Assessment of Disease Activity in Rheumatoid Arthritis: A Comparative Study of Clinical and Laboratory Evaluation with Musculoskeletal Ultrasonography Assessment

Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease and musculoskeletal ultrasonography (USG) is gaining popularity for assessing the disease activity bed side, objectively and cost effectively. There is paucity of such studies from India which establish the correlation between RA disease activity and musculoskeletal USG. Objective: The objective of this study was to compare the disease activity scores in RA patients, assessed by ‘clinical and laboratory evaluation’ with ‘musculoskeletal ultrasound scoring of the affected joints. Methodology: It was a cross sectional study conducted from December 2015to May 2017. We enrolled the diagnosed patients of RA, having at least one USG assessable joint with definite clinical synovitis. Disease activity was assessed by swollen joint count, tender joint count, Clinical Disease Activity Index (CDAI), Disease Activity Score (DAS) 28 ESR and DAS 28 CRP. Musculoskeletal USG was performed by experienced radiologist. Grayscale scores (GSUS) and Power Doppler scores (PDUS) were calculated in 22 joints as per SONAR criteria and each joint was examined as per standardized score. Results: Our study showed that DAS 28 CRP, DAS 28 ESR, CDAI, tender joint count and swollen joints count had positive correlation (p<0.001) with various musculoskeletal USG scores, whereas ESR and CRP failed to show any significant correlation. Conclusion: GSUS-PDUS can be used for diagnosing joint space narrowing, joint effusion, and synovial thickening. PD may become a cost-effective alternative to gadolinium enhanced MRI. Strong correlation exists between USG and physical examination of joint swelling as well as disease activity scores in RA patients.

A Case of Peripheral Neuropathy - A Presentation of Poems Syndrome with an Osteolytic Lesion

Introduction: POEMS syndrome is a rare paraneoplasticsyndrome that can often be mistaken for other neurologicdisorders.Case Report: A 48-year-old gentleman presented withprogressive mixed motor and sensory neuropathy involvinglower limbs, with generalized hyperpigmentation andbilateral pitting pedal edema. Neurological examinationshowed symmetrical wasting involving both proximaland distal groups of muscles of lower limbs, decreasedpower (Grade 4/5) of the lower limbs with weakness beingmore severe distally, generalized areflexia, absence ofvibration sense and proprioception over the lower limbs andgraded sensory loss over the dorsum of both feet. Workupshowed a demyelinating sensorimotor polyneuropathy onnerve conduction velocity study and albuminocytologicaldissociation in CSF. After inconclusive initial evaluation, aPET CT was done which picked up an FDG avid lytic lesionin the L1 vertebra, and lymphadenopathy, and an MRI LSspine confirmed an expansile lesion with ""Mini brain sign"",indicative of plasmacytoma. Serum free light chain ratio andserum protein electrophoresis were normal. Bone marrowshowed no evidence of marrow involvement. Consideringthe constellation of findings of demyelinating sensorimotorpolyneuropathy, lymphadenopathy, peripheral edema anda solitary plasmacytoma, the possibility of a rare variant ofPOEMS syndrome with an osteolytic lesion was thought of.The lesion was biopsied and proven to be a plasmacytoma.The patient responded well to localized radiation therapy tothe lesion, along with intravenous steroids.Conclusion: A subacute symmetric sensorimotor neuropathymay be a presentation of POEMS syndrome. There can be rareinstances of a lytic lesion on radiography in POEMS"