Comparison between STIR and T2-weighted SPAIR sequences in the evaluation of inflammatory sacroiliitis: diagnostic performance and signal-to-noise ratio / Comparação do desempenho diagnóstico e da relação sinal-ruído das sequências SPAIR T2 e STIR na avaliação de sacroiliite inflamatória

Abstract Objective: To compare two different fat-saturated magnetic resonance imaging (MRI) techniques-STIR and T2 SPAIR-in terms of image quality, as well as in terms of their diagnostic performance in detecting sacroiliac joints (SIJ) active inflammation. Materials and Methods: We included 69 consecutive patients with suspected spondyloarthritis undergoing MRI between 2012 and 2014. The signal-to-noise ratio (SNR) was calculated with the method recommended by the American College of Radiology. Two readers evaluated SIJ MRI following ASAS criteria to assess diagnostic performance regarding the detection of active SIJ inflammation. T1 SPIR Gd+ sequence was used as the reference standard. Results: The mean SNR was 72.8 for the T1 SPIR Gd+ sequence, compared with 14.1 and 37.6 for the STIR and T2 SPAIR sequences, respectively. The sensitivity and specificity of STIR and SPAIR T2 sequences did not show any statistically significant differences, for the diagnosis of sacroiliitis with active inflammation. Conclusion: Our results corroborate those in the recent literature suggesting that STIR sequences are not superior to T2 SPAIR sequences for SIJ evaluation in patients with suspected spondyloarthritis. On 1.5-T MRI, T2-weighted SPAIR sequences provide better SNRs than do STIR sequences, which reinforces that T2 SPAIR sequences may be an advantageous option for the evaluation of sacroiliitis.

Resumo Objetivo: O objetivo deste estudo foi comparar a qualidade da imagem das técnicas de saturação de gordura T2 SPAIR e STIR e, adicionalmente, comparar o desempenho diagnóstico das duas sequências para detecção de inflamação ativa nas imagens de ressonância magnética (RM) das sacroilíacas. Materiais e Métodos: Foram incluídos 69 pacientes consecutivos que realizaram RM das articulações sacroilíacas no período de 2012 a 2014. O cálculo da relação sinal/ruído (RSR) foi realizado pelo método do Colégio Americano de Radiologia. O desempenho diagnóstico foi realizado utilizando os resultados da leitura das imagens da sequência T1 SPIR Gd+ como referência. Resultados: A avaliação da RSR mostrou média de 72,8 para a sequência T1 SPIR Gd+. A sensibilidade e a especificidade das sequências STIR e SPAIR 2 para o diagnóstico de sacroiliite com inflamação ativa não apresentaram diferenças estatisticamente significantes. Conclusão: Nossos resultados reforçam a literatura recente sugerindo que não há superioridade da sequência STIR em relação à sequência SPAIR T2 para a avaliação das sacroilíacas em pacientes com espondiloartrite. A sequência SPAIR T2 apresenta melhor RSR em relação à sequência STIR em imagens de RM de 1,5 T, o que reforça que a sequência SPAIR T2 possa ser utilizada como opção vantajosa na avaliação da sacroiliite inflamatória.

Optimization of HLA-B*27 ALLELE Genotyping by PCR-SSP

OBJECTIVES: HLA-B27 is strongly associated with ankylosing spondylitis (AS) and its presence helps to confirm AS diagnosis. Due to the high HLA polymorphism and the differentiated contribution of alleles and molecules encoded by them, HLA-B*27 allele identification is relevant in the clinical follow-up, diagnosis, and treatment of this spondyloarthropathy. Inexpensive genotyping techniques with high specificity and sensitivity are of great interest in histocompatibility laboratories. This work aimed to optimize HLA-B*27 genotyping by Polymerase Chain Reaction Sequence-specific Primer (PCR-SSP), which is an accessible and inexpensive technique. METHODS: The PCR-SSP was standardized using 26 HLA-B*27 positive and 3 HLA-B*27 negative samples previously defined by Polymerase Chain Reaction Sequence-specific Oligonucleotide Probes (PCR-SSOP) (medium resolution, One Lambda®) and primers described by Duangchanchot et al. (2009). For validating the technique, 397 samples were genotyped using PCR-SSP as well as PCR-SSOP. RESULTS: The PCR-SSP technique was standardized for identifying the alleles HLA-B*27:02, HLA-B*27:CAFRW (05/13/16/17/28/37/38/39/42), HLA-B*27:CAFRZ (08/26/40), HLA-B*27:09 and HLA-B*27:12, which were found in 90 positive samples (22.67%). There was 100% agreement between the two techniques for heterozygous samples; however, two homozygous samples could not be detected by PCR-SSP. CONCLUSION: The HLA-B*27 genotyping using PCR-SSP, an easy-to-use, specific, and affordable technique, was optimized for heterozygous samples. This technique may contribute to AS diagnosis.

Clinical Presentation And Quality Of Life In Patients With Acute Anterior Uveitis Associated With Seronegative Spondyloarthropathies

Aim of the study. To characterize clinical features and quality of life in patients with acute anterior uveitis (AAU) associated with seronegative spondyloarthropathies (SpA). Material and Methods. 68 SpA patients with or without AAU were included in the prospective clinical study. VF-14 questionnaire, macula OCT, lens opacities using LOCS III were assessed. Results. Macula was thicker in uveitic (279.31 (53.64) μm) compared to fellow eyes (261.52 (43.714) μm), p<0.05. More patients without AAU were treated with methotrexate, p<0.05. VF-14 values differed between LOCS III grade P1 (93.29 (11.21)) and P3 (80.36 (8.18)); C1 (92.79 (11.79)) and C2 (85.92 (17.17)) and C3 (74.05 (11.89)); NO1 (92.06 (14.17)) and NO3 (84.82 (9.22) scores), p<0.05. Conclusions. Maculae thickness in uveitic eyes was increased. More patients without AAU were treated with methotrexate. VF-14 scores were lower for patients with higher LOCS III grade and recurrent AAU.

Comportamiento del síndrome poliglandular autoinmune tipo III en una cohorte de ocho casos / Behavior of autoimmune polyglandular syndrome type III in a cohort of eight cases

Introducción: el síndrome poliglandular autoinmune es una afección que se caracteriza por la presencia de varias afecciones entre las que destaca la presencia de diabetes insulinodependiente, enfermedad tiroidea y enfermedad autoinmune no tiroidea fundamentalmente. Pueden presentarse otras afecciones específicas como es el caso del vitiligo, la psoriasis, alopecia y anemia perniciosa entre otras. Objetivo: conocer el comportamiento clínico y epidemiológico del síndrome poliglandular autoinmune tipo III en pacientes con enfermedades reumáticas. Método: estudio de tipo descriptivo y retrospectivo, de una serie de 8 casos con presencia de enfermedades que permiten el diagnóstico de síndrome autoinmune tipo III. Se procedió a realizar una revisión exhaustiva de las historias clínicas que posibilitó la recogida de la información mediante un cuestionario creado específicamente para la investigación. La información recogida permitió describir las variables sociodemográficas, clínicas y de laboratorio planteadas para la investigación. Resultados: el promedio de edad fue de 47.34 ± 5 años. El 87.5 por ciento correspondió al sexo femenino y el 75 por ciento de los casos refirió algún hábito nocivo, de los cuales el de mayor representatividad (83,3 por ciento) fue el sedentarismo. El hipotiroidismo (87,5 por ciento) y el síndrome de Sjögren (37,5 por ciento) fueron las enfermedades que con mayor frecuencia se presentaron. Conclusiones: el síndrome poliglandular autoinmune es una afección múltiple que incluye diversas afecciones generando polifarmacia que pude incidir negativamente en la adherencia terapéutica de estos pacientes. La presencia de hábitos nocivos puede ser considerada como un posible agente desencadenante de muchas de las afecciones que componen el síndrome. Existe una tendencia a minimizar la importancia de las afecciones dermatológicas lo que genera un subregistro de las mismas(AU)

Introduction: autoimmune polyglandular syndrome is a condition that is characterized by the presence of several conditions among which the presence of insulin-dependent diabetes, thyroid disease and non-thyroid autoimmune disease is fundamental. There may be other specific conditions such as vitiligo, psoriasis, alopecia and pernicious anemia among others. Objective: to know the clinical and epidemiological behavior of type III autoimmune polyglandular syndrome in patients with rheumatic diseases. Methodo: estudio de tipo descriptivo y retrospectivo, de una serie de 8 casos con presencia de enfermedades que permiten el diagnóstico de síndrome autoinmune tipo III. Se procedió a realizar una revisión exhaustiva de las historias clínicas que posibilitó la recogida de la información mediante un cuestionario creado específicamente para la investigación. La información recogida permitió describir las variables sociodemográficas, clínicas y de laboratorio planteadas para la investigación. Results: the average age was 47.34 ± 5 years. 87.5 percent corresponded to the female sex and 75 percent of the cases reported some harmful habit, of which the one with the highest representation (83.3 percent) was a sedentary lifestyle. Hypothyroidism (87.5 percent) and Sjögren's syndrome (37.5 percent) were the diseases that most frequently occurred. Conclusions: autoimmune polyglandular syndrome is a multiple condition that includes various conditions generating polypharmacy that could negatively affect the therapeutic adherence of these patients. The presence of harmful habits can be considered as a possible triggering agent of many of the conditions that make up the syndrome. There is a tendency to minimize the importance of dermatological conditions, which causes underreporting(AU)

Onicólisis en el curso de la artropatía psoriásica. Presentación de un caso / Onycholysis in the course of psoriatic arthropathy. Presentation of a case

Las lesiones dermatológicas que se presentan en el curso de la antipatía psoriásica son diversas, entre ellas las manifestaciones ungüeales son características y con frecuencia facilitan el razonamiento médico y ayudan al diagnóstico nosológico de esta entidad; se presenta un paciente que a punto de partida de las lesiones onicolíticas de las uñas de los pie, oriento al estudio de otros elementos de laboratorio concluyendo como una de una artropatía psoriásica con seis puntos de la clasificación de Caspar para el estudio de esta entidad.

The dermatological lesions that occur in the course of psoriatic arthropathy are diverse, among which ungüeal manifestations are characteristic and often facilitate medical reasoning and help nosological diagnosis; a patient is presented who, starting point of the onicolitic lesions of the nails of the foot, is directed to the study of other laboratory elements, concluding as one of a psoriatic arthropathy with six points of the Caspar classification for the study of this entity.

Spondyloarthropathy: diagnostic imaging criteria for the detection of sacroiliitis / Espondiloartropatias: critérios de ressonância magnética na detecção da sacroileíte

Abstract Diagnostic imaging is crucial to the diagnosis and monitoring of spondyloarthropathies. Magnetic resonance imaging is the most relevant tool for the early detection of sacroiliitis, allowing the institution of therapeutic strategies to impede the progression of the disease. This study illustrates the major criteria for a magnetic resonance imaging-based diagnosis of spondyloarthropathy. The cases selected here present images obtained from the medical records of patients diagnosed with sacroiliitis over a two-year period at our facility, depicting the active and chronic, irreversible forms of the disease. Although computed tomography and conventional radiography can also identify structural changes, such as subchondral sclerosis, erosions, fat deposits, and ankylosis, only magnetic resonance imaging can reveal active inflammatory lesions, such as bone edema, osteitis, synovitis, enthesitis, and capsulitis.

Resumo A avaliação por imagem é fundamental para o diagnóstico e acompanhamento clínico dos pacientes com espondiloartropatias. A ressonância magnética é o método de imagem mais importante para a detecção precoce de sacroileíte, permitindo a instituição de terapias que podem impedir a progressão da doença. Este estudo ilustra os principais critérios de ressonância magnética na definição de sacroileíte nas espondiloartropatias, com imagens selecionadas dos prontuários dos pacientes diagnosticados no nosso serviço, demonstrando tanto os achados da doença em atividade como as alterações crônicas de caráter irreversível. Embora a tomografia computadorizada e a radiografia convencional possam identificar lesões estruturais crônicas, tais como esclerose subcondral, erosões, depósitos de gordura e anquilose, apenas a ressonância magnética é capaz de demonstrar lesões inflamatórias ativas, tais como edema ósseo, osteíte, sinovite, entesite e capsulite.

Acute myopericarditis as primary manifestation of urogenital reactive arthritis by Staphylococcus haemolyticus metilcilino resistant / Miopericarditis aguda como manifestación primaria de artritis reactiva urogenital por Staphylococcus haemolyticus resistente a meticilina

Reactive arthritis describes the relationship between the host and the environment. This leads to urogenital or gastrointestinal infections. It clinically presents with inflammatory lumbosacral pain, asymmetric oligoarthritis and enthesitis of the Achilles tendon and plantar fascia. Among the extra-articular manifestations are acute anterior uveitis, skin lesions, genital lesions, and oral ulcers, with the rarest being cardiovascular. A case is presented of a patient with a urogenital infection and cardiovascular manifestations, interpreted and managed as acute coronary syndrome. After further studies an acute myopericarditis was considered as a primary manifestation of reactive arthritis.

La artritis reactiva describe la interrelación entre el hospedero y el medio ambiente. Aparece después de infecciones urogenitales o digestivas. Clínicamente presenta dolor lumbosacro inflamatorio, oligoartritis asimétrica y entesitis del tendón de Aquiles y la fascia plantar. Entre las manifestaciones extraarticulares, se encuentran la uveítis anterior aguda, lesiones en piel, lesiones genitales y úlceras orales. Las más infrecuentes son las cardiovasculares. Describimos el caso de un paciente con infección urogenital y manifestaciones cardiovasculares interpretadas y manejadas como síndrome coronario agudo, pero que a la luz de estudios posteriores se consideró finalmente una miopericarditis aguda como manifestación primaria de una artritis reactiva.

Espondiloartropatía juvenil: una visión desde la pediatría / Juvenile spondyloarthropathy: a view from pediatrics

La espondiloartropatía juvenil (EAPj) representa un grupo de artropatías crónicas que se inician en la infancia y que corresponden a entidades cuyas clasificaciones se han modificado en el transcurso de las décadas. Las clasificaciones actuales las incluyen sólo parcialmente. Las manifestaciones clínicas incluyen compromiso articular periférico asimétrico, entesis, sacroilíaco y menos frecuentemente de columna han permitido agruparlas en cinco categorías entre el que se encuentra la forma anquilosante juvenil relacionada con HLA B27 (+), el prototipo de EAPj y que podría representar a la forma de inicio de espondiloartropatía anquilosante del adulto. Los recientes avances en los estudios genéticos, en la patogenia, el desarrollo de mejores técnicas de imagenología tales como la ecografía musculo-esquelética y resonancia magnética aplicada a la Reumatología pediátrica podrían contribuir a generar criterios de clasificación de manera tal que faciliten la comunicación científica con los Reumatólogos de adultos. Un diagnóstico precoz, la aplicación de medidas de actividad de la enfermedad validadas y el oportuno manejo terapéutico obtendrán un pronóstico más favorable. Los resultados terapéuticos en EAPj presentan evidencia limitada aún requiriéndose mayor tiempo de evolución para obtener resultados a largo plazo.

Juvenile spondyloarthropathy (EAPj) represents a heterogeneous group of juvenile articular inflammatory entities and their classification have been changed during the last decades. The current classifications include only partially. The clinical manifestations of diseases involves peripheral joints, enthesis, sacroiliac and less frequently spine and they are classified in five specific subgroups among which is the juvenile ankylosing HLA B27 (+); the EAPj’s prototype and that may represent one of ankylosing spondyloarthropathy adult diseases. Recently, novel insights into the epidemiology, pathogenesis, and development of the imaging techniques such as muscle-skeletal ultrasound and magnetic resonance applied to pediatric rheumatology could be contributing to new classification criteria in order to facilitate the scientific communication with Rheumatologist of adult patients. An early diagnosis a validated measures of disease activity and treatment can change the course and outcome of disease.

Espondiloartropatía entérica: presentación de un caso / Enteric spondyloarthropathy: a case presentation

Seronegative arthropathies or spondyloarthropathy belong to a group of diseases that share clinical and genetic characteristics associated strongly with major histocompatibility complex class I HLA-B27. We report a case of a female patient of 39 years old with nightly back pain, morning stiffness and diffuse lumbar pain in the right buttock. In the immunological study observed negative rheumatoid factor and radiographic study observed right sacroiliitis. The final diagnosis is an enteric spondyloarthropathy...

Las artropatías seronegativas o espondiloartropatías corresponden a un grupo de enfermedades que comparten características clínicas y genéticas, asociadas fuertemente con el complejo mayor de histocompatibilidad clase I HLA-B27. Se presenta el caso de una paciente de 39 años con dolor lumbar nocturno, rigidez matutina lumbar y dolor difuso en la región glútea derecha.En el estudio inmunológico se observa factor reumatoídeo negativo, y al estudio radiológico se constata sacroileítis derecha. El diagnóstico final es una espondiloartropatía entérica...

Caspase-1 Level in Synovial Fluid Is High in Patients with Spondyloarthropathy but Not in Patients with Gout

Activation of caspase-1 by NALP3 inflammasomes has been shown to be important in initiating acute gouty arthritis. The objectives of this study were to measure the levels of caspase-1 in synovial fluid in gout and various arthritides, and to elucidate the clinical significance of caspase-1 levels in synovial fluid. Caspase-1, IL-1beta, IL-18, and uric acid were measured in synovial fluid from 112 patients with gout and other arthritides, such as rheumatoid arthritis, osteoarthritis, and spondyloarthropathy. Caspase-1 in synovial fluid from patients with crystal-induced arthritis, inflammatory arthritis, osteoarthritis, and spondyloarthropathy was 35.9 +/- 86.7, 49.7 +/- 107.7, 2.1 +/- 7.0, and 152.6 +/- 155.7 pg/mL, respectively. The mean level and the frequency of high levels (> or =125 pg/mL) of caspase-1 in spondyloarthropathy were significantly higher than those in the other arthritides including gout. Caspase-1 was detectible in the synovial fluid of patients with the various arthritides. Contrary to our hypothesis, the caspase-1 level in the synovial fluid of patients with gout was not higher than in that of other arthritides. High levels of caspase-1 may be helpful in differentiating spondyloarthropathy from other arthritides.

Associação entre os níveis séricos de potenciais biomarcadores com a presença de fatores relacionados à atividade clínica e ao mau prognóstico em espondiloartrites / The association between serum levels of potential biomarkers with the presence of factors related to the clinical activity and poor prognosis in spondyloarthritis

INTRODUÇÃO: Biomarcadores séricos, tradicionalmente associados à atividade inflamatória e mau prognóstico em doenças reumáticas, não apresentam a mesma relação nas espondiloartrites. OBJETIVO: Estabelecer uma associação entre os níveis séricos de biomarcadores com a presença de fatores associados com a atividade clínica e com o mau prognóstico nas espondiloartropatias. MÉTODOS: Sessenta e dois pacientes (13 com artrite reativa, 19 com espondilite anquilosante e 30 com espondiloartropatia indiferenciada) foram comparados a 46 controles sadios. Foram realizadas avaliações clínicas, radiológicas e laboratoriais. Os resultados foram analisados de acordo com a presença de uveíte, entesite, lombalgia inflamatória, artrite, HLA-B27 e comprometimento das articulações sacroilíacas. Os biomarcadores utilizados foram: VHS, PCRus, SAA, LBP, FSC-M e MMP-3, além da dosagem dos níveis séricos das citocinas: IL-17, IL-6, IL-1α , TNF-α , IFN-γ, e IL-23. RESULTADOS: Quarenta e três (69,4%) pacientes eram homens. A média de idades foi de 31,9 ± 9,9 anos, enquanto a idade média para o aparecimento dos sintomas foi de 26,9 ± 7,3 anos. HLA-B27 foi positivo em 26 (41,9%) dos pacientes, lombalgia inflamatória esteve presente em 42 (67,7%), artrite em 44 (71,0%) e entesite em 34 (54,8%) pacientes. Os níveis séricos de IL-17, IL-23, TNF-α , IL-6, IL-1α e PCRus foram mais elevados em pacientes com espondiloartropatia em comparação com os controles. Os valores de PCRus (P = 0,04), IL-6 (P = 0,003), IL-1α (P = 0,03), e LBP (P = 0,03) se associaram de maneira significativa com presença de HLA-B27, dor lombar inflamatória e artrite. CONCLUSÃO: O aumento dos níveis séricos de PCRus, IL-6, IL-1α e LBP apresentaram associação com fatores relacionados a atividade clínica e mau prognóstico em pacientes com espondiloartrites.

BACKGROUND: Serum biomarkers traditionally associated with inflammatory activity and a poor prognosis in rheumatic diseases do not show the same relationship in spondyloarthritis. OBJECTIVE: To establish the association between serum levels of potential biomarkers with the presence of factors related to clinical activity and poor prognosis in spondyloarthritis. METHODS: Sixty-two patients were included: 13 with reactive arthritis, 19 with ankylosing spondylitis, and 30 with undifferentiated spondyloarthritis. The results were compared with those from 46 healthy controls. Clinical, radiological, and laboratory characteristics were assessed. The results were analyzed based on the presence of uveitis, enthesitis, inflammatory back pain, arthritis, HLA-B27 and sacroiliac involvement. The analyzed biomarkers included ESR, US-CRP, SAA, LBP, FSC-M, and MMP-3; and cytokine serum levels measured were: IL-17, IL-6, IL-1α , TNF-α , IFN-γ, and IL-23. RESULTS: Forty-three (69.4%) patients were male. The average age was 31.9 ± 9.9 years and the age at the onset of symptoms was 26.9 ± 7.3 years. HLA-B27 was positive in 26 (41.9%) patients, inflammatory back pain in 42 (67.7%), arthritis in 44 (71.0%), and enthesitis in 34 (54.8%). IL-17, IL-23, TNF-α , IL-6, IL-1α , and US-CRP levels were significantly higher in patients with SpA when compared to controls. US-CRP (P = 0.04), IL-6 (P = 0.003), IL-1α (P = 0.03), and LBP (P = 0.03) levels were associated with presence of HLA-B27, inflammatory back pain, and arthritis. CONCLUSION: An increase in serum levels of US-CRP, IL-6, IL-1α , and LBP was correlated with factors associated with clinical activity and poor prognosis in spondyloarthritis.

La ecografía en las espondiloartropatías seronegativas: rol y avances / Ultrasound in seronegative spondyloarthropathies: role and perspectives

La ecografía del aparato locomotor tiene una posición cada vez más importante en la evaluación de pacientes con espondiloartropatías seronegativas (EASN), ayudando en la detección y cuantificación del compromiso inflamatorio a nivel articular y tendinoso y permitiendo una precisa valoración del compromiso inflamatorio de las entesis, como una de las características clínicas distintivas en las EASN. Como es bien sabido, la mayoría de las entesitis en pacientes con EASN pueden no ser fácilmente reconocidas clínicamente, siendo la ecografía una técnica de imagen de bajo costo, no invasiva y ampliamente disponible que permite la detección de entesitis subclínica. La dactilitis, otro rasgo característico en las EASN, puede ser valorada por ecografía, permitiendo delinear con precisión las estructuras anatómicas realmente afectadas porel compromiso inflamatorio. La ecografía, además, puede ayudar al reumatólogo para guiar el correcto posicionamiento de la aguja dentro de la estructura anatómica inflamada, como entesis, articulaciones y vaina tendinosa, con el objetivo de llevar a cabo una punción diagnóstica y/o terapéutica. La capacidad de detectar mínimos cambios, principalmente a nivel de la microvascularización mediante la técnica Doppler de poder, a nivel de las diferentes estructuras anatómicas involucradas, brinda la posibilidad de valorar el efecto de la terapia local y/o sistémica, ayudando al reumatólogo para el seguimiento y monitoreo terapéutico de pacientes con EASN. El principal objetivo de esta revisión es proporcionar una actualización de los datos disponibles acerca de la utilidad de la ecografía en la evaluación de pacientes con EASN.

Ultrasound (US) has a progressively more important position in the assessment of patients with spondyloarthritis (SpA), helping to detect synovial and tendon inflammatory involvement and permitting an accurate evaluation of enthesitis, the clinical distinctive feature of SpA. Certainly, the majority of enthesitis are subclinical in SpA being US a low cost, Available and non-invasive imaging technique with an adequate ability to detect them. Dactylitis, another characteristic feature of SpA, can precisely delineate by US showing the real anatomical structures affected by the inflammatory process. US allows rheumatologists to guide needle positioning within involved anatomical structures, as entheses, joints and tendon sheats, in order to perform a diagnostic and/or local therapeutic puncture. The ability to detect minimal inflammatory changes by US, mainly with the power Doppler assessment, permits to evaluate the effects of local or systemic therapies, helping the rheumatologists for the therapeutic monitoring in SpA. The main aim of the present review is to provide an update of the available data about the utilityof US in the evaluation of SpA patients.

Nefropatia por IgA em portadores de espondiloartrites acompanhados no Serviço de Reumatologia do Hospital das Clínicas da UFMG / IgA nephropathy in patients with spondyloarthritis followed-up at the Rheumatology Service of Hospital das Clínicas/UFMG

OBJETIVO: Determinar a frequência das glomerulonefrites nos pacientes espondiloartríticos acompanhados em Serviço de Reumatologia Brasileiro e avaliar variáveis clínicas correlacionadas. PACIENTES E MÉTODOS: Os pacientes foram avaliados quanto às características sociodemográfi cas, tipo de espondiloartrite, tempo e atividade da doença, uso de anti-infl amatórios não esteroides, presença do HLA-B27, níveis de creatinina e ureia séricas, presença de comorbidades e presença de hematúria e/ou proteinúria. Os pacientes com hematúria foram submetidos à pesquisa de dismorfi smo eritrocitário, e aqueles com proteinúria submeteram-se à quantifi cação da proteína na urina de 24 horas. Biópsia renal foi indicada para aqueles com hematúria de origem glomerular e/ou proteinúria maior que 3,5 g. RESULTADOS: Foram avaliados 76 pacientes. A alteração mais frequente no exame de urina de rotina foi a hematúria microscópica (44,7 por cento), geralmente intermitente e em amostra isolada de urina durante o seguimento do paciente. Em oito (10,5 por cento) dos pacientes a hematúria sugeriu origem glomerular. A biópsia renal foi realizada em cinco deles, e mostrou nefropatia por IgA em quatro (5,3 por cento) e doença da membrana fi na em um paciente. CONCLUSÕES: Notou-se alta frequência de alterações no exame de urina desse subgrupo de pacientes, assim como alta prevalência de nefropatia por IgA. Apesar de mais estudos sobre o assunto serem necessários para melhor esclarecimento desses resultados, a realização periódica de exames de urina deveria ser recomendável.

OBJECTIVE: To determine the frequency of glomerulonephritis in patients with spondyloarthritis followed-up at a Brazilian Rheumatology Service, and to evaluate the clinical variables associated. PATIENTS AND METHODS: Patients were assessed for sociodemographic characteristics, type of spondyloarthritis, time since diagnosis and disease activity, non-steroidal anti-infl ammatory drug use, HLA-B27 positivity, creatinine and urea serum levels, major comorbidities, hematuria and proteinuria. Patients with hematuria were subsequently assessed for the presence of dysmorphic red blood cells in urine, and those with proteinuria underwent 24-hour urine protein measurement. Renal biopsy was performed in patients with glomerular hematuria and/or proteinuria over 3.5 g/24-hour. RESULTS: Seventy-six patients were assessed. Microscopic hematuria was the most frequently found abnormality in urinalysis (44.7 percent), usually intermittent and in spot urine samples during patients' follow-up. In eight patients (10.5 percent), glomerular hematuria was suspected. Renal biopsy was performed in fi ve of them, showing IgA nephropathy in four (5.3 percent) and thin membrane disease in one patient. CONCLUSIONS: A high frequency of urinalysis alterations was observed in that subgroup of patients, as well as a high prevalence of IgA nephropathy. Although further studies on this subject are needed to better clarify these results, periodic urinalysis of patients with spondyloarthritis should be recommended.

Comprendiendo la inmunopatogenia de las artropatías seronegativas / Understanding the immunopathogenesis of seronegative arthropathy

Las artropatías seronegativas o espondiloartropatías corresponden a un grupo de enfermedades que comparten características clínicas y genéticas, asociadas fuertemente con el complejo mayor de histocompatibilidad clase I HLA-B27. El rol patogénico del HLA-B27 es desconocido; se han propuesto múltiples teorías, entre las cuales cabe destacar tres: 1) péptido artritogénico, 2) cadenas pesadas aberrantes en la superficie celular y 3) estrés en el retículo endoplásmico rugoso. Es conocido que los linfocitos T CD4 tienen un rol primordial en esta patología. Se ha encontrado que en la mayoría de estas artropatías hay una gran producción de citoquinas del perfil Th1, sobre todo de TNF alfa, el que jugaría un rol crucial, pues se ha visto que con los fármacos anti TNF se produce una mejoría en la mayoría de estas patologías.

Seronegative arthropathies or spondyloarthropathy belong to a group of diseases that share clinical and genetic characteristics associated strongly with major histocompatibility complex class I HLA-B27. The pathogenic role of HLA-B27 is unknown, many theories have been proposed, among which we highlight three: 1) arthritogenic peptides, 2) aberrant heavy chains on the cell surface and 3) stress on the rough endoplasmic reticulum. It is known that CD4 T lymphocytes have a pivotal role in this pathology. A great production of Th1 profile cytokines have been found to exist in most of these arthropathies, especially TNF alpha., which may play a crucial role, since anti-TNF drugs have been known to produce an improvement in most of these pathologies.

MR Imaging of Ankylosing Spondylitis / 대한류마티스학회지

Magnetic resonance imaging (MRI) is a highly reliable tool for diagnosing ankylosing spondylitis. MRI can identify cartilage abnormalities, subcortical erosions, bone marrow edema with inflammation, and synovial enhancement. Subchondral sclerosis and juxta-articular fat deposition are noted in the chronic stage of ankylosing spondylitis. Spinal changes associated with spondyloarthropathy are florid anterior spondylitis (or Romanus lesion), florid diskitis (Anderson lesion), ankylosis, and arthritis of the apophyseal and costovertebral joints. A MRI grading system for inflammation in sacroiliac joints and the spine could help clinicians evaluate the anti-inflammatory efficacy of therapeutics. Newer technologies based on MRI are aimed at broadening the diagnostic scope and facilitating the quantification of active inflammation but still require extensive validation.

Prevalence and Association Factors of Posterior Longitudinal Ligament in Patients with Spondyloarthropathies

OBJECTIVE: To investigate prevalence of ossification of posterior longitudinal ligament (OPLL) in Korean patients with Spondyloarthropathies (SpA), and the associations between OPLL and clinical, radiologic findings of SpA. METHOD: A cross-sectional radiological review was performed in patients diagnosed with SpA from 2000 to 2007. Each of two physiatrists and musculoskeletal radiologists screened the cervical (lateral) and pelvis (anterior-posterior) radiographs of these patients separately, then confirmed presence of OPLL. Bath ankylosing spondylitis radiology index (BASRI) of the cervical spine and grade of sacroiliitis were also measured. A review of the medical records and laboratory findings was conducted to investigate the association between the clinical, laboratory findings and the OPLL. RESULTS: Among 172 patients with SpA, OPLL was found in 16 patients (9.3%; 95% CI 5.0, 13.6). There were significant associations between OPLL and old age (p=0.043), symptoms and signs of myeloradiculopathy (p=0.030), and diabetes mellitus (DM) (p=0.022). CONCLUSION: The prevalence of OPLL in Korean patients with SpA is 9.3%. OPLL in patients with SpA is associated with old age, symptoms and signs of myeloradiculopathy, and diabetes. However, no factors specific characteristics of SpA were associated with OPLL.

Efficacy of Total Glucosides of Paeony in the Treatment of Undifferentiated Spondyloarthropathies and Its Mechanism / 中国中医药信息杂志

Objective To evaluate the efficacy of total glucosides of paeony(TGP) in the treatment of undifferentiated spondyloarthropathies(uSpA) and investigate its mechanism.Methods One hundred and sixteen cases of uSpA were randomly assigned to 2 groups,one group was treated with TGP and diclofenac sodium,the other group with SASP and diclofenac sodium.The efficacy and side effects of the two groups were compared after 12 weeks treatment.The level of IL-6,IL-10 and TNF-? was determined at the same time.Result After 12 weeks treatment,the major clinical manifest and the indexes of disease activity were no difference of statistical significance in the two groups.The incidence of parenterally side effects was 8.6% in TGP group,and 25.9% in SASP group.There was difference at statistical significance between the two groups(? 2 =6.042,P=0.014).Before treatment,the level of IL-6,IL-10 and TNF-? in the serum of two groups were no statistical difference,while there was obviously difference after 12 weeks treatment(t= 2.672,2.483 and 2.088,P=0.009,0.014 and 0.039).Conclusion The efficacy of TGP and SASP has no significant difference in the treatment of uSpA.But the incidence of parenterally side effects in the TGP group was less than SASP group.The mechanism of efficacy of TGP may be related to inhibiting the production of IL-6,IL-10 and TNF-?.

Analysis of 24 cases with low back pain misdiagnosed as spondyloarthropathies / 中华风湿病学杂志

Objective To explore the misdiagnostic reasons of 24 cases with low back pain misdiagnosed as spondyloarthropathies and to raise the correctness of spondyloarthropathies diagnosis. Methods Using follow-up and counterchecking combined with review medical records, a retrospective analysis of 24 cases misdiagnosed as spondyloarthropathies in our hospital from 2001 to 2005 were done. Results Among the 24 patients misdiagnosed as spondyloarthropathies, 3 had sacral tubulocyst or parathyroid adenoma associated with hyperparathyroidism, 7 patients with benign or malignant tumors had persistent low back pain that aggrevated at night without morning stiffness. The pain could not be relieved by rest or exercise and could not be relieved by administration of multiple nonsteroidal anti-inflammatory drugs (NSAIDs). The final diagnosis of these 24 cases were as follows: 4 were malignant tumors (retroperitoneal adipose sarcoma, advanced gastric carcinoma, ovarian papillary epithelioma, acute lymphocytic leukemia), 6 were benign tumors (2 parathyroid adenoma associated with hyperparathyroidism, 1 intraspinal lipoma, 1 intraspinal ependymomas, 1 sacral tubulocyst and intraspinal and 1 schwannoglioma respectively). The other 14 cases were fibromyalgia syndrome (3), osteitis condensans (3), diffuse idiopathic skeletal hyperostosis (2), lubar intervertebral disc protrusion (1), congenital scoliosis (1), Wilson′s disease (1), ochronosis (1), Fanconi′s syndrome (1) and hypophosphatemic rhachiopathy (1). Although 11 patients had presented inflammatory low back pain defined by Calin, only 2 patients satisfied spondyloarthritides as defined by the classification criteria of the European Spondylarthropathy Study Group (ESSG). Conclusion The misdiagnosis of spondyloarthropathy can be improved by way of careful differential diagnosis of low back pain and holding the classification criteria of the European Spondylarthropathy Study Group (ESSG) as guideline.

The Comparison Between Behcet's Disease and Spondyloarthritides: Does Behcet's Disease Belong to the Spondyloarthropathy Complex?

This study was to clarify whether Behcet's disease (BD) could be classified into the spondyloarthropathy (SpA) complex. It was undertaken on 58 patients with BD (BD group), 56 patients with SpA (SpA group), and 3 patients who concurrently satisfied the criteria for BD and SpA (BDSpA group). The clinical parameters and known susceptible HLA antigens were compared between BD group and SpA group. In addition, 3 patients in BDSpA group were reviewed. The prevalence of definitive sacroiliitis (SI) in BD group and SpA group was 46.4% and 5.2%, respectively. However, none had a definitive SI in healthy controls. Enthesitis was observed in 3.4% of BD group and in 50% of SpA group. The patterns of eye involvement were different between these two groups. HLA-B27 was negative in all 49 patients of BD group, whereas it was positive in 67.9% of SpA group. The prevalence of HLA-B51 was 51.7% in BD group, and that in SpA group was 21.4%. One patient in BDSpA group was considered to have concurrent BD and ankylosing spondylitis (AS). Another patient was closer to AS, and the third to BD. Conclusively, it seems that BD could not be classified into the SpA complex.