Cumulative pulse methylprednisolone and its relation to disease activity, damage and mortality in systemic lupus erythematosus patients: A post hoc analysis of COMOSLE-EGYPT study.

OBJECTIVE: To investigate the relation between cumulative intravenous methylprednisolone dose and disease activity, damage, and mortality among a group of Egyptian SLE patients. PATIENTS AND METHODS: This is a post hoc analysis of a retrospective multicenter COMOSLE study. Cumulative pulse methylprednisolone dose was abstracted from COMOSLE database. Patients with cumulative pulse dose of ≤ 3.0 g (median dose) were compared to those with cumulative dose of > 3.0 g regarding demographic data, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and The Systemic Lupus International Collaborating Clinics/ACR Damage Index (SLICC) score as well as treatment received. Additionally, at 1.5, 3, 6, and 9 g of cumulative methylprednisolone, patients were compared regarding SLICC score and risk of mortality. RESULTS: Patients who received > 3 g of methylprednisolone were statistically significantly younger at disease onset, had longer disease duration, higher SLEDAI score at last visit, and higher SLICC score (p = 003, p = 0.002, p = 0.004 and p = < 0.001, respectively). Additionally, with every gram increase in the cumulative methylprednisolone, there was a significant increase in SLICC score by 0.169 (B = 0.169, CI = 0.122-0.216, p-value = < 0.001) and an increased risk of mortality by 13.5% (hazard ratio (HR) = 1.135, CI = 1.091-1.180, p-value = 0.001). The best cutoff value of methylprednisolone dose at which damage may occur, ranged between 2.75 (with sensitivity of 81.4% and specificity of 33.9%) and 3.25 g (with sensitivity of 48.3% and specificity of 71.5%). CONCLUSION: With every gram increase in the cumulative methylprednisolone, there may be increase in damage and mortality, especially in doses exceeding the range of 2.75-3.25 g. Key Points • Treatment of systemic lupus erythematosus should be with the least possible dose of steroids to decrease the risk of damage and mortality. • With every gram increase in the cumulative intravenous methylprednisolone there may be increase in damage and mortality.

Detection of asymptomatic cranial neuropathies in patients with systemic lupus erythematosus and their relation to antiribosomal P antibody levels and disease activity.

The objectives of this study are to assess the risk of asymptomatic cranial neuropathy among patients with systemic lupus erythematosus (SLE) and find any association with disease activity and antiribosomal P antibodies. This study is a case-control study including 60 female patients and 30 healthy female controls. Disease activity was measured with the SLE disease activity index (SLEDAI). All patients were evaluated using evoked potentials, blink reflex, and levels of antiribosomal P antibodies. Patients with abnormal electrophysiological parameters had significantly higher levels of antiribosomal P antibodies (P = 0.034) and secondary antiphospholipid syndrome (P = 0.044). Antiribosomal P antibodies (odds ratio 5.4, 95 % confidence interval 1.002-1.03, P = 0.002) and presence of anti-DNA antibodies (odds ratio 1.01, 95 % confidence interval 1.2-24.8, P = 0.032) were independent risk factors for the presence of the abnormal electrophysiological parameters. Disease duration was positively correlated with wave 1 of the auditory brain reflex (P < 0.001) and a latency of the evoked blink reflex (component R1, P = 0.013). SLEDAI scores were positively correlated with latencies of the visually evoked potential (P100, P = 0.02), wave 1 of the auditory brain reflex (P < 0.001), and a latency of the evoked blink reflex (R2c, P = 0.005). Steroid dosage was negatively correlated with P100 latencies (P = 0.042) and components of the evoked blink reflex (R1, P = 0.042; R2i, P = 0.041; R2c, P < 0.001). Because abnormalities in the visually evoked potential and blink reflex were associated with antiribosomal P antibodies, they can be useful for detecting asymptomatic cranial neuropathy. Further studies on large number of patients should be done to determine any association.

The frequency of low bone mineral density and its associated risk factors in patients with inflammatory bowel diseases.

OBJECTIVE: To detect the frequency and the predictive factors of low bone mineral density in inflammatory bowel disease (IBD) patients, so as to optimize bone mineral density (BMD) monitoring and treatment for those at risk. SUBJECTS AND METHODS: Thirty Asian patients were included in this study and were divided into 18 patients with ulcerative colitis (UC), and 12 patients with Crohn's disease (CD). All patients were diagnosed by colonoscopy and histopathological biopsy and were subjected to routine laboratory investigations in addition to 25 hydroxy vitamin D levels as well as serum calcium, phosphorus and alkaline phosphatise. BMD was measured by using dual-energy X-ray absorptiometry (DEXA) scan at lumbar spine and femoral neck; predictive factors for BMD were analyzed by group comparison and step-wise regression analysis. RESULTS: There was increased frequency of osteoporosis and osteopenia involving the lumbar spine in patients with IBD being more common among CD patients than in the UC group. Positive correlations were found between low BMD measurements and vitamin D levels, body mass index (BMI) (P < 0.001) as well as steroid cumulative dose and duration of therapy (P < 0.001); stepwise regression analysis showed that CD and vitamin D deficiency are predictive factors for both osteoporosis and osteopenia (P = 0.024, P = 0.027, respectively). CONCLUSION: Low BMD was found to be more frequent among patients with CD than UC; in addition CD and vitamin D deficiency act as predictive factors for low BMD. We recommend that calcium and vitamin D should be given to all IBD patients; in addition, bisphosphonate administration should be put into consideration.

Musculoskeletal manifestations in patients with malignant disease.

To detect and describe the incidence of musculoskeletal manifestations in different malignant diseases as well as their relation to the treatment received whether by chemotherapy or radiation therapy. Sixty patients with different malignant diseases were included in this study, 45 with solid tumors and 15 patients with hematological malignancy. The mean age was 46.55 +/- 11.04 years and the mean disease duration was 2 +/- 0.75 years. The patients were fully examined for any rheumatologic involvement, laboratory investigations were performed as well as dual energy X-ray absorptiometry study for bone densitometry. Treatment strategies were assessed including the chemotherapeutics, radiation therapy, and/or surgery. Myalgias and arthralgias were the most frequent followed by flexor tenosynovitis, frozen shoulder, and fibromyalgia syndrome. Hypertrophic osteoarthropathy was seen in five patients, cutaneous vasculitis in two patients as well as arthritis. Osteonecrosis was present in one of the lunate carpal bones of a patient with non-Hodgkin's lymphoma (1.67%) and receiving high dose steroids. Rheumatoid factor was positive in four patients, three of which had hepatitis C virus positivity and cryoglobulins. Anti-neutrophil cytoplasmic antibody was negative in all the studied patients. The bone mineral density was significantly reduced in the patients with malignancy compared to the control. Mild to moderate osteoporosis was present, being more evident in the spine and forearm. The bone loss was higher in those with solid tumors and even more obvious in those receiving aromatase inhibitors. Musculoskeletal manifestations occurring during malignancies and following the treatment represent a significant percentage of symptoms and signs which may raise a clue to differential diagnosis.

Clinical significance of anti-cyclic citrullinated peptide antibodies in Egyptian patients with chronic hepatitis C virus genotype IV infection.

BACKGROUND: Symmetric polyarthritis associated with hepatitis C virus (HCV) infection frequently displays a clinical picture like rheumatoid arthritis (RA). Antibodies to cyclic citrullinated peptide (CCP) have high specificity for the diagnosis of RA. This study examined the frequency and clinical significance of anti-CCP antibodies in patients with chronic HCV infection, with and without manifestations of joint involvement, compared to RA patients. METHODS: Serum anti-CCP antibodies and rheumatoid factor (RF) were evaluated in 30 patients with RA and 47 patients with chronic HCV infection. Of those with HCV infection, 20 patients had chronic HCV infection associated with articular involvement and 27 patients had chronic HCV infection without any articular involvement. RESULTS: Anti-CCP antibody level was positive in 70% of RA patients, 8.5% of HCV-infected patients, and in 20% of HCV patients with articular manifestations. RF was positive in 76% of RA patients and in 60% of HCV patients with articular involvement. Cryoglobulins were found in 29% of HCV-infected patients and in 16% of RA patients. Cryoglobulins were more frequent among HCV patients with articular affection (35%) compared to HCV patients without articular affection (26%). CONCLUSIONS: Although anti-CCP antibodies remain a useful diagnostic tool for RA, their interpretation in HCV-infected patients with arthritis should be applied with caution. The possibility that those patients could be prone to develop RA cannot be ruled out. Those patients need careful clinical and radiological follow-up. Further large-scale studies are warranted.