Chronic use of hydroxychloroquine did not protect against COVID-19 in a large cohort of patients with rheumatic diseases in Brazil

Abstract Background: There is a lack of information on the role of chronic use of hydroxychloroquine during the SARS-CoV-2 outbreak. Our aim was to compare the occurrence of COVID-19 between rheumatic disease patients on hydroxychloroquine with individuals from the same household not taking the drug during the first 8 weeks of community viral transmission in Brazil. Methods: This baseline cross-sectional analysis is part of a 24-week observational multi-center study involving 22 Brazilian academic outpatient centers. All information regarding COVID-19 symptoms, epidemiological, clinical, and demographic data were recorded on a specific web-based platform using telephone calls from physicians and medical students. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. Mann-Whitney, Chi-square and Exact Fisher tests were used for statistical analysis and two binary Final Logistic Regression Model by Wald test were developed using a backward-stepwise method for the presence of COVID-19. Results: From March 29th to May 17st, 2020, a total of 10,443 participants were enrolled, including 5166 (53.9%) rheumatic disease patients, of whom 82.5% had systemic erythematosus lupus, 7.8% rheumatoid arthritis, 3.7% Sjögren's syndrome and 0.8% systemic sclerosis. In total, 1822 (19.1%) participants reported flu symptoms within the 30 days prior to enrollment, of which 3.1% fulfilled the BMH criteria, but with no significant difference between rheumatic disease patients (4.03%) and controls (3.25%). After adjustments for multiple confounders, the main risk factor significantly associated with a COVID-19 diagnosis was lung disease (OR 1.63; 95% CI 1.03-2.58); and for rheumatic disease patients were diagnosis of systemic sclerosis (OR 2.8; 95% CI 1.19-6.63) and glucocorticoids above 10 mg/ day (OR 2.05; 95% CI 1.31-3.19). In addition, a recent influenza vaccination had a protective effect (OR 0.674; 95% CI 0.46-0.98). Conclusion: Patients with rheumatic disease on hydroxychloroquine presented a similar occurrence of COVID-19 to household cohabitants, suggesting a lack of any protective role against SARS-CoV-2 infection. Trial registration Brazilian Registry of Clinical Trials (ReBEC; RBR - 9KTWX6).

High prevalence of obesity in rheumatoid arthritis patients: association with disease activity, hypertension, dyslipidemia and diabetes, a multi-center study

Abstract Introduction: Rheumatoid arthritis (RA) is a well-documented independent risk factor for cardiovascular disease. Obesity may provide an additional link between inflammation and accelerated atherosclerosis in RA. Objective: To evaluate the association between obesity and disease parameters and cardiovascular risk factors in RA patients. Method: Cross-sectional study of a cohort of RA patients from three Brazilian teaching hospitals. Information on demographics, clinical parameters and the presence of cardiovascular risk factors was collected. Blood pressure, weight, height and waist circumference (WC) were measured during the first consultation. Laboratory data were retrieved from medical records. Obesity was defined according to the NCEP/ATPIII and IDF guidelines. The prevalence of obesity was determined cross-sectionally. Disease activity was evaluated using the DAS28 system (remission < 2.6; low 2.6—3.1; moderate 3.2-5.0; high >5.1). Results: The sample consisted of 791 RA patients aged 54.7 ± 12.0 years, of whom 86.9% were women and 59.9% were Caucasian. The mean disease duration was 12.8 ± 8.9 years. Three quarters were rheumatoid factor-positive, the mean body mass index (BMI) was 27.1 ±4.9, and the mean WC was 93.5 ± 12.5 cm. The observed risk factors included dyslipidemia (34.3%), type-2 diabetes (15%), hypertension (49.2%) and family history of premature cardiovascular disease (16.5%). BMI-defined obesity was highly prevalent (26.9%) and associated with age, hypertension and dyslipidemia. Increased WC was associated with diabetes, hypertension, dyslipidemia and disease activity. Conclusion: Obesity was highly prevalent in RA patients and associated with disease activity.

Leishmaniose tegumentar em paciente com espondilite anquilosante utilizando adalimumabe / Cutaneous leishmaniasis in a patient with ankylosing spondylitis using adalimumab

A leishmaniose é uma antropozoonose causada por espécies de Leishmania e pode apresentar-se de diversas formas clínicas, dependendo da interação parasita-hospedeiro. O fator de necrose tumoral-α (TNF-α) é uma citocina essencial para o controle de infecções, especialmente contra parasitas intracelulares como a Leishmania. A terapia anti-TNF-α tem importante papel no tratamento de doenças reumáticas, mas o uso desses antagonistas está relacionado ao aumento de infecções. Relatamos o primeiro caso de leishmaniose cutânea no Brasil em uma paciente portadora de espondilite anquilosante em uso de adalimumabe e metotrexato. Acreditamos que neste caso não houve relação entre o uso de anti-TNF-α e a leishmaniose cutânea, pois a doença estava limitada a apenas uma úlcera, que cicatrizou completamente após o tratamento. Mais estudos, entretanto, são necessários para entender melhor a possível associação entre agentes anti-TNF-α e leishmaniose.

Leishmaniasis is an anthropozoonosis caused by species of Leishmania and can have different clinical presentations, depending on the parasite-host relationship. Tumor necrosis factor-α (TNF-α) is a cytokine essential to infection control, especially against intracellular parasites such as Leishmania. Anti-TNF-α strategies have had a marked impact on the treatment of rheumatic diseases, but the clinical use of those antagonists has been accompanied by an increased report of infections. We report the first case of cutaneous leishmaniasis in a patient with ankylosing spondylitis treated with adalimumab and methotrexate in Brazil. We believe that, in this case, there was no association between the anti-TNF-α treatment and cutaneous leishmaniasis, because the disease was limited to only one ulcer that healed completely after treatment. More studies, however, are necessary to better understand the possible relationship between anti-TNF-α agents and leishmaniasis.

Uso do abatacepte em uma paciente com artrite psoriásica / Use of the abatacept in a patient with psoriatic arthritis

Artrite psoriásica (AP) é uma artrite inflamatória soronegativa de causa desconhecida. Classicamente, a AP apresenta cinco formas clínicas, sendo a oligoartrite assimétrica a mais comum. Descrevemos o caso de uma paciente com AP refratária às drogas modificadoras da doença, que evoluiu com hepatite medicamentosa após quimioprofilaxia com isoniazida, administrada previamente ao tratamento com anti-TNFα. Em virtude do risco de ativação de tuberculose (TB) latente pela administração de anti-TNFα, da hepatotoxicidade decorrente do tratamento da TB, e baseado no fato de o tratamento da AP se assemelhar ao da artrite reumatoide, optou-se pelo tratamento empírico com abatacepte. Aproximadamente vinte dias após a segunda dose do biológico, a paciente evoluiu com importante melhora clínica, resolução da artrite, regressão das lesões de pele e melhora da anemia e das provas de atividade inflamatória.

Psoriatic arthritis (PA) is an inflammatory seronegative arthritis of unknown origin. Classically, PA has five clinical forms, and asymmetric oligoarthritis is the most common type. We describe the case of a patient with PA refractory to disease-modifying drugs, who developed drug-induced hepatitis after chemoprophylaxis with isoniazid, administered prior to the treatment with an anti-TNFα agent. Due to the risk of activating latent tuberculosis with the administration of anti-TNFα and hepatotoxicity onset caused by the TB treatment and based on the fact that the treatment of PA is similar to the treatment of rheumatoid arthritis, a decision was made to use the empirical treatment with abatacept. Approximately twenty days after the second infusion of the drug, the patient showed clinical improvement, resolution of the arthritis, almost complete disappearance of the skin lesions and improvement of anemia and inflammatory tests.

Manifestações musculoesqueléticas em pacientes submetidos à hemodiálise / Musculoskeletal manifestations in patientes under hemodialysis

As anormalidades musculoesqueléticas em pacientes submetidos à hemodiálise são numerosas e freqüentes, sendo mais prevalentes naqueles em tratamento dialítico de longa duração. A artralgia é o sintoma mais comum, ocorrendo em mais de 70 por cento dos pacientes. O hiperparatireoidismo secundário é a principal causa da doença renal óssea, e as manifestações clínicas são: dor óssea, artralgia e prurido. A amiloidose, decorrente da deposição de proteína Beta2-microglobulina nos tecidos, manifesta-se pela presença de ombro doloroso, síndrome do túnel do carpo, dedo em gatilho, ruptura espontânea de tendão e fratura patológica. Outras manifestações musculoesqueléticas observadas são a artrite induzida por cristais, necrose avascular, artrite séptica, fraqueza muscular e cãibras musculares.

Pancreatite aguda no Hospital Geral de Fortaleza: aspectos clínicos, diagnósticos e evolutivos - análise retrospectiva de 35 casos / Acute pancreatitis at the Fortaleza General Hospital: clinical aspects, diagnosis, and evolution- retrospective analysis of 35 cases

A pancreatite aguda, uma doença comum, pode ser clinicamente leve ou grave, O objetivo deste trabalho foi reconhecer os fatores envolvidos com a doença em nosso meio e compará-los com os dados da literatura. Um estudo retrospectivo foi realizado avaliando 35 pacientes com pancreatite aguda internados no serviço de Gastroenterologia do Hospital Geral de Fortaleza, no período de janeiro de 2000 a dezembro de 2002. Os homens foram mais acometidos (54,3por cento) que as mulheres e a idade variou de 15 a 89 anos, com média de 42,88 anos. As principais causas foram a litíase biliar (48,6por cento) e o alcool (35,3por cento). A pancreatite aguda esteve associada à necrose em oito casos (22,9Por cento) e ao edema intersticial em 22 (62,9por cento). A normoamilasemia foi encontrada em seis pacientes ( 17,1por cento) e a média dos valores da proteína C-reativa foi duas vezes maior na forma necrotizante que na edematosa. A tomografia computadorizada com uso de contraste intravenoso, método de imagem de escolha para o diagnóstico e detecção de complicações como a necrose pancreática, foi realizada em 19 pacientes (54,3por cento). A ultra-sonografia abdominal, o método mais sensível para avaliação da árvore biliar na pancreatite aguda. Foi realizada em 32 casos (91,4por cento). Foram submetidos à colecistectomia todos os pacientes com pancreatite biliar sem contra-indicação cirúrgica. A taxa de mortalidade foi de 8,6por cento (37,5por cento na forma necrotizante e 0por cento na edematosa). Conclui-se que a pancreatite necrotizante associou-se a maior morbimortalidade e que os resultados do trabalho de modo geral, concordam com os da literatura