Background: Pain in knee osteoarthritis (OA) may have a neuropathic component. We used the Douleur Neuropathique in 4 questions (DN4) questionnaire to assess neuropathic pain in knee OA and to identify factors associated with neuropathic pain. Methods: A total of 161 patients with knee OA satisfying the American College of Rheumatology 1986 classification criteria for knee OA were prospectively studied. DN4 questionnaire was administered; a score of ≥4/10 was classified as diagnostic for neuropathic pain. The Indian version of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used to assess pain, stiffness, and physical function. Factors associated with neuropathic pain were explored. Results: Mean age was 55.7 ± 8.8 years. The mean total Indian WOMAC was 75.07 ± 13.8 and WOMAC pain score was 16.1 ± 3.6. Seventy-nine patients of 161 (49%) had DN4 score ≥4 (neuropathic pain present). When diabetics were excluded (n = 58), the proportion of patients with DN4 score ≥4 reduced to 45.6%. The most frequently described pain characteristic was sensation of electric shock (58.4%). Mean total WOMAC and physical function subscale were significantly higher in neuropathic pain group when compared to the group without neuropathic pain (DN4 ≤3), 77.5 ± 11.5 versus 72.6 ± 15.5, P = 0.024 and 54.3 ± 8.8 and 49.8 ± 12.6, respectively, P = 0.008. Conclusions: Neuropathic pain (DN4 ≥4) was seen in up to 49% patients with knee OA. Centrally acting drugs such as tricyclic antidepressants or duloxetine can be used to improve the quality of life and physical function of knee OA patients with neuropathic pain.

Background: Antitumor necrosis factor (TNF) drugs are highly efficacious in spondyloarthritis (SpA). We present retrospective analysis of our experience with 2 etanercept biosimilars (Etacept and Intacept). Methods: Clinical record of patients with axial and/or peripheral SpA (Assessment of SpA International Society [ASAS] criteria) registered during April 2013–September 2016 was retrieved. Those with active disease (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] >4), despite 1-month trial of two non-steroidal anti-inflammatory drugs (NSAIDs) (axial) and/or 3-month trial of disease modifying anti-rheumatic drugs (peripheral), received anti-TNF therapy. Etanercept biosimilar (50 mg) was administered weekly for the first 12 weeks. Patients achieving “major improvement” after 12 weeks (Ankylosing Spondylitis Disease Activity Score [ASDAS] reduction by >2 points) received the dose every 2 weeks subsequently. BASDAI, Bath Ankylosing Spondylitis Functional Index, and ASDAS and NSAID index were noted at baseline, 12, and 24 weeks. For Etacept, week 52 and 104 data were also available. Primary endpoint was BASDAI <4 at 12 weeks. Results: Males constituted the majority (76%) and mean ASDAS was 4.7. In patients receiving Etacept, BASDAI <4 and major improvement were achieved by 12 weeks in 77% (42/54) and 61% (33/54) patients, respectively. Forty-three patients had completed 52 weeks and 27 patients had completed 104 weeks of treatment. Among 27 patients completing 104 weeks, secondary end points: ASAS 20, 40, and ASAS-partial remission status were achieved by 89%, 67%, and 41%, respectively. Intacept results were available up to 24 weeks and were comparable to those of Etacept. Injection site reactions followed by upper respiratory tract infections were the most common adverse reactions. One patient developed tuberculous pleural effusion. Conclusion: Etanercept biosimilar therapy was found efficacious and safe.

Background: The aim is to study the clinical features and diagnosis of primary extra-spinal musculoskeletal manifestations of tuberculosis (TB) in otherwise healthy individuals. Methods: In this retrospective study of 10 years duration electronic database and case records of patients with musculoskeletal TB were analyzed. Patient's positive for HIV and rheumatic diseases with or without immunosuppressive drugs or biological agents were excluded from the study. Results: Fifty-one patients were identified with the mean age at presentation of 33.35 years (range 4–72), male: female ratio of 1.1:1 and mean duration of disease was 14.65 months (range, 0.25–120). The most frequent manifestation was articular (arthritis/arthralgia n = 40, monoarthritis n = 28, oligoarthritis n = 10, polyarthralgia n = 2) followed by tenosynovitis (n = 6), tuberculous osteomyelitis (n = 5), isolated bursitis (n = 1), and pyomyositis (n = 1). Poncet's disease was diagnosed in five patients. Disseminated TB was detected in four patients. Pain (n = 50) followed by swelling of the involved site (n = 37) were the most common presenting symptoms. Fever was present in 15 (29.4%) patients. Nine patients had a previous history of TB. Concurrent pulmonary TB was present in two patients. Lymph node enlargement was present in 12 (23.5%) patients. A definite diagnosis of musculoskeletal TB was made in 31 (61%) patients and probable TB in 20 (39%) patients. Conclusion: Musculoskeletal manifestations of TB can occur at any age. Chronic monoarthritis is the most common presentation; however, oligoarthritis and/or tenosynovitis may be a presenting manifestation. The absence of fever should not discourage the diagnosis of musculoskeletal TB.

Background: The revised Japanese criteria, the International study group (ISG), the International criteria for Behcet's disease (ICBD) 2006, and the revised ICBD 2010 are frequently used for the classification of Behcet's Disease (BD). In this study we evaluated the performance of these criteria sets in Egyptians. Methods: A total of of 461 Egyptian patients over 5 years were studied. It included 256 patients classified as BD based on expert opinion and 205 patients with other autoimmune and/or autoinflammatory diseases with symptoms similar to BD. Performance of the revised Japanese criteria, ISG, ICBD 2006, and the revised ICBD 2010 was evaluated evaluated in terms of sensitivity, specificity, negative predictive value (NPV), negative likelihood ratio (NLR), positive predictive value (PPV), positive likelihood ratio (PLR), diagnostic odd ratio (DOR), and Youden's index (YI). Results: ICBD 2010 carried the highest sensitivity (98.83%), NPV (98.48%), DOR (1645), and YI (0.94) with lowest NLR (0.01). On the other hand, ICBD 2006 and ISG were very specific (99.51%, 99.41%, respectively) with PPV (99.49%, 99.40%) and PLR (155.35, 126.33), respectively. Conclusions: ICBD 2010 is a very good criteria set to be used in Egyptian BD patients based on its very high sensitivity, accepted specificity, and power of discrimination that enables early patients classification, management, and prognosis.

Background: To study renal functions in patients with ankylosing spondylitis (AS) and compare with matched healthy controls and correlation between renal function parameters and disease activity markers. Methods: Renal functions of forty cases with AS and the same number of age- and sex-matched individuals were evaluated. Disease activity was assessed using Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index scores, C-reactive protein, and erythrocyte sedimentation rate. Results: Among AS cases, 31 AS cases (77.50%) had renal function abnormalities including hematuria (20%), proteinuria (30%), albuminuria (52.50%), increased 24 h urine protein (22%), raised serum creatinine (17%), and reduced glomerular filtration rate (GFR) (37%). Among healthy controls, 20/40 (50%) had renal function abnormalities including albuminuria (15%), raised serum creatinine (7.50%), and reduced GFR (20%). Abnormal renal functions were significantly more in AS cases (31/40, 77%) than healthy controls (20/40, 50%) (P < 0.05). Renal function abnormalities were more frequent among AS cases having elevated markers of disease activity. Renal abnormalities were more prevalent in cases taking nonsteroidal anti-inflammatory drugs (NSAIDs) for < 48 months than cases taking these drugs for ≥48 months, suggesting that these renal abnormalities were probably not due to NSAIDs-induced nephropathy but may be due to AS itself. Conclusions: In this study with small number of participants abnormalities in the renal function were common in patients with AS. No significant correlation was found between renal functions and markers of disease activity.

Autoimmune inflammatory rheumatic diseases have intrinsic increased risk of infection. The medications used in these diseases may further increase the infection risk. Therefore, vaccinations have gained increasing importance in preventing them in a most cost-effective manner. In this “practical guide,” the vaccines, their schedules, pricing, and the lifetime cost analysis, specifically for the Indian patients, are described in clear, concise language. Case scenarios have been used to further simplify the understanding of the vaccination schedules. This document can be kept in the clinic for day-to-day help in ensuring that the patients are properly covered against these preventable infections.

The shoulder joint may be involved in seronegative spondyloarthropathy, calcium pyrophosphate dihydrate disease and degenerative joint disease. Adhesive capsulitis, calcific tendonitis and rotator cuff degeneration are other diseases that can involve the shoulder. The shoulder joint area may be involved as a consequence of extra-articular disease, and massive shoulder swelling may rarely result. Herein, five uncommon diseases presenting with predominant large shoulder swelling are described. The typical clinical and radiological findings with diagnostic features are highlighted.