Rituximab: alternativa eficaz para la querotopatía ulcerativa periférica / Rituximab: effective alternative for peripheral ulcerative kerotopathy

El desarrollo de los fármacos biológicos ha permitido controlar de manera óptima las manifestaciones oftalmológicas de las enfermedades autoinmunes, el conocimiento de nuevas vías patogénicas y de nuevas dianas terapéuticas lo que está suponiendo una revolución en el tratamiento médico de numerosas entidades y donde la oftalmología no es una excepción. Se presenta el caso clínico de una paciente con artritis reumatoide con mal control y afectación multisistémica que presentó una queratopatía ulcerativa periférica de mal control que respondió con tratamiento biológico diferente al tradicionalmente usado: el rituximab(AU)

The development of biological drugs has allowed optimal control of the ophthalmologic manifestations of autoimmune diseases, the knowledge of new pathogenic pathways and new therapeutic targets, which is leading to a revolution in the medical treatment in numerous entities and where ophthalmology is no exception. We present the clinical case of a patient with poorly controlled rheumatoid arthritis and multisystemic condition. The patient presented a poorly controlled peripheral ulcerative keratopathy that responded to a different biological treatment than the one traditionally used: rituximab(AU)

Gynecological/Obstetric Background and Rheumatoid Arthritis: A Cross-sectional Study in Brazilian Patients / Antecedentes ginecológicos/obstétricos e artrite reumatoide: Um estudo transversal em pacientes brasileiros

Abstract Objective To study a sample of rheumatoid arthritis (RA) patients for their gynecological/obstetric history and compare them to controls to determine their influences on number of pregnancies, menarche, menopause and reproductive years following RA onset. Methods This is a cross-sectional study of 122 RA patients and 126 controls. Patients and controls were questioned about age of menarche, age of menopause, number of pregnancies and abortions. Reproductive years were calculated as the difference between age at menopause and age at menarche. For comparison, we used the Mann-Whitney, unpaired t, chi-squared, and Spearman tests. The adopted significance was 5%. Results In the RA patients with disease beginning in the postmenopausal years, the period of reproductive years (age at menopause - age of menarche) showed a positive correlation with age at disease onset (rho=0.46; 95% confidence interval [CI]=0.20- 0.55 with p=0.0008). The number of pregnancies was higher in patients with postmenopausal disease onset when compared with those with premenopausal disease onset (median of 3 with interquartile range [IQR]=2-4 versus median of 2 with IQR=1-3; p=0.009), and RA patients had more pregnancies than controls (p=0.0002). Conclusion The present study shows that, in our population, the duration of reproductive years and the number of pregnancies are linked to the onset of RA.

Resumo Objetivo Estudar uma amostra de pacientes com artrite reumatoide (AR), com investigação da história ginecológica e obstétrica, comparando-a com controles, visando conhecer suas influências no número de gestações, menarcas, menopausa e anos reprodutivos no início da AR. Métodos Trata-se de um estudo transversal de 122 pacientes com AR e 126 controles. Pacientes e controles foram questionados sobre idade da menarca, idade da menopausa, número de gestações e abortos. Os anos reprodutivos foram calculados com a diferença entre a idade da menopausa e a idade da menarca. Para comparação, foram utilizados Mann Whitney, Teste t não pareados, Teste qui-quadrado e teste de Spearman. A significância adotada foi de 5%. Resultados Nas pacientes comAR e início da doença na pós-menopausa, o período de anos reprodutivos (idade da menopausa - idade da menarca) apresentou correlação positiva com a idade de início da doença (rho=0,46; intervalo de confiança de 95% [IC95%]=0,20-0,55 com p=0,0008). O número de gestações foi maior nas pacientes cominício da doença no período pós-menopausa quando comparadas às pacientes em pré-menopausa (mediana de 3 comintervalo interquartil [IIQ]=2-4 versusmediana de 2 com IIQ=1-3; p=0,009). Nas pacientes com AR, foi observado ummaior número de gestações do que no grupo controle (p=0,0002). Conclusão O presente estudo mostra que, em nossa população, a diminuição dos anos reprodutivos e o alto número de gestações estão relacionados ao surgimento da AR.

Depressive symptoms are associated with impaired sleep, fatigue, and disease activity in women with rheumatoid arthritis

Abstract Objectives: To investigate the associations between sleep quality, fatigue, disease activity and depressive symptoms in women with rheumatoid arthritis (RA). Methods: Female patients with previous diagnosis of RA from a Rheumatology Outpatient Clinic at a tertiary referral centre, in Fortaleza, Brazil, were consecutively recruited into the study. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI); fatigue by the Fatigue Severity Scale (FSS); daytime sleepiness by the Epworth Sleepiness Scale (ESS); and depressive symptoms by the Beck Depression Inventory II (BDI-II). RA activity was measured by the disease activity score (DAS28). Results: One hundred ten women (mean age ± SD = 51.1 ± 13.0 y) were included in the study. On average, patients with depressive symptoms (BDI-II > 13), as compared to those without, showed poorer sleep quality (PSQI: 10.09 ± 4.1 vs 7.33 ± 3.55; p = 0.001 respectively), more fatigue (FSS: 4.69 ± 1.89 vs 3.34 ± 1.8; p = 0.001) and higher disease activity level (DAS28: 4.36 ± 1.53 vs 3.7 ± 1.39; p = 0,047). The logistic regression analysis showed that sleep quality is an independent predictor of depressive symptom severity. Conclusion: Depressive symptoms, impaired sleep and fatigue are common in women with RA. Poor sleep is associated with greater frequency and severity of depressive symptoms in these patients, suggesting that screening for sleep and mood problems may be relevant both in clinical research and routine patient care. Future studies investigating the impact of measures to promote healthy sleep on depressive symptom control in this patient population are warranted.(AU)

Tratamiento quirúrgico de las deformidades en Boutonniere y cuello de cisne del pulgar en la artritis reumatoidea / Traitement chirurgical des déformations du pouce en boutonnière et en col de cygne dans l'arthrite rhumatoïde / Surgical Treatment of Boutonniere and Swan-Neck Deformities in Rheumatoid Arthritis Thumb

Introducción: la artritis reumatoidea es una enfermedad sistémica, en la que son comunes las deformidades articulares, estas se pueden observar en el pulgar donde las de mayor frecuencia son las de Boutonniere y en cuello de cisne. Objetivo: el objetivo principal fue evaluar los resultados de la aplicación de las técnicas quirúrgicas en estas deformidades. Método: se realizó un estudio longitudinal prospectivo de intervención. Se trataron un total de 20 pacientes con este diagnóstico, atendidos en el Servicio de Miembro Superior Minifijación Externa y Microcirugía del Complejo Científico Ortopédico Internacional Frank País en el período comprendido desde enero 2011 a diciembre 2012. La evaluación de los pacientes se realizó según la escala confeccionada para este grupo particular en estudio. Resultados: se obtuvieron resultados excelentes en el 10 por ciento, buenos en el 75 por ciento y regulares en el 15 por ciento de los casos. Conclusiones: las técnicas quirúrgicas empleadas en el tratamiento de esta afección mostraron resultados alentadores(AU)

Introduction: Rheumatoid arthritis is a systemic disease, in which joint deformities are common; these deformities are observed in the thumb where the most frequent are Boutonniere and swan-neck deformities. Objective: Assess the results of the application of surgical techniques in these deformities. Method: A longitudinal prospective intervention study was conducted at Frank País International Orthopedic Scientific Complex from January 2011 to December 2012. Twenty patients with this diagnosis were treated in the Upper Limb Service for External Miniaturization and Microsurgery. The evaluation of the patients was performed according to the scale prepared for this particular study group. Results: 10 of the cases obtained excellent results, 75 percent obtained good results and 15 percent had moderate results. Conclusions: The surgical techniques used in the treatment of this condition showed encouraging results(AU)

Introduction: L'arthrite rhumatoïde est une maladie systémique caractérisée par des atteintes articulaires, surtout au niveau du pouce, telles que les déformations en boutonnière et en col de cygne. Objectif: Évaluer les résultats de l'application des techniques chirurgicales dans le traitement de ces déformations. Méthodes: Une étude longitudinale prospective interventionnelle a été réalisée. Un total de vingt patients, diagnostiqués d'arthrite rhumatoïde, ont été traités au Service d'orthopédie de membres supérieurs, mini-fixation externe et microchirurgie, au Complexe scientifique international d'orthopédie Frank Pais, dans la période comprise entre janvier 2011 et décembre 2012. Les patients de ce groupe ont été évalués selon une échelle élaborée pour cette étude. Résultats: On a obtenu des résultats excellents (10 pourcent), bons (75 pourcent), et passables (15 pourcent). Conclusions: Les techniques chirurgicales utilisées dans le traitement de cette affection ont montré des résultats encourageants(AU)

Posible papel de Porphyromonas gingivalis en el desarrollo de la artritis reumatoide / Possible role of Porphyromonas gingivalis in the develpment of rheumatoid arthritis

Varios estudios han sugerido una asociación entre la periodontitissevera, la prevalencia de la bacteria Porphyromonas gingivalis y el desarrollo de artritis reumatoide. Como fundamento de esta relación, se ha observado que esta bacteria secreta una enzima, peptidil-arginina deiminasa, que es capaz de citrulinar proteínas del hospedero y así favorecer una respuesta autoinmune. Sin embargo, debido a la heterogeneidad de diseños experimentales, selección de pacientes y valoración de los desenlaces, los resultados no han mostrado la reproducibilidad deseada. Asimismo, observaciones recientes apuntan a que la actividad enzimática podría ser generada por otras especies bacterianas, lo que hace más compleja su relación. Sin embargo, por otro lado, algunos estudios sugieren que el tratamiento periodontal puede limitar el desarrollo de la artritis reumatoide.

Various studies have suggested a link between severe periodontitis,the prevalence of Porphyromonas gingivalis, and the development ofrheumatoid arthritis. As evidence of this relationship, P. gingivalis hasbeen found to secrete an enzyme, peptidyl arginine deiminase, which isable to citrullinate host proteins and thus help activate an autoimmuneresponse. However, due to the heterogeneity of experimental designs,patient selection, and assessment of clinical outcomes, the results havenot shown the desired reproducibility. Furthermore, recent fi ndingsindicate that the enzymatic activity may be produced by other species ofbacteria, which suggests the relationship is more complex. However, anumber of studies have shown that periodontal treatment could inhibitthe development of rheumatoid arthritis.

Facteurs associés aux érosions osseuses dans la polyarthrite rhumatoïde à Abidjan

Objectif : Identifier les facteurs associés aux érosions osseuses dans la polyarthrite rhumatoïde observée à Abidjan. Matériels et méthode : Etude rétrospective et descriptive menée au service de rhumatologie du CHU de Cocody de Janvier 2005 à Avril 2017. Ont été inclus les patients souffrant d'une polyarthrite rhumatoïde répondant aux critères de l'ACR 1987 et de l'ACR-EULAR 2010, avec des érosions osseuses. Résultats : La fréquence des érosions osseuses étaient de 51,72% soit 58 sur 112 patients recrutés pendant la période d'étude. Notre effectif comportait 41 femmes et 17 hommes âgés de 46,62+/-13,02 ans. La majorité des patients étaient de niveau socioéconomique précaire (68,96%) et scolarisés (65,51%). Le délai diagnostique moyen était 28,9+/-9,7 mois. Tous les patients présentaient une polyarthrite proximale et distale. Une raideur matinale supérieure à 1 heure (44,8%), une atteinte cervicale (51,72%), des déformations (51,72%), une atteinte viscérale (48,27%), une fièvre (41,37%) et un amaigrissement (58,62%) ont été notés. On notait une vitesse de sédimentation moyenne à 22,9mm et une CRP moyenne à 47,7mg/l. Les facteurs rhumatoïdes et les anti-CCP étaient positifs respectivement chez 37,93% et 34,4% des patients. Les facteurs associés significativement aux érosions osseuses étaient la durée de la raideur matinale (P=0,04), l'atteinte des grosses articulations (P=0,025), l'atteinte du rachis cervical (0,038), la présence de déformations (0,025), l'élévation de la CRP (P=0,004) et la positivité des antiCCP (P=0,01). Conclusion : La durée de la raideur matinale, l'atteinte des grosses articulations, l'atteinte du rachis cervical (0,038), la présence de déformations, l'élévation de la CRP et la positivité des anti-CCP (P=0,01) sont associés aux érosions osseuses dans la polyarthrite rhumatoïde à Abidjan

Exposição à periodontite no intervalo de um ano antes do tratamento antidiabético e risco de artrite reumatoide em pacientes com diabete mellitus: estudo de coorte populacional / Periodontitis exposure within one year before anti-diabetic treatment and the risk of rheumatoid arthritis in diabetes mellitus patients: a population-based cohort study

Objetivo: Examinar se uma história de periodontite (PD) antes do tratamento antidiabético está associada a risco de ocorrência de artrite reumatoide (AR) em pacientes com diabetes melittus (DM) tratados de novo. Métodos: Fizemos um estudo retrospectivo populacional com os dados de reivindicações do National Health Insurance (NHI) de 1997-2009 referentes a um milhão de indivíduos representativos da totalidade de matriculados. Adultos com DM (≥ 20 anos) que iniciaram o tratamento antidiabético durante 2001-2009 foram classificados como pacientes DM tratados de novo. Identificamos 7.097 indivíduos DM com história de PD em um intervalo de um ano antes do tratamento antidiabético (data-índice). Na equiparação desses 7.097 indivíduos para idade por ocasião da data-índice, gênero e ano da data-índice, extraímos aleatoriamente 14.194 pacientes DM sem história de PD em um intervalo de um ano antes do tratamento antidiabético. As razões de risco ajustadas (aRR) com um intervalo de confiança (IC) de 95% foram calculadas mediante a aplicação do modelo de riscos proporcionais de Cox com o objetivo de quantificar a associação entre história de PD e risco de AR. Resultados: Em comparação com pacientes DM sem exposição à PD no intervalo de um ano antes do tratamento antidiabético, RR bruta e RR ajustada para AR entre pacientes DM e com exposição à PD no intervalo de um ano antes do tratamento antidiabético foram, respectivamente, 4,51 (IC 95%, 1,39-14,64) e 3,77 (IC 95%, 1,48-9,60). Conclusão: A exposição à PD no intervalo de um ano antes do tratamento antidiabético foi associada a maior risco de AR em pacientes DM tratados de novo. A ausência do status de tabagismo em nível individual é importante ...

Objective: To examine whether a history of periodontitis (PD) before anti-diabetic treatment is associated with risk of rheumatoid arthritis (RA) development in newly-treated diabetes mellitus (DM) patients. Methods: We conducted a population-based retrospective cohort study using the 1997-2009 National Health Insurance (NHI) claims data of one million representative individuals from all NHI enrollees. Adults with DM (aged ≥20 years) starting anti-diabetic treatment during 2001-2009 were classified as newly-treated DM patients. We identified 7097 DM subjects with PD history within one year before initiating anti-diabetes treatment (index date). By matching these 7097 subjects for age on the index date, sex, and year of the index date, we randomly extracted 14,194 DM subjects without PD history within one year before antidiabetic treatment. Adjusted hazard ratios (aHRs) with a 95% confidence interval (CI) were calculated by applying Cox proportional hazards models to quantify the association between PD history and RA risk. Results: Compared with DM patients without PD exposure within one year before anti-diabetic treatment, crude HR and adjusted HR of RA among DM patients with PD exposure within one year before anti-diabetic treatment were 4.51 (95% CI, 1.39-14.64) and 3.77 (95% CI, 1.48-9.60). Conclusion: PD exposure within one year before anti-diabetic treatment was associated with increased RA risk in newly treated DM patients. The lack of knowledge about individual smoking status is a major limitation of this study. .

Tarsal tunnel syndrome in patients with rheumatoid arthritis, electrophysiological and ultrasound study

Tarsal tunnel syndrome [TTS] is an entrapment neuropathy of the tibial nerve at the ankle. Rheumatoid arthritis is one of the systemic causes that has been responsible for TTS. In this study thirty feet of patients diagnosed as rheumatoid arthritis with complaints of burning pain or paresthesia on the plantar aspect of the foot and toes with 15 feet of age and sex matched control subjects were included. The aim of this study: To detect TTS among patients with rheumatoid arthritis. All patients included in this study were subjected to history taking, clinical examination [general and local], nerve conduction studies and ultrasonography of both tarsal tunnels. In this study, we detected the presence of TTS in rheumatoid arthritis patients group and none was found in the control group. A total of 28 cases were confirmed as having TTS. In the patients group a strong statistically significant correlations were found between ultrasonographic and electrodiagnostic findings. So it is concluded that TTS is detected in patients suffering from rheumatoid arthritis and that the use of both methods could lead to more reliable confirmed diagnosis which could lead to better management

Hallazgos clínicos y radiográficos en la articulación temporomandibular en pacientes con artritis reumatoidea / Clinical and radiographic findings in temporomandibular joints of patients with rheumatoid arthritis

Durante el curso de la artritis reumatoidea (AR), la enfermedad compromete a la articulación temporomandibular (ATM). Este artículo presenta los hallazgos encontrados durante el análisis de 190 ATMs en pacientes con AR y 44 controles sin AR, incluyendo una descripción de signos y síntomas, hallazgos radiográficos en la mano y en la ATM. La muestra incluía 57,89 por ciento de los pacientes asociados a dolor espontáneo en la ATM, 87,89 por ciento con signos de destrucción radiográfica, 58,94 por ciento con menos de 20 piezas dentarias. Apertura bucal disminuida en 42,1 por ciento y de este grupo el 71 por ciento bloqueada. Existió una asociación altamente significativa A/S (r=0,62) entre las erosiones de la mano y las de la ATM. La temprana evaluación de esta articulación y el trabajo en conlaboración entre el odontólogo y reumatólogo es necesario para un mejor manejo de la enfermedad.

Artrite reumatoide: uma visão atual / Rheumatoid arthritis: a current view

INTRODUÇÃO: A artrite reumatoide (AR) é uma doença autoimune inflamatória e crônica que afeta aproximadamente 1 por cento da população adulta mundial. A doença caracteriza-se pela inflamação do tecido sinovial de múltiplas articulações, levando a destruição tecidual, dor, deformidades e redução na qualidade de vida do paciente. Sua etiologia é complexa e em grande parte desconhecida, porém estudos demonstram a influência de fatores genéticos e ambientais em sua patogênese. Devido à forte influência genética, familiares de pacientes com AR formam um grupo de risco para o desenvolvimento da doença, principalmente em sua forma mais grave. Apesar de seu elevado potencial incapacitante, o curso da AR pode ser modificado por meio do diagnóstico precoce e do manejo adequado do paciente. No entanto, o diagnóstico precoce da AR é ainda bastante difícil diante da heterogeneidade das manifestações clínicas da doença, o que acaba retardando a implantação terapêutica. O tratamento da AR baseia-se no uso de anti-inflamatórios não esteroidais (AINEs), corticosteroides, drogas antirreumáticas modificadoras do curso da doença (DMARD) e agentes imunobiológicos. Além da terapia medicamentosa, também são adotadas medidas como educação do paciente e terapias psico-ocupacionais. Atualmente, estudos têm se voltado à identificação de fatores preditores de doença mais grave, como autoanticorpos como fator reumatoide (FR) e anticorpo antipeptídio cíclico citrulinado (anti-CCP), que constituem importantes marcadores imunológicos de diagnóstico e prognóstico da AR. DISCUSSÃO E CONCLUSÃO: Apesar dos significativos avanços tanto no entendimento como no diagnóstico e no tratamento da AR, ainda persistem inúmeros desafios a serem superados.

INTRODUCTION: Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease, which affects approximately 1 percent of the world's adult population. It is characterized by the inflammation of synovial tissue from multiple articulations, leading to tissue destruction, pain, deformities and reduced quality of life. RA etiology is complex and largely unknown, although studies support the influence of genetic and environmental factors on its pathogenesis. Due to its major genetic component, relatives from RA patients are part of the risk group, mainly as to the development of the most severe forms. In spite of its high disability risk, RA development can be affected through early diagnosis and adequate therapy. Nonetheless, its early diagnosis is still very demanding due to the heterogeneity of its clinical presentations, which delays therapeutic approach. RA treatment includes non-steroidal anti-inflammatory drugs, corticosteroids, disease-modifying antirheumatic drugs (DMARD), and immunobiologic agents. Furthermore, raising patient's awareness and developing psyco/occupational therapies are also part of the therapeutic approach. Currently, several studies focus on the identification of predictive factors for severe RA such as rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) autoantibodies, which are major immunological diagnostic and prognostic markers for RA. DISCUSSION AND CONCLUSION: Despite the fact that there has been substantial progress in the investigation, diagnosis and treatment of RA, there are still several challenges to be overcome.

Association analysis of anti-Epstein-Barr nuclear antigen-1 antibodies, anti-cyclic citrullinated peptide antibodies, the shared epitope and smoking status in Brazilian patients with rheumatoid arthritis

INTRODUCTION: Epstein-Barr virus exposure appears to be an environmental trigger for rheumatoid arthritis that interacts with other risk factors. Relationships among anti-cyclic citrullinated peptide antibodies, the shared epitope, and smoking status have been observed in patients with rheumatoid arthritis from different populations. OBJECTIVE: To perform an association analysis of anti-Epstein-Barr nuclear antigen-1 antibodies, anti-cyclic citrullinated peptide antibodies, the shared epitope, and smoking status in Brazilian patients with rheumatoid arthritis. METHODS: In a case-control study, 140 rheumatoid arthritis patients and 143 healthy volunteers who were matched for age, sex, and ethnicity were recruited. Anti-Epstein-Barr nuclear antigen-1 antibodies and anti-cyclic citrullinated peptide antibodies were examined using an enzyme-linked immunosorbent assay, and shared epitope alleles were identified by genotyping. Smoking information was collected from all subjects. A comparative analysis of anti-Epstein-Barr nuclear antigen-1 antibodies, anti-cyclic citrullinated peptide antibodies, the shared epitope, and smoking status was performed in the patient group. Logistic regression analysis models were used to analyze the risk of rheumatoid arthritis. RESULTS: Anti-Epstein-Barr nuclear antigen-1 antibodies were not associated with anti-cyclic citrullinated peptide antibodies, shared epitope alleles, or smoking status. Anti-cyclic citrullinated peptide antibody positivity was significantly higher in smoking patients with shared epitope alleles (OR = 3.82). In a multivariate logistic regression analysis using stepwise selection, only anti-cyclic citrullinated peptide antibodies were found to be independently associated with rheumatoid arthritis (OR = 247.9). CONCLUSION: Anti-Epstein-Barr nuclear antigen-1 antibodies did not increase the risk of rheumatoid arthritis and were not associated with the rheumatoid arthritis risk factors studied. Smoking and shared epitope alleles were correlated with anti-cyclic citrullinated peptide-antibody-positive rheumatoid arthritis. Of the risk factors, only anticyclic citrullinated peptides antibodies were independently associated with rheumatoid arthritis susceptibility.

Curso de reumatologia: aula 10: tratamento atual da artrite reumatoide / Course of rheumatology: class 10: current treatment of rheumatoid arthritis

Os autores discutem a terapêutica para a artrite reumatoide (AR), com foco no tratamento biológico. Novos conhecimentos dos mecanismos patogênicos da AR mais a aplicação de biotecnologia propiciaram o desenvolvimento de tratamentos específicos contra moléculas envolvidas na inflamação da doença, os chamados tratamentos biológicos. Estes fármacos representam o maior avanço no controle da AR nesta última década. 0s agentes biológicos habitualmente aprovados para uso na AR são: etanercepte, receptor solúvel do TNE infliximabe e adalimumabe, ambos anticorpos monoclonais contra TNF. Todos estão disponíveis para uso pela secretaria de saúde. Outros aprovados para uso e não disponibilizados pela secretaria são o rituximabe e o abatacepte. Neste artigo discutimos cada um destes biológicos.

Authors discuss the therapies for rheumatoid arthritis focused on biological therapies. Biological therapies are the result of new insights into the pathogenic mechanisms of RA and the application of biotechnology on the development of therapies directed specifically against molecules involved with the inflammatory process of the disease. These agents represent the greatest advance in the control of RA during the last decade. Biological agents currently approved and accessible by government for the treatment of RA include: etanercept, a soluble recombinant anti-TNF receptor construct, in fliximab and adalimumab, both monoclonal antibodies against TNF. The others biologic, rituximab and abatacept, are also approved for treatment of RA but not available by government. In this essay authors study each one of these biologics agents.

Enfermedad de Mucha Habermann asociada a artritis reumatoide / Mucha Habermann disease associated with a rheumatoid arthritis

La pitiriasis liquenoide varioliforme aguda o enfermedad de Mucha Habermann es una afección cutánea rara de etiología no precisada, probablemente autoinmune, caracterizada por lesiones papulares de aparición aguda, con formación de pseudovesículas que sufren necrosis central, a veces con tendencia a formar costras. Se presentó el caso de una mujer de 36 años, con antecedentes de artritis reumatoidea, que ingresa por erupción generalizada en piel con formación de vesículas sobre fondo eritematoso, algunas coalescentes, con costras, prurito moderado y fiebre de hasta 39,2 °C, a la que se realiza biopsia de piel que confirma este diagnóstico, evolutivamente mejoran las lesiones en piel pero presenta infartos digitales propios de vasculitis de pequeños vasos, que apoya la controversial hipótesis del origen vasculítico. La paciente evolucionó favorablemente con tratamiento sintomático, por tener la enfermedad un curso autolimitado y generalmente benigno

Acute varioliform lichenoides pityriasis or Mucha Haberman disease is a rare cutaneous affection of unknown etiology, probably autoimmune, characterized by popular lesions of acute appearance with formation of pseudovesicles with central necrosis, sometimes with a trend to crusts. This is the case of a woman aged 36 with a history of rheumatoid arthritis admitted due to a cutaneous systemic eruption with formation of vesicles over erythematous arrangement, some underwent coalescence with crusts, a moderate pruritus and fever up to 39.2 °C; skin biopsy confirmed this diagnosis, skin lesions improve in a evolutionary way but with digital infarction typical of small vessels vasculitis supporting the polemic hypothesis of vascular origin. Patient evolved favourably with symptomatic treatment because of the disease has a self-limited and generally benign course

Pulmonary manifestations in connective tissue disorders: Hospital-based study at a Tertiary Care Hospital.

Background. The pleuro-pulmonary manifestations frequently occur in patients with the connective tissue disorders (CTDs), and limited data are available on this topic from India. Methods. Between January 2002 and December 2006, 195 patients with various CTDs having respiratory symptoms were evaluated for respiratory system involvement. Results. Interstitial lung disease (ILD) was the commonest (38.5%) presentation of CTDs. It was observed in nearly threefourth of the cases with scleroderma followed by rheumatoid arthritis (RA) cases (44.5%). Pulmonary arterial hypertension was observed in 53.8% and 60% of cases with scleroderma and mixed connective tissue disorder (MCTD), respectively. In RA and systemic lupus erythematosus (SLE), pulmonary hypertension was a rare presentation. Pulmonary function tests were abnormal in all the patients with MCTD, 89.9% patients with RA, 84.6% patients with scleroderma and nearly one-third patients with SLE. Restrictive defect was the most common abnormality [RA (88.7%), scleroderma (72.7%), SLE (66%)]. High resolution computed tomography revealed reticulonodular lesions (n=78); pleural effusion (n=15, mainly in patients with RA and SLE); honeycomb appearance (n=14; mainly in patients with RA and scleroderma); and bronchiectasis (n=9, mainly in patients with RA). Conclusions. Pulmonary manifestations are common in patients with CTDs, ILD being the most common pulmonary involvement. All patients with CTDs should be systematically evaluated and monitored for pulmonary involvement.

Curso de Reumatologia: aula 2: Importância Clínica da Caquexia Reumatoide / Course of Rheumatology: class 2: Clinical importance of rheumatoid arthistis

A artrite reumatoide é doença autoimune sistêmica de etiologia ainda desconhecida que pode causar destruição de cartilagem e osso. Afeta aproximadamente 1 por cento da população e é duas a três vezes mais frequente nas mulheres do que nos homens. Apesar de agredir predominantemente as articulações, apresenta inúmeras manifestações sistêmicas, entre elas a caquexia - que se manifesta em aproximadamente 66 por cento dos pacientes reumatoides. A caquexia reumatoide é conceituada como perda involuntária de massa celular, predominantemente de músculo esquelético, mas que também ocorre em vísceras e sistema imune. A causa é multifatorial, mas os mecanismos mais importantes são a produção de citocinas, principalmente TNFα e II-1ß, diminuição da ação periférica da insulina e pouca atividade física. Neste artigo discutem-se aspectos relacionados à patogenia, às implicações clínicas e abordagens terapêuticas.

Rheumatoid arthristis is a chronic, systemic, autoimmune disease of unknow etiology that causes destruction of joint cartilage and bone. It affects approximately 1 per cent of the population and predominates among womwn than men. Cachexia, from the Greek "bad condition", generally connotes as state of advanced malnutrition and wasting. However, more recently cachexia has been used to denote the loss of body cell mass which occurs in illness. So rheumatoid cachexia can be defined as an involuntary loss of body cell mass, that predominates in skeletal muscle, and occurs with little or no wegith in the presence of stable or increased fat mass. The etiology is likely multifactorial, and involves excess inflamatory cytokine production, namely excess tumor necrosis factor-α and interleukin-1ß production; reduced peripheral insulin action; and low habitual physical activity. In this article, we evaluate pathogenesis of rheumotoid cachexia, its clinical disclosures and discuss potential therapies.

Cambio en la capacidad funcional, calidad de vida y actividad de la enfermedad, en un grupo de pacientes colombianos con artritis reumatoide refractaria al tratamiento convencional, que recibieron terapia con infliximab como medicamento de rescate / Changes in the functional capacity, quality of life and activity of the disease in a group of colombian patients with rheumatoid arthritis refractory to the conventional treatments, who were treated with infliximab as rescue therapy / Mudança na capacidade funcional, qualidade de vida e atividade da doença, num grupo de pacientes colombianos com artrites reumatoide refratária ao tratamento convencional, que receberam terapia com infliximab como medicamento de resgate

Rheumatoid arthritis is a chronic inflammatory process that effects mostly the joints leading to destruction of the joint, deformity, incapacity and deterioration of the quality of life. As a result of technologic advances and the better knowledge of the pathophisiology of the disease, there are new therapeutic options with biologic agents. There are no reports from Colombia about the experience with Infliximab in patients with rheumatoid arthritis. The objective of this study was to quantify the changes in quality of life, functional capacity, signs and symptoms related to the inflammatory activity and the therapeutic efficacy, in a group of Colombian patients with long term rheumatoid arthritis (13±10 years) refractory to conventional treatments. A total of 31 patients, 22 women and 9 men, aged 51±12 years and an average evolution of disease of 13.2±10.4 years, who had active disease in spite of having received Methrotexate or Leflunomide in combination with other agents, such as low doses of glucocorticoids, analgesics and antiinflammatories, received infusions of Infliximab at doses of 3mg/kg during weeks 0, 2, 6, 14, and 22, following the guidelines of the Colombian Rheumatology Association. It was determined that the median functional capacity measured by HAQ-DI went from 1,2±0,54 to 0,29±0.28, that the quality of life measured by Spanish-AIMS improved globally from 48,4±14.4 to 29,4±8.2 in each of its eight components. There was also improvement in the components of SF-12 since the physical health went from 39,9±13,7 to 55,5±24,1 and mental health from 57,0±24,2 to 74,6±17,0. Although 71% of the patients had some type of side effect, they were minor and the medication was not stopped. These findings agree with the international reports that the administration on Infliximab induces a significative improvement in those patients with refractory rheumatoid arthritis. Taking into account the potential side effects and the real risk of tuberculosis in our country, the administration of Infliximab must be carried out in specialized units with well trained personnel and under the strict supervision of a rheumatologist.

La artritis reumatoide (AR) es una enfermedad inflamatoria crónica que afecta principalmente las articulaciones, produciendo destrucción articular, deformidad, discapacidad y deterioro de la calidad de vida. Como nuevas opciones de tratamiento, producto del avance tecnológico y del conocimiento de la fisiopatología de la enfermedad, han aparecido recientemente en el mercado los denominados agentes biológicos. Teniendo en cuenta que no hay reportes colombianos sobre la experiencia con infliximab en pacientes con AR, el objetivo de este estudio fue cuantificar en un grupo de pacientes colombianos con AR de larga evolución (13±10 años) y refractarios al tratamiento convencional, el cambio en la calidad de vida, la capacidad funcional, en los síntomas y signos relacionados con la actividad inflamatoria y en la seguridad terapéutica producidos por infliximab. Un total de 31 pacientes, 22 mujeres y 9 hombres, con edades de 51±12 años y un promedio de evolución de enfermedad de 13,2±10,4 años, que permanecieron activos a pesar de recibir metotrexate o leflunomida en combinación con otros agentes modificadores de la enfermedad, bajas dosis de glucocorticoides, analgésicos y antiinflamatorios, recibieron infusiones de infliximab de tres mg/kg dosis durante 22 semanas, siguiendo las recomendaciones de la Asociación Colombiana de Reumatología, en las semanas 0, 2, 6, 14 y 22. Se encontró que la capacidad funcional medida por HAQ-DI pasó de 1,2±0,54 a 0,29±0.28, que la calidad de vida medida por Spanish-AIMS mejoró en su calificación global de 48,4±14.4 a 29,4±8.2 y en cada uno de sus ocho componentes. Hubo también mejoría en los componentes del SF-12, pues la salud física pasó de 39,9±13,7 a 55,5±24,1 y la salud mental de 57,0±24,2 a 74,6±17,0. Aunque el 71% refirió algún evento adverso durante el seguimiento, estos fueron menores y no obligaron a la suspensión del medicamento. Sólo tres pacientes fueron retirados, uno por hipotensión repetitiva al inicio de la infusión, otro por reacción anafiláctica que requirió reanimación y el otro por tuberculosis pleural luego de dos meses de iniciado el medicamento. Se encontró entonces que de acuerdo con los reportes internacionales, la administración de infliximab conlleva a una mejoría significativa en los enfermos con AR refractaria a los tratamientos comunes, evidenciada en los signos y síntomas relacionados con la actividad de la AR, así como en la calidad de vida y en la capacidad funcional. Teniendo en cuenta la posibilidad las reacciones adversas durante la aplicación y que en nuestro país la tuberculosis es un riesgo real, la administración del infliximab debe hacerse en unidades especializadas con personal entrenado y bajo la supervisión estricta del reumatólogo...

A artrite reumatóide (AR) é uma doença inflamatória crônica que afeta principalmente as articulações, produzindo destruição articular, deformidade, incapacidade e deterioração da qualidade de vida. Como novas opções de tratamento, produto do avanço tecnológico e do conhecimento da fisiopatologia da doença, apareceram recentemente no mercado os denominados agentes biológicos. Tendo em conta que não há reportes colombianos sobre a experiência com infliximab em pacientes com AR, o objetivo deste estudo foi quantificar num grupo de pacientes colombianos com AR de longa evolução (13±10 anos) e refratários ao tratamento convencional, a mudança na qualidade de vida, a capacidade funcional, nos sintomas e signos relacionados com a atividade inflamatória e na segurança terapêutica produzidos por infliximab. Um total de 31 pacientes, 22 mulheres e 9 homens, com idades de 51±12 anos e uma média de evolução de doença de 13,2±10,4 anos, que permaneceram ativos apesar de receber metotrexate ou leflunomida em combinação com outros agentes modificadores da doença, baixas doses de glucocorticoides, analgésicos e antiinflamatórios, receberam infusões de infliximab de três mg/kg dose durante 22 semanas, seguindo as recomendações da Associação Colombiana de Reumatologia, nas semanas 0, 2, 6, 14 e 22. Encontrou-se que a capacidade funcional medida por HAQ-DEI passou de 1,2±0,54 a 0,29±0.28, que a qualidade de vida medida por Spanish-AIMS melhorou em sua qualificação global de 48,4±14.4 a 29,4±8.2 e em cada um de seus oito componentes. Teve também melhoria nos componentes do SF-12, pois a saúde física passou de 39,9±13,7 a 55,5±24,1 e a saúde mental de 57,0±24,2 a 74,6±17,0. Ainda que o 71% referiu algum evento adverso durante o seguimento, estes foram menores e não obrigaram à suspensão do medicamento. Só três pacientes foram retirados, um por hipotensão repetitiva ao início da infusão, outro por reação anafilática que requereu reanimação e o outro por tuberculose pleural depois de dois meses de iniciado o medicamento. Encontrou-se então que de acordo com os reportes internacionais, a administração de infliximab implica uma melhoria significativa nos enfermos com AR refratária aos tratamentos comuns, evidenciada nos signos e sintomas relacionados com a atividade da AR, bem como na qualidade de vida e na capacidade funcional. Tendo em conta a possibilidade às reações adversas durante a aplicação e que em nosso país a tuberculose é um risco real, a administração do infliximab deve fazer-se em unidades especializadas com pessoal treinado e sob a supervisão estrita do reumatólogista...

Factor reumatoideo y marcadores de respuesta inflamatoria. Comportamiento en una muestra de individuos. Resultados preliminares / Rheumatoid factor and inflammatory answer markers. Behavior in a sample of individuals. Preliminary results

El factor reumatoideo es un marcador serológico de autoinmunidad asociado con varias enfermedades, y con una elevada demanda en el laboratorio clínico del hospital Faustino Pérez de Matanzas. Por estas razones nos motivamos a realizar un estudio transversal para analizar el comportamiento sérico de factor reumatoideo, proteína C reactiva, C3 y C4 complemento, IgG, IgM, e IgA en una muestra supuestamente sana y enferma de esta provincia. Para ello se realizó la determinación cuantitativa inmunoturbidimétrica de estas variables en 112 individuos, 70 controles supuestamente sanos y 42 pacientes, mediante el empleo de diagnosticadores Futura System. El Test-T para comparación de medias entre grupos arrojó niveles significativamnte superiores (p<0,05) de factor reumatoideo, proteína C reactiva, IgG, e IgA: 98,64 v/s 17,81 U/ml, 26,4 v/s 5,31 mg/L, 14,35 v/s 12,65 g/L, 4,12 v/s 2,59 g/L, en los pacientes con relación a los controles, respectivamente; y niveles inferiores de C3, 1,40 v/s 1,68 g/L, y C4, 0,29 V/S 0,36 G/L, en los primeros (p<0.05). Además, se detectaron niveles significativamente superiores de C3 complemento en pacientes en estadío de exacerbación clínica con relación a aquéllos en remisión, 1,48 v/s 1,02 g/L (p=0,018), y en pacientes con Artritis Reumatoidea frente a aquéllos con otros diagnósticos, 1,65 v/s 1,21 g/L (p=0,004); así como de IgG en pacientes en remisión con relación a los activos, 16,77 v/s 13,78 g/L (p=0,050). No fue encontrada diferencia significativa para el resto de las variables entre los pacientes. Estos resultados podrían deberse a la participación de la respuesta inflamatoria activada en los pacientes estudiados y en la regulación de los niveles de factor reumatoideo en diferentes enfermedades, y a la activación del C3 complemento, principalmente en pacientes con Artritis Reumatoidea...

The rheumatoid factor is a serologic marker of autoimmunity associated with several diseases, and with a great demand at the clinical laboratory of the hospital Faustino Pérez of Matanzas. For that reason we carried out a transversal study to analyze the seric behavior of the rheumatoid factor, reactive C protein, complements C3 and C4, IgG, IgM, and IgA in a supposed healthy and unhealthy sample of this province. For that reason the immunoturbidimetric quantitative determination of these variables was made in 112 individuals, 70 controls supposedly healthy and 42 patients, using diagnosers Futura System. The Test-T to compare the averages among groups, showed significant higher levels (p<0,05) of rheumatoid factor, C reactive protein, IgG, and IgA: 98,64 v/s 17,81 U/ml, 26,4 v/s 5,31 mg/L, 14,35 v/s 12,65 g/L, 4,12 v/s 2,59 g/L, in patients in relation with the controls, respectively; and lower levels of 1,40 v/s 1,68 g/L, and C4, 0,29 v/s 0,36 G/L, in the first ones (p<0.05). Besides that, there were detected significantly higher levels of the complement C3 in patients at the clinical exacerbation level in relation with those in remission, 1,48 v/s 1,02 g/L (p=0,018), and in patients with Rheumatoid Arthritis versus those with other diagnosis, 1,65 v/s 1,21 g/L (p=0,004); and also of IgG in patients in remission in relation with the active ones, 16,77 v/s 13,78 g/L (p=0,050). There were not found significant differences for the rest of the variables among the patients. These results might be due to the participation of the activated inflammatory answer in the studied patients, to the regulation of the levels of the rheumatoid factor in different diseases, and to the activation of the C3 complement, mainly in patients with Rheumatoid Arthritis.

Evaluación de anticuerpos anti-péptido cíclico citrulinado y anti-vimetina mutada en pacientes con artitris reumatoide / Evaluation of ciclic citrulinated anti-peptide antibodies and anti-vimentin muted in patients with rheumatoid arthritis

La Artritis Reumatoide (AR) es una enfermedad inflamatoria crónica y multisistémica de etiología desconocida, que afecta principalmente las articulaciones periféricas. Su diagnóstico desde el laboratorio se ha limitado al empleo del Factor Reumoatoide (FR) como único marcador considerado por le Colegio Americano de Reumatología (CAR) entre sus criterios de detección para la enfermedad, conociendo su relativa sensibilidad y baja especificidad, surgió el propósito de hallar un marcador seológico con sensibilidad y especificidad suficiente capaz de contribuir al diagnóstico de la AR. Para dar cumplimiento con el objetivo general, se llevó a cabo la evaluación de los ensayos de anticuerpos anti-péptidos cíclicos citrulinados de segunda generación a través de dos metodologías (anti-CCP2, ELISA el Inmunofluorometría-enzimática) y anti-vimentina mutada citrulinada (anti-MCV, ELISA) y su correlación posterior con el FR y anticuerpos anti-nucleares (AAN), por lo cual, se seleccionaron 59 pacientes con AR y 29 pacientes con otras enfermedades autoinmunes. observándose que el ensayo anti-MCV (ELISA) presentó mayor sensibilidad diagnóstica, en tanto que el anti-CCP2 (ELISA) reflejó mayor especificidad, sin embargo, se obtuvo mejor correlación y concordancia entre los ensayos anti CCP2 (Inmunofluorometría-enzimática) y anti-MCV (ELISA). Así mismo se obtuvo moderada concordancia entre el FR y el anti-CCP2 (ELISA) y, entre los AAN y el anti-CCP2 (ELISA). Concluyendo que el anti-MCV (ELISA) presentó un mejor comportamiento para el diagnóstico de la enfermedad, sin dejar en consideración que el anti-CCP2 a través de sus dos metodologías también puede ser utilizado por el Reumatológo en la evaluación del paciente con AR.

The rheumatoid arthritis (RA) is a chronic multisystemic inlfammatory disease of unknown etiology that principally effects the peripheral articulations. It's diagnose from the laboratory has been limited to the emplyment of the rheumatoid factor (RF) as the only marker considerate by the American College of Rheumatology (ACR) between there criteria for the disease detection. Knowing its relative sensibility and low specificity, we proposed to find a serologic marker wih adequate sensibility and specificity to contribute in the diagnosis of RA. To perform the general objective, we evaluated the assays of cyclic citruliated anti-peptide antibodies of second generation by two methodologies (anti-CCP2, ELISA and Enzymatic Immunofuorometry) and muted anti-vimetin citrulinated (anti-MCV, ELISA) and it's correlation with the RF and anti-nuclear antibodies (ANA). There were selected 59 patients with RA and 29 patients with other autoimmune disease. We observed that the anti-MCV (ELISA) assay presented mayor diagnostic sensibility, while the anti-CCP2 (ELISA) reflected mayor specificity. But with he (anti-CCP2, ELISA and Enzimatic Inmunofluoremetry) and anti-MCV (ELISA) we obtained better correlations and concodance. We also obtained moderate concordante between FR and anti-CCP2, (Elisa), and between ANA and anti-CCP2 (ELISA). Concluding that the anti-MCV (ELISA) presented a better behavior for the diagnosis of the disease, without considerating that the anti-CCP2 by it's both methodologies can be utilized by the Rheumatologist for the evaluation of the patient with RA.