Management of Peripheral Arthritis in Patients With Psoriatic Arthritis: An Updated Literature Review Informing the 2021 GRAPPA Treatment Recommendations.

OBJECTIVE: We aimed to compile evidence for the efficacy and safety of therapeutic options for the peripheral arthritis domain of psoriatic arthritis (PsA) for the revised 2021 Group in Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations. METHODS: A working group consisting of clinicians and patient research partners was convened. We reviewed the evidence from new randomized controlled trials (RCTs) for PsA treatment from February 19, 2013, to August 28, 2020. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-informed approach to derive evidence for the classes of therapeutic options for 3 patient groups: (1) naïve to treatment, (2) inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and (3) inadequate response to biologic DMARDs (bDMARDs). Recommendations were derived through consensus meetings. RESULTS: The evidence review included 69 RCTs. We derived GRADE evidence for each class of therapeutic options and achieved consensus for the recommendations. For patients naïve to treatment, the working group strongly recommends csDMARDs (methotrexate, sulfasalazine, leflunomide) and phosphodiesterase 4 inhibitors, and emphasizes regular assessment and early escalation to achieve treatment target. bDMARDs (tumor necrosis factor inhibitors [TNFi], interleukin 17 inhibitors [IL-17i], IL-12/23i, IL-23i) and Janus kinase inhibitors (JAKi) are also strongly recommended. For patients with inadequate response to csDMARDs, we strongly recommend TNFi, IL-17i, IL-12/23i, IL-23i, and JAKi. For those who had prior experience with bDMARDs, we strongly recommend a second TNFi, IL-17i, IL-23i, and JAKi. The evidence supporting nonpharmacological interventions was very low. An expert panel conditionally recommends adequate physical activity, smoking cessation, and diet to control weight gain. CONCLUSION: Evidence supporting optimal therapy for the peripheral arthritis domain of PsA was compiled for the revised 2021 GRAPPA treatment recommendations.

Epidemiology of spondyloarthritis in Colombia.

There are no formal statistics about the incidence, prevalence or demographics of patients with spondyloarthropathies (SpAs) in Colombia. However, information from a few studies provides a preliminary snapshot of SpAs in the country. In this article, the authors review what has been published; document what their group is doing and outline what they still need to do in the future. The analysis suggests that although information on SpA in Colombia is limited, it is known that the diagnostic entities of SpA are different than those reported at other latitudes. Thus, it is important to improve and expand the current database of SpA, particularly undifferentiated SpA, not only in Colombia but in all of Latin America.

Diagnóstico de Artritis Psoriática / Diagnosis of Psoriatic Arthritis

La artritis psoriática es una enfermedad de relativamente reciente descripción en el campo de la reumatología, pues previamente se consideraba que este tipo de pacientes cursaban con dos entidades nosológicas distintas que convergían en el tiempo: psoriasis y artritis reumatoide. Han sido múltiples los intentos por clasificar adecuadamente a estos pacientes y esto ha llevado a la aparición de 7 criterios de clasificación en los últimos 36 años. En el presente artículo haremos un recuento de las principales características clínicas, de laboratorio e imagenológicas de la artritis psoriática. Además, cada uno de los criterios de clasificación se describirá en orden cronológico de aparición.

Psoriatic arthritis is a relatively recent description disease in the rheumatology field. Previously physicians considered that the patient with psoriasis and any type of arthropathy had two diseases that coincided at the time: psoriasis and rheumatoid arthritis. There have been many attempts to classify these patients adequately. In the last 36 years seven criteria for the classification of this entity have appeared. In this article we made a summary of the clinical characteristics, laboratories and imaging in psoriatic arthritis. Furthermore, we intend to describe the classification criteria in chronological order.

Epidemiología de las vasculitis primarias en Colombia y su relación con lo informado para Latinoamérica / Epidemiology of primary vasculitis in Colombia and its relation with reported for latin america

Propuesta: las vasculitis primarias se expresan de forma variable entre pacientes y entre regiones, con frecuencias variables a través del mundo. Su incidencia promedio está calculada en 0,3 a 20 casos por millón de habitantes. Nosotros describimos la frecuencia de las vasculitis primarias en Colombia y la comparamos con lo informado en otros países de Latinoamérica (LA). Métodos: se revisó lo publicado en la literatura de vasculitis primaria en Colombia y en LA desde 1945 hasta 2007 en OLD Medline, Pub Med, BIREME, SciELO Colombia, LILACS. FEPAFEN, incluyendo publicaciones en inglés, español y portugués. La literatura incluye la información publicada del Hospital San Juan de Dios, Bogotá, Colombia y casos sin publicación enviados directamente por los autores. Nosotros calculamos el porcentaje para todos los casos que fueron informados para Colombia. Resultados: se identificaron 857 casos de vasculitis primaria en Colombia. La arteritis de Takayasu fue la vasculitis más frecuente en un 13,3% (114 casos) seguida de la enfermedad de Buerger en 11,2% (96 casos), las vasculitis cutáneas primarias y la poliarteritis nodosa en un 10% (86 casos) cada una. En niños, la vasculitis más frecuente fue la púrpura de Henoch Schönlein en un 24% (206 casos). En Latinoamérica se publicaron 177 artículos con 1605 casos informados. Se evidenció mayor presencia de arteritis de Takayasu en México y Brasil, y de poliangeítis microscópica en Chile y Perú. Conclusión: la mayoría de publicaciones sobre vasculitis primarias provienen de Europa, Norteamérica, Japón, Kuwait y Nueva Zelanda. Existen una serie de publicaciones y experiencia con estas patologías en LA. Un número considerable de publicaciones y casos con vasculitis primarias se han informado en Colombia en los recientes años, incluyendo la reciente descripción de la variante nodular de la vasculitis cutánea. La arteritis de Takayasu fue la variante más reportada del promedio de vasculitis, al igual que en Brasil y México. En contraposición a los hallazgos realizados en Brasil, Colombia y Mexico, las vasculitis asociadas a ANCA fueron la forma más informada en países como Chile y Perú. La mayoría de casos informados en LA provienen de México, siendo Colombia el segundo país en frecuencia. Es posible que exista más información pero no la conocemos, por no estar publicada. No existen estudios de incidencia y prevalencia. A escala mundial solo existen estudios de incidencia de las vasculitis primarias, y solo se han realizado estudios de incidencia y prevalencia en la granulomatosis de Wegener.

Purpose: primary vasculitis occurs with variable expression in individual patients and regions, and variable frequency throughout the world. Their overall incidence has been calculated to be 40 cases per million populations. We sought to describe the frequency of vasculitis in Colombia and compare it with vasculitis reported from other countries of Latin America (LA). Methods: review of available published literature on vasculitis in LA from 1945 to 2007 in OLD Medline, Pub Med, BIREME, SciELO Colombia, LILACS, FEPAFEN, including publications in English, Spanish and Portuguese. The literature included published information from San Juan de Dios hospital, Bogota, Colombia, and unpublished cases submitted directly to the authors. We calculated the percentage of all cases which are reported from Colombia. Results: we identified 857 cases of primary vasculitis in Colombia. Takayasu arteritis was the most common vasculitis in 13.3% (114 cases) followed by Buerger's disease in 11.2% (96 cases), primary cutaneous vasculitis and polyarteritis nodosa in a 10% (86 cases) each. In children, the vasculitis was more frequent in Henoch Schonlein purpura in 24% (206 cases). In Latin America, 177 articles were published in 1605 reported cases. It showed increased presence of Takayasu's arteritis in Mexico and Brazil, and microscopic poliangeiitis in Peru and Chile. Conclusion: while the majority of publications on primary vasculitis are from Europe and North America, there is a substantial literature and experience with these disorders in LA. A considerable number of publications and cases have emerged from Colombia in recent years, including case descriptions of a recently described variant of nodular cutaneous vasculitis. Takayasu arteritis was the most frequently reported form of primary vasculitis overall, and also from Brazil and Mexico. However, ANCA related vasculitis were the most commonly reported forms in Chile and Peru instead. The greatest numbers of cases were reported from Mexico, the LA's most populous country, with Colombia a close second.

Effective treatment of refractory pulmonary hemorrhage with monoclonal anti-CD20 antibody (rituximab).

We report a 19-year-old female with systemic lupus erythematosus and lupus nephritis who developed pulmonary hemorrhage (PH) refractory to conventional immunosuppressive treatment. She was initially treated with intravenous methylprednisolone and cyclophosphamide pulses. She required mechanical ventilation due to a lack of responsiveness and her disease was considered refractory to conventional treatment. Rituximab was administered and this was followed by clinical improvement in both PH and nephritis. Rituximab may be a useful therapeutic option for the treatment of refractory PH.

Kawasaki disease: clinical spectrum of 88 patients in a high-prevalence African-American population.

Kawasaki disease (KD) is a systemic vasculitis that predominantly affects infants and young children. Asian race has been described as an important factor for the development of this disease. We reported our experience in a cohort of patients with KD. Clinical and laboratory data from initial presentation and follow-up visits were reviewed in 88 patients with KD treated at Children's Hospital of New Orleans between March 1993 and November 2004. Forty-nine (56%) patients were African American, 35 (40%) Caucasian, two (3%) Asian and two (3%) Hispanic. Coronary artery aneurysms (CAAs) were detected in 15 (17%) patients. CAAs were less frequent in African-American patients compared to Caucasians [relative risk (RR)=0.2, 95% CI: 0.04400-0.8405, p=0.0164]. Eighty-three patients responded to one dose of intravenous human immunoglobulin (IVIG), five patients responded to a second infusion of IVIG, and two who were IVIG resistant responded only following methylprednisolone pulse. Hemoglobin (Hb) levels of <10 g/dl and presence of polymorphic rash were significantly correlated with development of CAAs. No deaths were observed.

Toll-like receptor-2 expression is upregulated in antigen-presenting cells from patients with psoriatic arthritis: a pathogenic role for innate immunity?

OBJECTIVE: To study Toll-like receptor-2 (TLR-2) and TLR-4 expression in antigen-presenting cells from patients with psoriatic arthritis (PsA). METHODS: We measured expression of TLR-2 and TLR-4 in monocyte-derived dendritic cells from patients with PsA and with rheumatoid arthritis (RA), and in healthy controls. Dendritic cells were obtained from freshly isolated monocytes, stimulated with granulocyte macrophage-colony stimulating factor (GM-CSF) and interleukin 4 (IL-4) after 6 days in culture. To obtain mature dendritic cells, lipopolysaccharide stimulation and 2 additional days in culture were necessary. The expression of TLR-2, TLR-4, HLA-DR, and CD86 was studied at baseline, at 6 days, and at 8 days by flow cytometry. To establish the functional properties of TLR expression we studied the following cytokines in cell supernatants: tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), IL-2, IL-4, IL-5, IL-10, IL-12, IL-13, and GM-CSF. TLR-2 expression was confirmed by Western blot analysis. RESULTS: Ten PsA patients with active disease and 8 healthy controls were studied, along with 4 patients with RA. TLR-2 expression was increased in immature dendritic cells from patients with PsA. Monocytes and mature dendritic cells did not show statistically significant differences. No difference was observed in the expression of TLR-4 in any cell type. The supernatant expression of cytokines showed a Th1 pattern, mostly with increased expression of TNF-alpha, IFN-gamma, and IL-2. Western blot analysis confirmed the increased expression of TLR-2. CONCLUSION: Upregulation of TLR-2 expression provides support for a role of the innate immune system in the pathogenesis of PsA.

Low frequency of anticyclic citrullinated peptide antibodies in psoriatic arthritis but not in cutaneous psoriasis.

BACKGROUND: Anticyclic citrullinated peptide (anti-CCP) antibodies are highly specific for the diagnosis of rheumatoid arthritis (RA). The clinical distinction between RA and psoriatic arthritis (PsA) is often difficult to establish; therefore, the presence of rheumatoid factor (RF) and anti-CCP antibodies could be useful. Seven percent to 40% of patients with longstanding psoriasis will develop PsA at some point. Therefore, it is important to study the positivity of these antibodies in these two interrelated populations. OBJECTIVE: The aim of this study was to determine the seropositivity of anti-CCP antibodies in patients with psoriasis and PsA and to compare it with that seen in patients with other inflammatory, noninflammatory (osteoarthritis) arthritides and healthy controls. PATIENTS AND METHODS: Serum anti-CCP antibodies were measured in 106 patients with cutaneous psoriasis, 72 patients with PsA, 41 healthy controls (HC), 41 patients with undifferentiated or early inflammatory arthritis (UA), and 41 patients with RA and 41 with osteoarthritis using a commercial second-generation enzyme-linked immunosorbent assay. We considered a positive result to be >20 UI/mL, as recommended by the manufacturer. RESULTS: Of 106 patients with PsA, 55 were women and 51 men. The mean age was 42.87 +/- 17.71 years and the mean disease duration was 5.3 +/- 2.10 years. Anti-CCP antibodies were not present in patients with psoriasis without arthritis. In contrast, 7 of 72 (9.72%) patients with PsA were positive for anti-CCP antibodies with a median titer of 7.16 units. Only one patient with PsA was positive for RF. Most of these patients were female with polyarticular joint involvement. Distal interphalangeal involvement was present in 4 and 2 had dactylitis. We found clear differences when we compared patients with PsA with patients with psoriasis (P = 0.001). Of the 43 patients with UA studies, 4 initially exhibited a low titer positive anti-CCP antibody, and at follow up, another patient developed anti-CCP antibodies and later developed RA. None of the patients with UA developed PsA at 5-year follow up. Thirty-two of the 41 patients had a positive anti-CCP antibody and the mean +/- standard deviation of the anti-CCP units was 80.61 +/- 55.5.2. Six of the 41 (14.6%) patients with osteoarthritis studied had positive anti-CCP with a mean titer of 7.388. None of the healthy controls exhibited positively for anti-CCP antibodies. CONCLUSION: Anti-CCP antibodies may be found in patients with PsA and not in our patients with only cutaneous psoriasis. These antibodies may also be found in some patients with osteoarthritis and rarely in patients with UA; such patients will be of interest to follow prospectively.

Autoimmune hepatitis and pregnancy: a rheumatologist's dilemma.

OBJECTIVES: To review the course, predisposing risk factors, treatment employed, and complications of autoimmune hepatitis (AIH) during pregnancy. Maternal and fetal outcomes will be discussed. METHODS: We reviewed the literature from February 1966 to January 2004 using MEDLINE and the key words autoimmune hepatitis, chronic active hepatitis, lupoid hepatitis, and pregnancy. An additional case of ours was included as she had AIH since childhood with worsening of liver disease during pregnancy. RESULTS: Including the present case, 58 pregnant women with AIH were reported in 17 case reports and series. In the 101 pregnancies documented in these cases, there were 47 flare-ups, 5 clinical improvements, 45 stabilizations of the disease during pregnancy, and 4 cases in which the disease course was not reported. Two maternal deaths occurred. A perinatal mortality of 4% and 19 fetal deaths were described. Most women were treated with prednisone alone; however azathioprine was used in a number of patients. CONCLUSIONS: Pregnancy course in patients with AIH is unpredictable. AIH exacerbates in some patients and is associated with a high rate of fetal complications including prematurity and death. Low-dose prednisone seems to be the preferred treatment. The use of azathioprine must be individualized and further studies are needed to better define its role and safety during pregnancy in patients with AIH. RELEVANCE: A better understanding of the course of pregnancy in patients with AIH should help design appropriate therapeutic schemes to improve pregnancy outcomes for both mother and fetus.

HIV-associated musculoskeletal involvement.

Various rheumatic manifestations associated with HIV infection have been recognized, ranging from infectious conditions, such as septic arthritis, to seronegative spondyloarthropathy. Other musculoskeletal manifestations include lupus-like and Sjögren-like diseases and HIV-related malignancy. The introduction of HAART has changed the spectrum of the clinical manifestations of rheumatic disease seen today, with infections and articular involvement being the most frequently observed.

Human immunodeficiency virus-associated rheumatic disorders in the HAART era.

OBJECTIVE: To define the frequency and characteristics of human immunodeficiency virus (HIV)-associated rheumatic manifestations in patients receiving highly active antiretroviral therapy (HAART) referred to a rheumatology clinic. METHODS: A total of 75 patients with HIV infection receiving HAART were prospectively evaluated for the presence of rheumatic complaints. Diagnosis of HIV infection was performed by ELISA and confirmed by Western blot, and all HIV patients were classified according to the US Centers for Disease Control criteria. RESULTS: Seventy-five individuals with HIV infection and musculoskeletal manifestations were evaluated: 65 (86%) men and 10 (14%) women. Mean age was 32 +/- 4.5 years (range 21-58). The group included 40 (53%) heterosexuals, 30 (40%) intravenous drugs users, 9 (12%) homosexuals, 3 (4%) who had received blood transfusion, and 2 (2.6%) with unknown risk factors. Septic manifestations were the most common complications seen in 31 (41%) out of 75, and included septic arthritis, cellulitis, osteomyelitis, diskitis, and pyomyositis. Fibromyalgia was present in 13 (17%), seronegative symmetric polyarthritis in 4, oligoarthritis in 4, psoriatic arthritis in 2, carpal tunnel syndrome in 2, and enthesitis in 2. Mutifocal bone non-Hodgkin's lymphoma was present in 7 (9.3%) and Kaposis's sarcoma of bone in 2 (2.6%) patients. Hypertrophic osteoarthropathy in 3 (4%) and aseptic bone necrosis of multiple bones was seen in 3 (4%) patients. Ten patients exhibited only arthralgias. Most patients had moderately elevated erythrocyte sedimentation rate and C-reactive protein. Mean CD4 cell count was 250 mm3 (range 20-450), and mean HIV viral load was 5210 (range 0-75,300) copies/ml. CONCLUSION: Rheumatic manifestations were highly frequent in HIV patients receiving HAART referred to a rheumatology clinic, although the clinical spectrum differed from the pre-HAART era with septic and malignant complications being the most common manifestations seen.

Granulomatous vasculitis.

Granulomatous vasculitis is a subset of systemic necrotizing vasculitis and has granulomatous inflammation as the main histopathologic feature. Etiopathogenesis remains poorly understood, although recent advances suggest an important role for certain pro-inflammatory cytokines, such as tumor necrosis factor-alpha. They are a heterogeneous group of clinical disorders with protean manifestations. Serologic abnormalities are present, and the presence of granular cytoplasmic staining-antineutrophil cytoplasmic antibodies is most important and is particularly useful for the diagnosis of active Wegener's granulomatosis. Corticosteroids and cyclophosphamide remain very useful in the treatment of most of these disorders.