies (two cases) and/or rheumatoid factor (two cases). The short-term outcome of cutaneous lesions was rapidly favourable in most cases with systemic steroids (one case) or Non Steroidal Anti-Inflammatory Drugs (one case), and spontaneously in one case. This entity, defined by the presence of inflammatory arthritis and cutaneous lesions of various clinical types, either more specific but infrequent (cord-like), or less specific but more frequent (plaque-like), and featuring a peculiar histological pattern, chiefly affects women aged between 30 and 80 years. Pathophysiological mechanisms and nosological borders are debatable and authors consider this condition as either an autonomous disease or else a mere subset of vasculitis with palisading granulomas in collagen vascular disorders, despite the rarity of authentic vasculitis. A setting of autoimmunity is frequently present. Furthermore, a fairly similar histological pattern is sometimes seen in some lesions forming a subset of cutaneous side-effects of drugs. Articular outcome may be unfavourable with joint destruction in more than half of patients, whether or not in a setting of rheumatoid arthritis. Spontaneous resorption can occur. Treatment has not yet been codified and is based primarily on anti-inflammatory drugs.

Modern biologics used in orthopaedic surgery

In this review we summarize some of the most recent research in the area of local bone regeneration. These innovations may be relevant in the orthopaedic treatment of patients with rheumatoid arthritis, or other inflammatory arthridities, as such patients often present with inadequate bone stock. Bone grafting remains the standard treatment for bone deficiency. Several new approaches, such as the use of concentrated blood products or osteoprogenitor cells in conjunction with grafts, have been developed but remain to be tested clinically. Experimental studies have elucidated important aspects of the biology of bone graft remodeling and osteoprogenitor cell differentiation. Materials that can serve as graft alternatives continue to be developed. Positive experimental findings have resulted from combinations of such materials with osteoprogenitor cells or osteoinductive factors such as bone morphogenetic proteins. While few studies to date have examined the specific use of these new strategies in the setting of rheumatoid arthritis, many hold promise for patients with rheumatoid arthritis and other inflammatory and metabolic conditions that affect bone quality and quantity.

Chronic Pain: Management Strategies That Work

Chronic Pain: Management Strategies That Work

Peripheral ulcerative keratitis in the setting of rheumatoid arthritis: Treatment with immunosuppressive therapy

Peripheral ulcerative keratitis (PUK) is a rare but serious inflammatory eyecondition that can complicate rheumatoid arthritis. PUK can be a warning sign of impending vasculitis, and cytotoxic therapy may be necessary to induce remission. We have encountered three patients with PUK in the past year. Two patients had long-standing quiescent rheumatoid arthritis who developed photophobia. Diagnosis was made by slit lamp examination. Treatment with local cyclophosphamide and prednisone resulted in prompt remission of the ulcer within 8 weeks. Cytotoxic therapy was discontinued altogether within 6 months. The third patient was also treated successfully with oral steroids and azathioprine. In all patients, sicca was noted. None of them had any evidence of systemic vasculitis. PUK, when recognized early and treated aggressively, can result in remission of the ulcer and in the prevention of vasculitis. Keratoconjunctivitis sicca can accompany PUK independent of the activity of rheumatoid arthritis.