Chronic arthritis related to SARS-CoV-2 infection in a pediatric patient: A case report

ABSTRACT Although the pattern of proinflammatory cytokines induced in COVID-2019 is similar to that of rheumatoid arthritis, the association of arthritis with SARS-CoV-2 infection is extremely rare and the symptoms are generally acute and self-limited. Herein we present the clinical case of a child who developed chronic arthritis after SARS-CoV-2 infection. An 11-year-old girl started with symptoms of multisystem inflammatory syndrome temporally associated with COVID-19 infection and subsequently developed chronic arthritis. After six weeks of arthritis, corticosteroids were started which resulted in clinical improvement after two weeks of use. Serology for SARS-CoV-2 was positive in the fifth week after symptom onset. Currently, the patient has no clinical complaints but continues to experience morning stiffness, high erythrocyte sedimentation rate, and synovial hypertrophy with no power Doppler signal on ultrasound. We alert to the possibility that SARS-CoV-2 may be a trigger of chronic arthritis.

Artritis crónica en una paciente pediátrica posterior a Chikungunya / Chronic arthritis in a pediatric patient following Chikungunya

Resumen El virus Chikungunya produce una enfermedad de reciente aparición y creciente incidencia en Costa Rica. Las manifestaciones crónicas de la enfermedad se consideran de importancia en el área de la reumatología. La paciente presentó factores de riesgo para cronicidad como el sexo, la duración y severidad de la fase aguda, el número de articulaciones comprometidas y la asociación con el síndrome de activación macrofágica. En una artritis idiopática juvenil, que es el principal diagnóstico diferencial, se esperaría un inicio más insidioso y no agudo como en este caso; además, la paciente no presentó hepatomegalia o serositis e inicialmente no tuvo trombocitosis, pero manifestó un síndrome de activación macrofágica, que es una complicación inflamatoria descrita en artritis idiopática juvenil. La remisión del cuadro de artritis crónica con el uso de metotrexate, no ayuda al diagnóstico diferencial, porque se ha reportado que este es el tratamiento crónico de elección en ambas patologías. En este reporte se presenta el caso de una paciente pediátrica que ingresó con un cuadro agudo de Chikungunya confirmado serológicamente, y que evolucionó con criterios de una artritis idiopática juvenil sistémica y un síndrome de activación macrofágica secundario.

Abstract Chikungunya virus produce a disease of recent emergence and increasing incidence in Costa Rica. Chronicmanifestations of the disease are considered of importance in the rheumatology area. The patient presented risk factors for chronicity such as sex, the duration and severity of the acute phase, the number of joints involved, and the association with macrophage activation syndrome. In juvenile idiopathic arthritis, which is the main differential diagnosis, a more insidious and non-acute onset would be expected, as in this case, in addition, the patient did not present hepatomegaly or serositis and initially did not have thrombocytosis, but had a macrophage activation syndrome, which is an inflammatory complication described in juvenile idiopathic arthritis. Remission of the chronic arthritis condition with the use of methotrexate does not help the differential diagnosis, because it has been reported that this is the chronic treatment of choice in both pathologies. This report presents the case of a pediatric patient who was admitted with an acute episode of Chikungunya confirmed serologically and who evolved with systemic juvenile idiopathic arthritis criteria and secondary macrophage activation syndrome.

Tocilizumab for juvenile idiopathic arthritis: a single-center case series

ABSTRACT BACKGROUND: Juvenile idiopathic arthritis (JIA) is the commonest chronic rheumatic disease among children. When not treated effectively, JIA can lead to functional disability, due to joint damage, along with long-term morbidities. OBJECTIVES: To describe the use of tocilizumab therapy for 11 patients with polyarticular JIA (pJIA) and systemic JIA (sJIA) who presented inadequate response or were refractory to disease-modifying anti-rheumatic drugs (DMARDs) and/or other biological therapies; and to evaluate its benefits, safety and tolerability. DESIGN AND SETTING: Observational retrospective case series at a tertiary-level training and research hospital. METHODS: We reviewed the medical records of 11 consecutive patients with JIA who received tocilizumab (anti-IL-6) therapy in our pediatric nephrology and rheumatology outpatient clinic. We analyzed their demographic data, clinical and laboratory findings, treatment response and adverse reactions. We determined the efficacy of tocilizumab treatment using the American College of Rheumatology (ACR) pediatric (Pedi) response criteria, including ACR Pedi 30, 50, 70 and 90 scores. We used the Wilcoxon test to compare measurements before and after treatment. RESULTS: Tocilizumab was given to seven patients with sJIA and four with pJIA (one of the pJIA patients was rheumatoid factor-positive). In most patients, we observed improvement of symptoms, absence of articular and extra-articular inflammation and continued inactive disease. ACR Pedi 30, 50 and 70 scores were achieved by 90.9% of the patients. Five patients showed minor side effects, possibly due to use of tocilizumab. CONCLUSIONS: Tocilizumab therapy should be considered for treating patients with diagnoses of pJIA or sJIA who are resistant to non-biological DMARDs and/or other biological therapies.

Managing chikungunya arthritis using etanercept

Chikungunya virus or Aedes-borne alpha virus causes infection through an acute viremic phase and can be complicatedwith a chronic arthritis phase. The present case highlights the benefits of using etanercept for managing chikungunyaarthritis, especially in scenarios where NSAIDS and steroids are contraindicated due to multiple comorbidities.

Doença periodontal e artrite idiopática juvenil: uma inter-relação bidirecional / Periodontal disease and juvenile idiopathic arthritis: a bidirectional inter-relationship

Parece haver similaridades entre a patogenia de doenças reumatológicas (artrite reumatoide e artrite idiopática juvenil) e periodontite. Alguns estudos têm sido conduzidos com o objetivo de elucidar os mecanismos que explicam a inter-relação entre essas condições. A artrite reumatoide parece aumentar a suscetibilidade à doença periodontal destrutiva em adultos e em pacientes com artrite idiopática juvenil. No entanto, ainda são pouco conhecidas as vias de associação entre essas condições crônicas infl amatórias (periodontite e artrite). Desta forma, o objetivo deste trabalho foi promover uma revisão da literatura sobre a inter-relação artrite idiopática infantil e doença periodontal.

Similarities between rheumatologic diseases (rheumatoid arthritis and juvenile idiopathic arthritis) and periodontitis pathogenesis are discussed. Some studies have been conducted to elucidate the mechanisms that explain the relationship between these conditions. Rheumatoid arthritis appears to increase susceptibility to destructive periodontal disease in adults and in patients with juvenile idiopathic arthritis. However, the pathway of association between these chronic infl ammatory conditions are barely known. Thus, the aim of this study was to review the literature concerning the relationship between juvenile idiopathic arthritis and periodontitis.

Incidence of active mycobacterial infections in Brazilian patients with chronic inflammatory arthritis and negative evaluation for latent tuberculosis infection at baseline - A longitudinal analysis after using TNFa blockers

Several studies point to the increased risk of reactivation of latent tuberculosis infection (LTBI) in patients with chronic inflammatory arthritis (CIAs) after using tumour necrosis factor (TNF)a blockers. To study the incidence of active mycobacterial infections (aMI) in patients starting TNFa blockers, 262 patients were included in this study: 109 with rheumatoid arthritis (RA), 93 with ankylosing spondylitis (AS), 44 with juvenile idiopathic arthritis (JIA) and 16 with psoriatic arthritis (PsA). All patients had indication for anti-TNFatherapy. Epidemiologic and clinical data were evaluated and a simple X-ray and tuberculin skin test (TST) were performed. The control group included 215 healthy individuals. The follow-up was 48 months to identify cases of aMI. TST positivity was higher in patients with AS (37.6%) than in RA (12.8%), PsA (18.8%) and JIA (6.8%) (p < 0.001). In the control group, TST positivity was 32.7%. Nine (3.43%) patients were diagnosed with aMI. The overall incidence rate of aMI was 86.93/100,000 person-years [95% confidence interval (CI) 23.6-217.9] for patients and 35.79/100,000 person-years (95% CI 12.4-69.6) for control group (p < 0.001). All patients who developed aMI had no evidence of LTBI at the baseline evaluation. Patients with CIA starting TNFa blockers and no evidence of LTBI at baseline, particularly with nonreactive TST, may have higher risk of aMI.

Fiebre de Chikungunya: reporte de tres casos del Hospital Naval Almirante Nef / Chikungunya fever: report of three cases from Almirante Nef Naval Hospital

Chikungunya fever is an emerging infection in our country due to travelers to endemic areas. It presents acutely with high fever, fatigue, headache, myalgia, skin rash and arthritis, usually as a symmetric polyarthritis compromising the interphalangeal and metacarpophalangeal joints, wrist, elbow, ankle and knee. While most of the symptoms last about a week, arthralgias may become chronic and generate significant functional impairment. Chikungunya has been postulated as a triggering factor for rheumatoid arthritis because of the presence of positive rheumatoid factor. We present the three confirmed cases in Almirante Nef Naval Hospital with the review of the published literature...

La fiebre de Chikungunya es una infección novedosa en nuestro país pues su contagio se produce por viajeros en zonas endémicas. Se presenta generalmente en forma aguda con fiebre alta, astenia, cefalea, mialgia, rash cutaneo y artritis, mayoritariamente como poliartritis simétrica comprometiendo las articulaciones interfalángicas, metacarpofalángicas, muñecas, codos, tobillo y rodillas. Si bien la mayoría de los síntomas duran aproximadamente una semana, las artralgias pueden hacerse crónicas y generar un importante deterioro funcional. Se ha postulado que podría ser un factor gatillante de artritis reumatoide ante la presencia de factor reumatoideo positivo. A continuación se presentan los tres casos confirmados del Hospital Naval Almirante Nef junto a la revisión de la literatura publicada hasta el momento...

The Relation between Chronic Aseptic Arthritis and Previous Chlamydia Infection among Middle Aged Iraqi Patients.

Aims: This study was conducted to detect and evaluate the relation between chronic aseptic arthritis and previous Chlamydia trachomatis infection among middle aged Iraqi patients. Study Design: Cross sectional study Place and Duration of Study: private clinic in Al-Door city/ Salahaddin Province / Iraq, between October 2012 and May 2013. Methodology: This study included 33 known patients with chronic arthritis, with negative rheumatoid factor (RF) in their sera, aging from 26 to 61 years. Septic arthritis was excluded by history, clinical examination, and blood investigations. The ESR for these patients was estimated. Other 33 subjects were taken as a control group. Chlamydia trachomatis IgM and IgG were estimated by ELISA test (sandwich method) for both groups' sera, and results were statistically analyzed. Results: The female: male ratio in current study is (5.6: 1), with mean age of (46) years old. More than half of cases (52%) were having ESR value of 40-60. A highly significant statistical difference (P<0.001) was noticed between study groups in regard to C. trachomatis IgG mean levels in their sera calculated by unpaired T- test. Conclusion: There is a significant relation between chronic arthritis and previous Chlamydia infection in current study (demonstrated by high titer of anti- Chlamydia trachomatis IgG).

Perfil epidemiológico da espondiloartrite de início juvenil comparada com a espondiloartrite de início na vida adulta em uma grande coorte brasileira / Epidemiologic profile of juvenile-onset compared to adult-onset spondyloarthritis in a large Brazilian cohort

Objetivo Analisar as características clínicas e epidemiológicas das espondiloartrites (EpA) de início juvenil (< 16 anos) e compará-las com um grupo de pacientes com EspA de início na vida adulta (≥ 16 anos). Pacientes e métodos Coorte prospectiva, observacional e multicêntrica com 1.424 pacientes com diagnóstico de EspA de acordo com o European Spondyloarthropathy Study Group (ESSG) submetidos a um protocolo comum de investigação e recrutados em 29 centros de referência participantes do Registro Brasileiro de Espondiloartrites (RBE). Os pacientes foram divididos em dois grupos: idade no início<16 anos (grupo EspAiJ) e idade no início ≥ 16 anos. Resultados Entre os 1.424 pacientes, 235 manifestaram o início da doença antes dos 16 anos (16,5%). As variáveis clínicas e epidemiológicas associadas com a EspAiJ foram: gênero masculino (p<0,001), artrite em membro inferior (p=0,001), entesite (p=0,008), uveíte anterior (p=0,041) e HLA-B27 positivo (p=0,017), em associação com escores mais baixos de atividade da doença (Bath Ankylosing Spondylitis Disease Activity Index – BASDAI; p=0,007) e de capacidade funcional (Bath Ankylosing Spondylitis Functional Index – BASFI; p=0,036). A psoríase cutânea (p<0,001), a doença inflamatória intestinal (p=0,023), a dactilite (p=0,024) e o envolvimento ungueal (p=0,004) foram mais frequentes em pacientes com EspA de início na vida adulta. Conclusões Nessa grande coorte brasileira, os pacientes com EspAiJ se caracterizavam predominantemente pelo gênero masculino, envolvimento periférico (artrite e entesite), HLA-B27 positivo e escores de doença mais baixos. .

Objective To analyze the clinical and epidemiologic characteristics of juvenile-onset spondyloarthritis (SpA) (< 16 years) and compare them with a group of adult-onset (≥ 16 years) SpA patients. Patients and methods Prospective, observational and multicentric cohort with 1,424 patients with the diagnosis of SpA according to the European Spondyloarthropathy Study Group (ESSG) submitted to a common protocol of investigation and recruited in 29 reference centers participants of the Brazilian Registry of Spondyloarthritis (RBE – Registro Brasileiro de Espondiloartrites). Patients were divided in two groups: age at onset<16 years (JOSpA group) and age at onset ≥ 16 years (AOSpA group). Results Among the 1,424 patients, 235 presented disease onset before 16 years (16.5%). The clinical and epidemiologic variables associated with JOSpA were male gender (p<0.001), lower limb arthritis (p=0.001), enthesitis (p=0.008), anterior uveitis (p=0.041) and positive HLA-B27 (p=0.017), associated with lower scores of disease activity (Bath Ankylosing Spondylitis Disease Activity Index – BASDAI; p=0.007) and functionality (Bath Ankylosing Spondylitis Functional Index – BASFI; p=0.036). Cutaneous psoriasis (p<0.001), inflammatory bowel disease (p=0.023), dactylitis (p=0.024) and nail involvement (p=0.004) were more frequent in patients with adult-onset SpA. Conclusions Patients with JOSpA in this large Brazilian cohort were characterized predominantly by male gender, peripheral involvement (arthritis and enthesitis), positive HLA-B27 and lower disease scores. .

Radiosinovectomía de muñeca guiada por ultrasonido: experiencia de un caso clínico y revisión del tema / Ultrasound-guided wrist radiosynovectomy: case report and topic review

Radiosynovectomy is a local form of radiotherapy used as second-line treatment in the management of inflammatory and non-inflammatory arthropathies with unsatisfactory response to local or systemic corticosteroid therapy. Its efficacy is similar to that of surgical synovectomy, with the advantages of being a low-cost and minimally- invasive treatment that requires a shorter recovery time. Its efficacy is greater in the treatment of inflammatory arthritis characterized by synovitis, such as rheumatoid arthritis and juvenile chronic arthritis with mono/oligoarticular involvement, especially in upper extremity joints. A number of isotopes can be used in colloidal suspensions. Rhenium-186-sulphide colloid is currently indicated for the treatment of medium-sized joints. The ultrasound-guided injection is suitable for small joints, such as wrist. For proper and safe use and administration of this technique the collaboration of a trained and experienced radiologist is critical to successful treatment.

La radiosinovectomía es una forma local de radioterapia utilizada como tratamiento de segunda línea en el manejo de artropatías inflamatorias y no inflamatorias con respuesta insatisfactoria a la terapia sistémica o local con corticoesteroides. Tiene una eficacia similar a la sinovectomía quirúrgica, con las ventajas de ser un tratamiento de menor costo, menos cruento y con menor tiempo de convalecencia. Su eficacia es mayor en artropatías inflamatorias caracterizadas por sinovitis, como la artritis reumatoide y artritis crónica juvenil, con compromiso mono u oligoarticular y en articulaciones de extremidades superiores. Existen múltiples isótopos que se pueden utilizar en suspensiones coloidales, siendo el sulfuro coloidal de renio-186 el utilizado para la articulación radiocarpiana. Una técnica de administración adecuada es fundamental para el éxito del tratamiento, siendo la inyección con guía ultrasonográfica adecuada para articulaciones de volumen pequeño, instancia en la que la colaboración del médico radiólogo entrenado es fundamental.

Delta sleep instability in children with chronic arthritis

The objective of the present study was to evaluate the expression of a cyclic alternating pattern (CAP) in slow wave sleep (SWS) in children with the well-defined chronic syndrome juvenile idiopathic arthritis (JIA). Twelve patients (9-17 years of age), 7 girls, with JIA were compared to matched controls by age, pubertal stage and gender. After one night of habituation in the sleep laboratory, sleep measurements were obtained by standard polysomnography with conventional sleep scoring and additional CAP analyses. The sleep parameters of the JIA and control groups were similar for sleep efficiency (91.1 ± 6.7 vs 95.8 ± 4.0), sleep stage in minutes: stage 1 (16.8 ± 8.5 vs 17.8 ± 4.0), stage 2 (251.9 ± 41 vs 262.8 ± 38.1), stage 3 (17.0 ± 6.0 vs 15.1 ± 5.7), stage 4 (61.0 ± 21.7 vs 77.1 ± 20.4), and rapid eye movement sleep (82.0 ± 27.6 vs 99.0 ± 23.9), respectively. JIA patients presented nocturnal disrupted sleep, with an increase in short awakenings, but CAP analyses showed that sleep disruption was present even during SWS, showing an increase in the overall CAP rate (P < 0.01). Overall CAP rate during non-rapid eye movement sleep was significantly higher in pediatric patients who were in chronic pain. This is the first study of CAP in pediatric patients with chronic arthritis showing that CAP analyses can be a powerful tool for the investigation of disturbance of SWS in children, based on sleep EEG visual analysis.

Artrite crônica e periodontite / Chronic arthritis and periodontitis

Como parecem existir similaridades entre os mecanismos patogenéticos de doenças reumatológicas, como a artrite reumatóide e a artrite idiopática juvenil com a periodontite, alguns estudos têm sido publicados com o objetivo de levantar evidências de uma possível inter-relação entre essas condições. A artrite reumatóide parece modular a resposta imune do hospedeiro, podendo aumentar a suscetibilidade à doença periodontal destrutiva em adultos. Recentemente, evidenciou-se que também pacientes com artrite idiopática juvenil possuíam maior suscetibilidade à doença periodontal destrutiva comparados a indivíduos saudáveis da mesma idade. No entanto, ainda se desconhecem os mecanismos que justificariam uma hipótese de associação entre essas condições crônicas inflamatórias. Sendo assim, o objetivo deste trabalho foi promover uma revisão da literatura sobre uma possível relação entre artrite crônica e periodontite.

As similarities between pathogenetic mechanisms concerning rheumatic diseases, such as rheumatoid arthritis and juvenile idiopathic arthritis, with periodontitis may exhist, some studies have been published with the objective of showing evidences of a possible relationship between these conditions. Rheumatoid arthritis seems to modulate the host's immune mechanisms and may increase the susceptibility of adults to destructive periodontal disease. Recently evidences showed that also patients with juvenile idiopathic arthritis had an increased susceptibility to destructive periodontal disease compared to healthy individuals of the same age. Nevertheless the mechanisms of association of these chronic inflammatory conditions remain unclear. So, this study aims to review literature concerning a possible relationship between chronic arthritis and periodontitis.

A Correlational Study on the Mastery and Depression in Chronic Arthritis Patients / 재활간호학회지

PURPOSE: The purpose of this study was to investigate the relationship between the level of mastery and depression in chronic arthritis patients. METHOD: The subjects for this study were 100 patients registered in S University Hospital, and the period of data collection was from June 20, 2006 to August 30, 2006. RESULTS: The cronbach's alpha of the research instruments were .70-.86. In data analysis, SPSSWIN 12.0 program was used for descriptive statistics. The results were as follows. 1) The range of total mastery scores was from 11 to 28 and the mean score of the depression in chronic arthritis patients was 17.88. 2) The range of total depression scores was from 20 to 72 and the mean score of the depression in chronic arthritis patients was 39.99. 3) The level of mastery was significant correlation with the level of depression in chronic arthritis patients(r=-.466, p<.01). CONCLUSION: Mastery had significant correlation with depression in patients who have chronic arthritis. Therefore, the strategy of nursing intervention which improve mastery must be developed for patients who have chronic arthritis.

The Study of Pain, Depression and Quality of Life According to the Coping Strategy in Chronic Arthritis Patients / 성인간호학회지

PURPOSE: The aim of this study was to investigate the difference of in the level of pain, depression, and quality of life by coping strategy in the chronic arthritis patients. METHOD: These data were collected by means of a self-reported questionnaire from 90 chronic arthritis patients undergoing treatment at a university hospital in Daegu city from June 10, 2000 to July 15, 2000. The instruments of study were coping strategy scale by Jeon(1985), pain scale by Lee and Song(1987), depression scale by Radloff(1977) and quality of life scale by Cho(1987). Data analysis was done by SPSS Win 10.0 program and Pearson correlation, t-test, Cronbach's-alpha were used. RESULT: The results of this study were as follows: 1. The item mean score of pain for chronic arthritis patient was 6.54. The item mean score of depression for chronic arthritis patient was 2.18. The item mean score of quality of life for chronic arthritis patient was 5.69. 2. The chronic arthritis patients with problem-focused coping experienced pain higher than those with emotion-focused coping(t=o.400, p=o.o45). The chronic arthritis patients with emotion-focused coping experienced depression higher than those with problem-focused coping(t=-2.564, p=0.012). The chronic arthritis patients with problem-focused coping experienced quality of life higher than emotion-focused coping(t=-1.682, p=0.046). CONCLUSION: In conclusion this study showed that any coping strategy can control the arthritis patient's problem. Therfore, The development of a coping strategy to reduce pain and depression and improve the quality of life in the chronic arthritis patient will be needed.

Effects of the Ground Exercise for Arthritis Program(GEAP) on Pain, Fatigue, Self-esteem, Perceived Health Status and Self-efficacy in Patients with Chronic Arthritis / 기본간호학회지

PURPOSE: To examine the effects of the GEAP on pain, fatigue, self-esteem, perceived health status and self-efficacy in patients with chronic arthritis. METHODS: One group pre- & post-test design was used. Outcome domains included pain, number of painful joints, fatigue, self-esteem, perceived health status and self-efficacy. Thirty-four patients were recruited over four times from a rheumatic clinic affiliated to a university medical center in Seoul, Korea. The GEAP is an exercise program modified by the investigators from PACE program which developed by Arthritis Foundation. The program duration is about 60 minutes, three times a week for 6 weeks. Participants were predominantly women (68%); on average 57.3 years old; and diagnossed with RA (58.8), osteoarthritis (29.4) or other (11.8). RESULTS: After completing the GEAP, subjects showed significant improvement in pain (p=0.02), number of painful joints (p=0.04), fatigue (p=0.0001), and perceived health status (p=0.006). There were no improvements in self-esteem and self-efficacy score for adults with chronic rheumatic diseases. CONCLUSION: This study showed that the GEAP is an effective exercise intervention for improving outcomes for patients with chronic arthritis. More sample and research are needed to 1) accurately evaluate on self-esteem and self-efficacy; 2) understand and improve adherence. And also a longer follow up period is recommended to evaluate long-term effects of the PACE program.

The Relationships among Quality of Life, ADL, Depression and Self-Efficacy in people with Chronic Arthritis / 성인간호학회지

This study was conducted to identify the relationships among quality of life, ADL, depression and self-efficacy in people with chronic arthritis. Firth two patients with chronic arthritis participated in this study. The data were collected from 5th Jan. To 15th Oct., 1997. SPSS program was utilized for data with mean, standard deviation, pearson's correlation coefficient. The results of this study were as follows ; 1. The mean score of quality of life was 5.47, representing moderate degree of quality of life. The mean scores were 2.54 for ADL, 2.06 for depression and 61.69 for self-efficacy. 2. Significant correlations between quality of life and ADL, self-efficacy, and depression were found. quality of life was positively related to ADL and self-efficacy, while negative correlation was shown between quality of life and depression. 3. When correlated with demographic characteristics, quality of life was significantly negatively related to duration of illness. The study results suggested that nursing intervention such as, self-help education improving self-efficacy would be useful for patients who are depressed and have limited ADL.