Unexplained chest pain in a patient with giant cell arteritis? Think aortic dissection.

Giant cell arteritis (GCA) is the commonest of the large-vessel vasculitides. Aortic inflammation in patients with GCA was first described over 80 years ago, but it has only been possible to study this systematically following the development of more sophisticated imaging techniques such as computed tomography angiography, magnetic resonance angiography and positron emission tomography. Both NICE and the European League Against Rheumatism (EULAR) recognise that aortic dissection may complicate GCA but stop short of recommending routine imaging. We report a case that highlights a possible need for large-vessel imaging at the time of diagnosis and during follow-up to enable earlier recognition of aortitis and associated complications including dissection.

Implications of a diagnosis of rheumatoid arthritis in resource-poor countries.

Rheumatoid arthritis (RA) is a multisystemic autoimmune disease that predominantly affects synovial joints. It causes marked disability, reduces health-related quality of life, and leads to high mortality. The diagnosis of RA is often made by standard criteria, and the management of this condition is usually undertaken according to the established guidelines. In resource-poor settings, the diagnosis and management of RA are hampered by diverse factors such as late presentation, inadequate trained personnel, poor healthcare infrastructure, low socioeconomic status, poor access to both conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics, and a high burden of infectious diseases such as tuberculosis, hepatitis, and human immunodeficiency virus. There is a need to establish registries in these settings to provide adequate information on the pattern, medication, and long-term outcome of RA in resource-poor countries in order to provide a practical and evidence-based management guide for rheumatologists, which is appropriate for these settings.

Patient educational needs and challenges in psoriatic arthritis.

PURPOSE OF REVIEW: To provide an overview of the recent research publications on educational needs of patients with psoriatic arthritis (PsA) and the associated challenges. RECENT FINDINGS: The rate of good treatment adherence in PsA can be as low as 57.7% and successful patient education can help improve treatment adherence. Also, 78.7% of patients who stopped their disease modifying anti-rheumatic drugs during the first wave of the COVID-19 pandemic did so without the advice of their clinician. In delivering educational needs, the aspects of disease process, treatment, self-help measures, managing pain, movement, psychological and social needs should all be addressed, whilst at the same time, recognising that PsA patients with multidomain disease, are likely to be dealing with more than just pain. Arthritis self-care management education is potentially beneficial, but up to 11% of educational YouTube videos may contain misleading patient opinion and many existing apps do not meet the needs of the patients with PsA. SUMMARY: Significant room for improvement exists in treatment adherence in PsA and patient education addressing the relevant educational needs could assist with this issue. However, patients should be advised to be wary of internet videos and other educational aids that were not created by health professionals.

Frequency, pattern, and associations of generalized osteoarthritis among Nigerians with knee osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a common degenerative condition leading to significant pain, functional limitation, and economic loss. Generalized OA (GOA) is associated with greater morbidity and accounts for 5-25% of total OA cases depending on definition used. This paper aims to determine the frequency and pattern of GOA, compare clinical and laboratory parameters of GOA and non-GOA subjects, then identify independent associations of GOA among Nigerians with knee OA. METHODS: A cross-sectional study of 180 knee OA patients with knee and generalized OA defined using ACR criteria. Questionnaire administration was followed by physical examination and appropriate radiographs. Data was summarized using tables and figures. Multivariate regression was done to identify independent GOA associations with statistical significance p<0.05. Ethical approval was obtained for the study. RESULTS: There were 180 participants with mean age 59.7±9.1 years. Twenty-eight patients (15.6%) had GOA of which 26 were female. The hip/knee/spine pattern was the commonest while hand OA was rare. Comparisons showed that GOA patients were significantly older with longer pain duration, higher pain score, more Heberden's nodes, and greater fatigue. There were no significant differences between both groups in levels of inflammatory markers and other laboratory parameters. Further analysis identified joint stiffness as the only independent association of GOA (OR 3.34, p=0.01). CONCLUSION: A 15.6% frequency of GOA was identified among knee OA sufferers with the hip/knee/spine pattern most frequent. Nigerians with GOA are predominantly females with a large joint phenotype. Joint stiffness was the only independent association of GOA observed. Key Points • Generalized osteoarthritis occurs in 15.6% of Nigerian patients with knee osteoarthritis. • Females are predominantly affected with a large joint phenotype involving the hip/knee/spine. • Joint stiffness is an independent association of generalized osteoarthritis.

African League Against Rheumatism (AFLAR) preliminary recommendations on the management of rheumatic diseases during the COVID-19 pandemic.

OBJECTIVES: To develop recommendations for the management of rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic. METHOD: A task force comprising of 25 rheumatologists from the 5 regions of the continent was formed and operated through a hub-and-spoke model with a central working committee (CWC) and 4 subgroups. The subgroups championed separate scopes of the clinical questions and formulated preliminary statements of recommendations which were processed centrally in the CWC. The CWC and each subgroup met by several virtual meetings, and two rounds of voting were conducted on the drafted statements of recommendations. Votes were online-delivered and recommendations were pruned down according to predefined criteria. Each statement was rated between 1 and 9 with 1-3, 4-6 and 7-9 representing disagreement, uncertainty and agreement, respectively. The levels of agreement on the statements were stratified as low, moderate or high according to the spread of votes. A statement was retired if it had a mean vote below 7 or a 'low' level of agreement. RESULTS: A total of 126 initial statements of recommendations were drafted, and these were reduced to 22 after the two rounds of voting. CONCLUSIONS: The preliminary statements of recommendations will serve to guide the clinical practice of rheumatology across Africa amidst the changing practices and uncertainties in the current era of COVID-19. It is recognized that further updates to the recommendations will be needed as more evidence emerges. Key Points • AFLAR has developed preliminary recommendations for the management of RMDs in the face of the COVID-19 pandemic. • COVID-19 is an unprecedented experience which has brought new concerns regarding the use of some disease-modifying anti-rheumatic drugs (DMARDs), and these recommendations seek to provide guidelines to the African rheumatologists. • Hydroxychloroquine shortage has become rampart across Africa as the drug is being used as prophylaxis against COVID-19 and this may necessitate a review of treatment plan for some patients with RMDs. • Breastfeeding should continue for as long as possible if a woman is positive for SARS-CoV-2 as there is currently no evidence that the infection can be transmitted through breast milk.

The impact of COVID-19 on rheumatology practice across Africa.

OBJECTIVES: To identify the changes in rheumatology service delivery across the five regions of Africa from the impact of the COVID-19 pandemic. METHODS: The COVID-19 African Rheumatology Study Group created an online survey consisting of 40 questions relating to the current practices and experiences of rheumatologists across Africa. The CHERRIES checklist for reporting results of internet e-surveys was adhered to. RESULTS: A total of 554 completed responses were received from 20 countries, which include six in Northern Africa, six in West Africa, four in Southern Africa, three in East Africa and one in Central Africa. Consultant grade rheumatologists constituted 436 (78.7%) of respondents with a mean of 14.5 ± 10.3 years of experience. A total of 77 (13.9%) rheumatologists avoided starting a new biologic. Face-to-face clinics with the use of some personal protective equipment continued to be held in only 293 (52.9%) rheumatologists' practices. Teleconsultation modalities found usage as follows: telephone in 335 (60.5%), WhatsApp in 241 (43.5%), emails in 90 (16.3%) and video calls in 53 (9.6%). Physical examinations were mostly reduced in 295 (53.3%) or done with personal protective equipment in 128 (23.1%) practices. Only 316 (57.0%) reported that the national rheumatology society in their country had produced any recommendation around COVID-19 while only 73 (13.2%) confirmed the availability of a national rheumatology COVID-19 registry in their country. CONCLUSION: COVID-19 has shifted daily rheumatology practices across Africa to more virtual consultations and regional disparities are more apparent in the availability of local protocols and registries.

Connective tissue disease--associated interstitial lung disease: an underreported cause of interstitial lung disease in Sub-Saharan Africa.

Interstitial lung disease (ILD) occurs in 15% of connective tissue disease (CTD) patients causing considerable morbidity and mortality. Data is scarce regarding its clinical characteristics and outcomes in Africa. We aim to study the frequency, clinico-radiological characteristics, and treatment outcomes of African CTD-ILD patients. A retrospective cross-sectional study of ILD among 318 CTD patients diagnosed using relevant ACR criteria at the rheumatology unit of Lagos State University Teaching Hospital (LASUTH), Lagos from 2012 to 2019. Socio-demographics, clinical features, radiological findings, and treatment outcomes were documented. Data was analyzed using SPSS version 21 with p < 0.05. The LASUTH ethics committee approved the study. Interstitial lung disease occurred in 31 (9.7%) of 318 CTD cases. Their mean age was 38.8 ± 13.3 years, range 19-68 years with 28 (90.3%) females. Proportions of CTD-ILD were Sjogren's syndrome (50%), UCTD (50%), systemic sclerosis (46.7%), MCTD (33.3%), PM/DM (25%), SLE (6.5%), and RA (2.6%). Commonest presentations were cough (93.5%) and bibasal inspiratory crackles (83.9%) with a restrictive pattern in 83.9%. Antinuclear antibody occurred in 100% and anti-ENA in 67.7%. Traction bronchiectasis (89.7%) and ground glass opacities (96.6%) were frequent HRCT findings. Treatments included pulse-dose prednisolone, cyclophosphamide, mycophenolate mofetil, pirfenidone, and rituximab. Outcomes were ambulatory oxygen therapy (12.9%) and mortality (16.1%) with 9.7% lost to follow-up. CTD-ILD is a female predominant disease occurring in 9.7% of CTD patients mostly those with Sjogren's syndrome and systemic sclerosis. Due to significant morbidity and mortality, we advocate routine ILD screening for all CTD patients including those with undifferentiated disease. Key Points: • Interstitial lung disease occurs in 9.7% of patients with underlying connective tissue disease. • Females are predominantly affected especially those with Sjogren's syndrome and systemic sclerosis. • Mortality occurs in roughly 1 in every 6 patients with CTD-ILD.

Fibromyalgia in a rheumatology clinic in north-central Nigeria: An audit of the characteristics of the syndrome and the sensitivities of 4 sets of American College of Rheumatology criteria.

OBJECTIVES: To describe the characteristics of fibromyalgia among Nigerian patients and assess the sensitivities of the American College of Rheumatology (ACR) criteria of 1990, 2010, 2011, and 2016 for making the diagnosis of fibromyalgia. METHODS: Consecutive patients diagnosed clinically with fibromyalgia by a rheumatologist were assessed. ACR criteria for fibromyalgia of 1990, 2010, 2011, and 2016 were applied to each patient. Polysymptomatic distress scores (PSD) were calculated from the Widespread Pain Index and Symptom Severity Scores. Sleep was assessed using the Pittsburgh Sleep Quality Index; fatigue by the Fatigue Severity Scale and the severity of fibromyalgia was determined using the Revised Fibromyalgia Impact Questionnaire (FIQR). RESULTS: A total of 660 new patients were seen out of which a diagnosis of fibromyalgia was made in 114 (17.3%). The mean age of the patients was 44.6 ± 15.6 years and females accounted for 84.2%. Twenty-one (18.4%) patients had changed or quit their jobs due to fibromyalgia. Problematic fatigue was present in 80 (70.2%), and sleep disturbance was reported in 83 (72.8%) patients. The severity of fibromyalgia, poor sleep, severe or very severe PSD, and male gender were associated with problematic fatigue, but only moderate/severe fibromyalgia independently predicted problematic fatigue (P = .004). The number of tender points (P = .001) and FIQR score (P = .038) were associated with changing or quitting jobs. The sensitivities of the ACR1990, ACR2010, ACR2011 and ACR2016 were 38.5%, 68.2%, 76.7% and 76.7%, respectively. CONCLUSION: The ACR1990 had low sensitivity when used to diagnose fibromyalgia in this population and the ACR2010 encounters problems while applying the somatic symptom list.

Tossing and turning with degenerative arthropathy: an assessment of poor sleep quality in knee osteoarthritis.

OBJECTIVES: To determine the frequency and predictors of sleep abnormalities among patients with knee osteoarthritis (OA) in Nigeria. MATERIAL AND METHODS: A multi-centre, hospital-based, cross-sectional study, involving 250 knee OA patients. Consenting patients 18 years and above, who satisfied the American College of Rheumatology (ACR) criteria for knee OA were recruited from five Nigerian tertiary centres over 3 months. An interviewer-administered questionnaire was used to collect demographic and relevant clinical information. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality with scores ≥ 5 indicating poor sleep. Other variables assessed were pain, depression, functional class and family functioning. Data were summarized using appropriate measures of central tendency and dispersion. Multiple logistic regression analysis was done to identify predictors of poor sleep. Analysis was done using SPSS version 21.0 with p < 0.05 considered significant. Study approval was obtained from the ethical committees of each of the study sites. RESULTS: Participants included 209 females (83.6%) with mean age 59.9 ±10.6 years. One hundred and forty-one participants (56.4%) had PSQI scores ≥ 5 (poor sleep). This was significantly associated with depression (p < 0.001), level of education (p = 0.001), higher pain scores (p < 0.001), body mass index (p = 0.040), medial knee OA (p = 0.032) and patello-femoral OA (p = 0.002). Higher level of education, worse depression scores and higher WOMAC pain scores were the best predictors of poor sleep quality. CONCLUSION: Sleep quality was poor in over half of our knee OA patients and best predicted by depression, pain and level of education. Regular sleep quality assessment for knee OA patients is recommended.

Rowell Syndrome in Nigeria: Systemic Lupus Erythematosus Presenting as Recurrent Erythema Multiforme in a Young Woman.

Dear Editor, Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease characterized by diverse patterns of auto-antibody production with multi-organ affectation. Cutaneous involvement, either alone or in association with other systemic illnesses, is one of its most common manifestations (1). Dermatologic disorders like malar and discoid rashes are quite suggestive of SLE. However, the occurrence of non-specific skin lesions like erythema multiforme (EM) in patients with SLE (Rowell syndrome) can rarely occur (1). In such patients, a diagnosis of SLE may be missed or delayed in the absence of other overt clinical features of lupus. Herein we report a case of recurring EM-like eruptions as the cardinal cutaneous manifestation of previously undiagnosed, active SLE in a young Nigerian woman. A 26-year-old Nigerian woman presented with a three-day history of non-pruritic, generalized, and target-like, erythematous annular patches and plaques which mostly affected the trunk. A few lesions had presented with crusting and erosions at the time of examination (Figure 1). Associated symptoms included oral painful ulcers, low grade fever, and malaise. The patient had no other systemic symptoms and her prior drug history was not remarkable. Her erythrocyte sedimentation rate (ESR) was 66 mm/hour using the Westergren method. Screening for HIV and hepatitis B and C was negative. Herpes simplex, cytomegalovirus, and Epstein Barr viruses could not be screened for. Other baseline investigations (complete blood count, electrolytes, urea and creatinine as well as urinalysis) were within normal limits. The patient was managed as a case of EM of an unidentified inciting agent and her symptoms resolved with supportive care and antibiotics. However, she developed a recurrence about 5 weeks later, with more extensive and coalescent skin lesions (Figure 2). Additionally, there was a new onset of alopecia and pain in the small joints of the hands as well as both knees and ankles. At this time, the patient's ESR had gone up to 112 mm/h and she had developed significant proteinuria, with a protein creatinine ratio of 1.3 g/g (reference <0.5 g/g). Her antinuclear antibody (ANA) titer was high (1:320) with a speckled pattern. Anti-Smith antibody was also positive. A renal biopsy was declined. A tentative diagnosis of Rowell syndrome was made. The patient was started on high-dose steroids and hydroxychloroquine 200 mg twice daily. Subsequent care included the use of mycophenolate mofetil 1 g twice daily for 6 months. This was then changed to azathioprine at 50 mg twice daily. Follow-up after 6 months showed sustained clearance of skin lesions, resolution of fever and joint pains, as well as improvement in the renal profile, with a urine protein-creatinine ratio of 0.77 g/g. The presence of systemic lupus erythematosus, EM-like lesions, and a speckled pattern of antinuclear antibody in our patient fulfils the revised diagnostic criteria for RS put forward by Zeitouni et al. at the turn of the twenty-first century (2). Considering the rarity of EM-like lesions in SLE and the possibility of constitutional symptoms in EM, a diagnosis of RS may be readily overlooked in patients like the one described, whose major cutaneous manifestation of severe active SLE was EM-like lesions. In contrast to classic EM, where skin lesions are concentrated in the extremities, a predominant truncal distribution of EM-like lesions as found in our patient may favor a clinical consideration of RS (3). However, some authors have challenged the existence of Rowell syndrome as a distinct clinical laboratory entity. Arguments put forward in this regard include the fact that none of the immunological markers that have been described in RS are specific to any disorder. Additionally, the annular polycyclic dermatosis seen in sub-acute cutaneous lupus erythematosus (SCLE) can be difficult to clinically and histologically differentiate from EM (4,5). Patients with SLE also have a higher likelihood of developing adverse drug reactions (6). The inherent complexity of SLE may make for delayed and oftentimes difficult diagnosis, especially in a country where immunologic tests are expensive and rheumatologists are scarce. When patients do occasionally present with recurrences of skin lesions in the spectrum of EM, Steven-Johnson syndrome, and toxic epidermal necrolysis in the absence of a definite inciting agent, undiagnosed lupus may indeed be present in some of these individuals and should be considered in the differential diagnosis. In conclusion, while it is very rare, SLE may present first with recurrent episodes of EM-like rash. Despite the various possibilities which underlie their association, prompt identification and treatment of SLE in patients presenting with EM is important to prevent death or irreversible organ damage.

How much gloom is in groans? Depression and its determinants in Nigerian patients with knee osteoarthritis: a multi-center cross-sectional study.

OBJECTIVES: To determine the prevalence of depression and its determinants among Nigerian patients with knee osteoarthritis (OA). METHODS: Two hundred and fifty patients satisfying the American College of Rheumatology classification criteria for knee OA were recruited from five centers. Pain was assessed using Western Ontario and McMaster Universities Index (WOMAC) pain subscale, functional status was determined by Steinbrokers criteria, radiographic knee OA was graded using Kellgren-Lawrence criteria, depression was determined using the Patient Health Questionnaire (PHQ-9), sleep quality by the Pittsburgh Sleep Quality Index (PSQI), and family functioning by Family APGAR (Adaptation, Partnership, Growth, Affection, and Resolve). Factors associated with depression in KOA following bivariate analyses were adopted as independent variables in logistic regression analysis to determine the predictors of depression in KOA. The study was approved by the Ethical Review Committee of each of the study centers. RESULTS: The mean age of patients was 59.90 ± 10.62 years and 209 (83.6%) were females. Their mean PHQ-9 score was 4.68 ± 4.19 with 105 (42%) having depression (PHQ-9 ≥ 5). Eighty-four (80%) of patients with depression had poor sleep quality (PSQI≥ 5.0). Depression was significantly associated with poor sleep, WOMAC pain scores, medial compartment KOA, lateral compartment KOA, and patellofemoral OA. Poor sleep quality was the best predictor of depression (OR 4.555, CI (2.241-9.257), p < 0.001) followed by moderate to severe pain (OR 2.490, CI (1.119-5.542), p < 0.025). CONCLUSION: Depression is common among patients with knee OA, and depression can be predicted by poor sleep quality and moderate to severe pain.

The impact of ocular manifestations of rheumatoid arthritis on the health-related quality of life and the functional ability of black Africans.

Objectives To determine the patterns, predictors and overall impact of ocular manifestations of rheumatoid arthritis (RA) on the health-related quality of life and disability index. METHODS: A total of 50 Nigerian patients with RA were studied. Full ocular evaluation was done to determine the presence of each defined ocular manifestation of RA. All patients completed the Medical Outcome Study 36-Item Short Form Health Survey (SF-36) and the Health Assessment Questionnaire-Disability Index (HAQ-DI) questionnaires. RESULTS: The mean ± SD age of the patients was 47.2 ± 12.5 years. A total of 42 cases of ocular diseases were found in 23 (46%) patients. Keratoconjunctivitis sicca was found in 15 (30%) patients; cataract, 13 (26%); scleritis/episcleritis, 4 (8%); disk edema, 4 (8%); glaucoma, 3 (6%); ulcerative keratitis, 1 (2%); vitreitis, 1 (2%); and macula edema, 1 (2%) patient. There is an association of the presence of ocular manifestations with the physical component summary (PCS) [T = - 3.398, P = 0.001] and the mental component summary (MCS) [T = - 2.616, 0.012] of the SF-36 but not with the HAQ-DI (T = 1.685, 0.099). Following multiple regression analysis, the predictors of the presence of ocular manifestations were age greater than 45 years and positive anti-citrullinated protein antibody. Following linear regression analyses, Steinbrocker's functional class independently predicted the PCS while both Steinbrocker's functional class and female sex predicted the MCS. CONCLUSIONS: The development of ocular disorders associated with RA is associated with a significant negative impact on the quality of life of the patients.

Prevalence of minimal hepatic encephalopathy among patients with chronic liver disease in Ilorin, Nigeria.

BACKGROUND: Minimal Hepatic encephalopathy is the mildest form of Hepatic Encephalopathy which presents with significant cognitive impairment and affectation of activities of daily living. The literature is scanty on the prevalence of minimal hepatic encephalopathy in Nigerians with chronic liver disease. AIM: This study aimed at determining the prevalence of minimal hepatic encephalopathy among patients with chronic liver disease using neuro-psychometric tests. METHODS: The study was a hospital-based cross-sectional study carried out at the University of Ilorin Teaching Hospital, Ilorin from February 2015 to February 2016. Chronic liver disease was diagnosed with the presence of peripheral stigmata of liver disease, liver biochemistry, prothrombin time, and sonographic findings in keeping with liver disease. Minimal hepatic encephalopathy was diagnosed using number connection tests-A and B for patients who were educated while Line tracing test and constructional dyspraxia were used for patients without any formal education. Data obtained were analysed using Statistical Package for the Social Sciences (SPSS) version 20 computer software package. RESULTS: Sixty-four patients with chronic liver disease were recruited. The mean age (SD) of the patients was 47.1±14.6 yrs, and the 30-39 and 40-49 yrs age groups each had the highest frequency of 21(32.8%). There were 54 (84.4%) males and 10 (15.6%) females. The prevalence of Minimal Hepatic Encephalopathy was 43.8%. CONCLUSION: The prevalence of Minimal Hepatic Encephalopathy in this study was similar to previous studies. Significant number of patients with minimal HE were in Child-Pugh class B and C. FUNDING: None.

Thrombotic thrombocytopenic purpura as the first presentation in systemic lupus erythematosus.

Thrombotic thrombocytopenic purpura (TTP) is an uncommon, life-threatening disease characterized by severe thrombocytopenia, microangiopathic haemolytic anaemia, neurologic abnormalities, renal insufficiency, and fever commonly associated with infections, malignancy, drugs, and autoimmune diseases. Coexistence of TTP with systemic lupus erythematosus (SLE) is extremely rare, and the emergence of the full manifestation of SLE starting with TTP is even rarer. Black people due to genetic risk factors are at increased risk of TTP. In the present article the authors describe the case of a Nigerian woman who developed classical features of TTP as the first manifestation of SLE. The patient's condition was stabilized after treatment with intravenous pulses of methylprednisolone and subsequently on oral prednisolone and hydroxychloroquine treatment.

Is rheumatoid arthritis an innocent bystander in female reproductive problems? A comparative study of fertility in Nigerian women with and without rheumatoid arthritis.

OBJECTIVE: Contrary to the old belief that rheumatoid arthritis (RA) is rare in sub-Saharan Africa, recent reports have increasingly recognized that the burden of the disease has probably been long under-appreciated in West Africa. Thus, fertility and other attributes of the reproductive lives among women with RA have not received research attention in Africa. We aimed to compare the fertility between married Nigerian women with and without RA. METHODS: A comparative study of 50 women with RA and 50 women without RA was conducted via the specialist rheumatology clinics at two teaching hospitals in Nigeria. The participants were aged 18 years or older. Patients with RA were recruited on the basis of the fulfillment of the 1987 American College of Rheumatology classification criteria for RA, whereas the control participants were age-matched to the patients. Using an interviewer-administered questionnaire, demographic and clinical information was collected from each participant. Clinical details at the time of diagnosis of RA were extracted from the hospital records of the patients. The patients were tested for rheumatoid factor and anti-cyclic citrullinated peptide antibody, and the disease activity was assessed using the Clinical Disease Activity Index. The functional status was determined using the Steinbrocker functional classification. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp.; Armonk, NY, USA). The proportions of individuals with history of infertility, irregular menstruation, and menopausal states were compared between the two groups using χ2 and Fisher's exact tests, whereas the durations of infertility and parities were compared using Mann-Whitney U and independent t-tests, respectively. RESULTS: A positive history of infertility was found in 22 (44%) patients and 14 (28%) controls (p=0.096), while 17 (34%) patients and 23 (46%) controls were found to be postmenopausal (p=0.221). History of irregular menstruation was present in 15 (30%) patients and 4 (8%) controls (p=0.005). The median duration of infertility was 60 (range: 16-132) months among the patients and 36 (range: 12-72) months among the controls (p=0.036), while the mean parity was 2.85±1.8 among the patients and 3.77±2.2 among the controls (p=0.027). A significant association was found between infertility and functional class as well as methotrexate treatment. CONCLUSION: Infertility is not uncommon among patients with RA, and like many aspects of rheumatic diseases, it may have been under-recognized in the Nigerian patients.

The impacts of state and trait anxiety as moderated by perceived social support among Nigerian patients with rheumatoid arthritis.

OBJECTIVES: To assess the levels of state and trait anxiety and determine their relationships with perceived social support among Nigerian patients with rheumatoid arthritis (RA). MATERIAL AND METHODS: A cross-sectional study of 50 patients satisfying the 2010 American College of Rheumatology/European League against Rheumatism Classification Criteria for RA was conducted. Anxiety was assessed using the Spielberger State-Trait Anxiety Inventory (STAI), perceived social support by the Interpersonal Support Evaluation List (ISEL), health-related quality of life (HRQoL) by the Medical Outcome Study 36-Item Short Form Health Survey (SF-36) and disability by the Health Assessment Questionnaire-Disability Index (HAQ-DI). RESULTS: The mean state anxiety (STAI-S), trait anxiety (STAI-T) and ISEL scores among the patients were 35.2 ±10.2, 36.7 ±8.8 and 87.2 ±21.2 respectively. Pathological degrees of state and trait anxiety were found among 7 (14%) and 5 (10.4%) patients respectively. There was a negative correlation between the STAI-T score and the ISEL score (r = -0.362, p = 0.011). However, the correlation between STAI-S and ISEL was not statistically significant (r = -0.193, p = 0.179). A moderate-to-high correlation was found between each of STAI-S and STAI-T and all subscales and component summaries of the SF-36. ISEL score correlated significantly with role emotional (r = 0.377, p = 0.008), mental health (r = 0.482, p ≤ 0.001) and bodily pain (r = 0.320, p = 0.025) domains and the mental component summary (r = 0.380, p = 0.007) of SF-36. HAQ-DI correlated strongly with both STAI-S (r = 0.735, p ≤ 0.001) and STAI-T (r = 0.575, p ≤ 0.001) but not with ISEL. CONCLUSIONS: State and trait anxiety correlate negatively with all aspects of HRQoL and disability, and there is a notable relationship between perceived social support and trait anxiety as well as the mental aspect of HRQoL.

Hyperacute muscle weakness in an unusual coexistence of antisignal recognition particle and anti-Mi-2 antibodies.

Idiopathic inflammatory myopathies are a heterogeneous group of systemic diseases characterised by variable phenotypes of chronic progressive muscle weakness. Myositis-specific antibodies (MSAs) include antibodies to cytoplasmic signal recognition particle (SRP) and various tRNA synthetases as well as the nuclear helicase protein Mi-2. These antibodies are typically found only in a fraction of true myositis cases and they tend to be mutually exclusive. Few cases of coexistence of two MSAs in the same patient have been reported and these cases all involve an antisynthetase antibody coexisting with either anti-SRP or anti-Mi-2 antibody. Peculiar clinical manifestations may be associated with different combinations of MSAs but the rarity of these cases makes their characterisation difficult. We report the first ever case of anti-SRP and anti-Mi-2 copositive polymyositis in a 19-year-old boy who presented with a week history of profound muscle weakness that attained its peak within 24 hours of onset.