Pattern and prognosis of haematological and non-haematological presentatations of juvenile SLE: five years longitudinal study

To assess the pattern of hematological disorders in juvenile systemic lupus erythematosus [SLE] and its impact on prognosis and survival. The prevalence of SLE in a Pediatric Hematology Unit was also assessed through a five years longitudinal study. A prospective follow up study of 32 SLE patients diagnosed and treated in the Children's Hospital and in the Rheumatology and Rehabilitation Department, Ain Shams University Hospitals, during a period of 5 years was done. Follow up of patients with acquired hematological diseases [n=235] diagnosed in a Pediatric Hematology Unit, in the same period was done to assess the prevalence of SLE in that population. Among the 32 SLE patients, 30 were females and two were males, the mean age at diagnosis was 13.3 +/- 3.5 years. Fifteen patients had an initial hematological presentation. Anemia and thrombocytopenia were the commonest hematological presentation [68.8% and 40.6% respectively]. The main non-hematological presenting features included nephropathy [71.9%], cutaneous manifestations [50%] and arthritis [65.6%]. At presentation, ANA antibodies and anti DNA were positive in 67.7% and 67.8% respectively, reaching values of 90.4% and 86.4% respectively during follow up. As regard fate, 25.2% were in remission, 15.6% lost follow up and 59.4% had progressive disease. Ten children out of the studied 235 patients with acquired hematological diseases [4.3%] developed four or more American College of Rheumatology criteria for the diagnosis of SLE during five years follow up. They were 5 out of 186 children with idiopathic thrombocytopenic purpura [2.7%], 2 out of 12 with autoimmune hemolytic anemia [16.7%], 2 out of 3 with Evan's Syndrome [66.6%] and 1 out of 5 with pure red cell aplasia [20.0%]. None of hypoplastic anemia [n=29] developed SLE. Hematological disorders are common features in childhood SLE with an impact on the prognosis. SLE constitutes the underlying pathology in 4.3% of children with acquired hematological disorders

Role of ultrasonography in the diagnosis and management of plantar fasciitis

To evaluate the sonographic features of plantar fasciitis and to investigate the efficacy of ultrasound-guided local steroid injection in its management. Forty patients, aged 25-55 years who had a clinical diagnosis of plantar fasciitis, 1-3 years previously and twenty age-matched healthy volunteers [control group], were evaluated with conventional x-rays then with ultrasound using a 7.0 MHZ linear-array transducer. All patients had calcaneal spurs in their X-rays. Heel pain was unilateral in 24 patients and bilateral in 16. Sagittal sonograms were obtained, and the thickness of plantar fascia was measured at its proximal end near its insertion into the calcaneus. Other findings including hypoechoic fascia, fiber rupture, perifascial fluid collections and calcifications were searched for. Evaluations were performed before, at 2 weeks and 3 months after a single dose of ultrasound-guided local steroid [7 mg Betamethasone and 0.5ml of 1% lidocaine] injection into the inflamed plantar fascia. Pain intensity was quantified with a tenderness threshold [TT] and visual analog scale [VAS]. Plantar fascia thickness was significantly increased in heels of patients with plantar fasciitis [mean 3.91 +/- 0.53] as compared to control [mean 2.13 +/- 0.18] [p<0.0005]. The mean thickness of the plantar fascia had decreased significantly on evaluation after 2 weeks [mean 3.73 +/- 0.53] [p<0.05]. While after 3 months there was a highly significant decrease [mean 2.39 +/- 0.43] [p<0.0005]. The mean VAS score and TT showed a highly significant improvement on evaluation after 2 weeks and 3 months [mean 4.57 +/- 0.98, 1.55 +/- 0.84 and 7.12 +/- 0.75, 9.47 +/- 1.66 respectively, p<0.0005]. The comparison between the second and third evaluations of all our parameters showed a highly significant improvement [p<0.0005]. The proximal plantar fascia was diffusely hypoechoic as compared to controls. No fascial rupture, perifascial fluid collection or calcifications were identified. Increased thickness of the fascia and hypoechoic fascia are sonographic findings of plantar fasciitis. Sonography provides sufficient information for the physician to confirm an initial diagnosis of plantar fasciitis and assess individual treatment regimens

Membrane cofactor protein as a marker of activity in systemic lupus erythematosus

1] Measure the percentage of membrane cofactor protein [MCP, CD46] expression on mononuclear cells. 2] Evaluate its role in the pathogenesis of systemic lupus erythematosus [SLE]. 3] Correlate it with disease activity or activated complement system. Thirty Egyptian SLE patients [27 females and 3 males] were enrolled in this study. All of them were subjected to thorough clinical examination and laboratory tests including complete blood picture, ESR, serum C3 and C4, serum creatinine, in addition to complete urine analysis and estimation of the percentage of MCP expression on monocuclear cells using flowcytometry. Ten normal healthy subjects were included as a control group. They were matched for age and sex with SLE patients. The percentage of MCP expression differentiated lupus patients from the control subjects and the difference was statistically highly significant [p<0.0001]. Moreover, MCP expression correlated with SLE disease activity scores [r=0.82], and with the parameters of renal damage such as serum creatinine [r=0.33] and serum C3 [r=-0.55]. This might implicate its role as an important indicator for active evolution of SLE as well as in the pathogenesis of lupus nephritis. This study suggests a role of MCP as a useful marker in evaluating SLE activity and a possible therapeutic implicator as a complement inhibitor in SLE patients

Serum interleukin-1 receptor antagonist: clinicopathological correlations with lupus nephritis

To evaluate the relationship between serum interleukin-1 receptor antagonist [IL-1ra] concentrations and renal involvement in SLE and to study its impact on laboratory, immunological and renal histopathological findings in SLE patients as well as its association with disease activity. We studied 26 [23 females, 3 males] SLE patients who had distinct clinical manifestations [22 had vasculitic skin rash, 20 had photosensitivity, 13 had oral ulcerations, 8 had neuropsychiatric manifestations]. They were classified into two subgroups; group Ia included 18 patients who had impaired renal function, 14 of them were proved by renal biopsy and group Ib that included 8 patients without renal affection. Ten healthy subjects matched for age and sex with the patient group were taken as a control group [group II] All patients were subjected to full history taking with stress on clinical manifestations of renal dysfunction, serum samples were tested for interleukin-1 receptor antagonist [IL-1ra] in addition to levels of C3, C4, creatinine levels and for the presence of anti ds-DNA antibodies. Light and electron microscopic examination [LM and EM respectively] of renal biopsy samples were performed for patients of group Ia. The 14 biopsy samples were classified according to the world health organization [WHO] classification as follows: Class I and II [inactive nephritis] n=1, class III and IV [active nephritis], n=11 and class V, n=2. The activity index [AI] and chronicity index [CI] in those 14 renal biopsy specimens were also determined. This study showed that the pattern of IL-1ra in active SLE varies in a manner that is dependent on which organs are involved. Serum IL-1ra concentrations were compared to normal blood donors [t=3.28, p<0.0001 highly significant]. However, significant higher levels of IL-1ra were observed in patients with extra-renal disease group Ib as compared to other patients group Ia [mean +/- SD were 1006.3 +/- 823.9 pg/ml, range 470-3000 and 147.1 +/- 58.5 and range 53-260 pg/ml] for patients without and with renal involvement respectively]. Elevated IL-1ra concentrations in patients with renal manifestations correlated positively with C3 and C4 levels [r=0.56 and 0.36 respectively] and negatively with degree of proteinuria and serum creatinine levels [-0.44 and -0.4 respectively] but not with disease activity index score SLEDAI [r=0.16]. Moreover, there was a high significant difference between the group of patients who were negative for anti ds-DNA [n=4] and those who where positive [n=22] as regards serum IL-1ra levels, being significantly lower in the positive group who were positive for anti ds DNA [t=2.8, p <0.01]. Furthermore, the highermost level of IL-1ra in group Ia [with renal impairment] was 260 pg/ml and the lowermost level of IL-1ra in group Ib was 470 pg/ml so a cut off value was selected at 370 pg/ml and the sensitivity and specificity values for IL-1ra for detection and diagnosis of lupus nephritis were found to be 100% for both. Therefore, a relative decrease of IL-1ra response appears to be a feature characteristic of kidney involvement and IL-1ra elevation clearly correlates with SLE involving other organs. So it may be a useful marker of lupus nephritis

association between rheumatoid arthritis and hepatitis C virus infection

To study the association between rheumatoid arthritis and HCV infection. The study included 40 RA patients diagnosed according to the ACR criteria [group I]. It also included 20 inflammatory arthritis patients with RF positive but not fulfilling the criteria for diagnosis of RA [group II]. Ten age and sex matched subjects were taken as controls. Anti HCV antibodies were detected in the sera of these patients. 0.5% of the patients of group I had anti HCV antibodies while 20% of patients of group II had anti HCV antibodies. As regards the control group, none was anti HCV antibody positive. There is a strong association between the presence of anti HCV antibodies and rheumatoid factor that is stronger than the association between anti HCV antibodies and rheumatoid arthritis. Patients with anti HCV antibodies may have rheumatoid factor positive in their serum, but the picture may not fulfill the criteria of RA. Thus in any case of inflammatory arthritis, hepatitis C virus must be put in consideration