Background: ESR and CRP are two commonly used laboratory inflammatory parameters. The controversy remains which of the two is a better measure to use and which parameter closely reflects the clinical measures of inflammation as well the disease process in Rheumatoid arthritis. Methods: We used mountain plot analysis to find out the congruency of ESR and CRP individually with clinical measures namely Tender joint count (TJC), Swollen joint count (SJC) and Visual analogue scale for Pain (VAS). 303 RA patients who are in our regular follow-up were included in the study. There TJC, SJC and VAS pain and ESR and CRP were retrieved. Results: 242 were female and 61 were male patients. The mean age was 46.8 years (17-79 years), mean duration of illness was 70.81 (3-307) months. All of them were on conventional DMARD with majority on combination of methotrexate, Hydroxychloroquine and/or leflunomide. Both ESR and CRP correlated with all three measures such as TJC, SJC and VAS. The correlation was stronger with ESR than CRP. When the effectiveness of ESR vs CRP was compared for their overlapping on the clinical parameters TJC, SJC and VAS by using mountain plot method, CRP performed better than ESR and coincided with all three clinical parameters of the disease RA. Conclusion: Our study emphasizes the fact that CRP is a better measure of inflammation than ESR and represents the information on the inflammatory component provided by both TJC and SJC, as appreciated by the close overlap. The CRP can replace the clinical measures (joint counts and Pain scale) more effectively than ESR, provided other causes for elevation of CRP are excluded.

Background: Stanford HAQ (S-HAQ) and several versions are used worldwide to measure physical function. Based on traditions and life style, a maiden Indian version (CRD Pune) was developed and used extensively (1996e2011). We report clinimetric properties and long term use. Methods: The Indian version was finalized in a step wise consensus building process between doctors, community and patients. It remained similar to S-HAQ in basic structure (categories) and score/disability index. Current data was selected from controlled drug trials in active RA, referral community patients (clinic and camps) and WHO ILAR COPCORD (community oriented program for control of rheumatic diseases) Bhigwan. Standard statistics were used; significant p < 0.05. Results: Testeretest and correlation statistics confirmed face and content (Cronbach's index >0.8) and construct validity and reliability at several time points. There was fair to good (0.2e0.6) correlation between Indian HAQ and pain visual analog scale, joint counts for pain/tenderness and swelling, sedimentation rate and radiological score (joint damage). The efficacy variables explained up to 70% variation in HAQ (dependent) regression models. The Indian HAQ scored significantly higher than the S-HAQ but the difference was not clinically relevant. The Indian HAQ was sensitive to change (effect size 0.7) over 24 week treatment with hydroxychloroquin. Generic use in COPCORD survey showed moderately severe HAQ disability in all patient groups including 'ill-defined aches' and soft tissue rheumatism. HAQ improved patient satisfaction. Conclusion: The Indian HAQ (CRD Pune) was a valid and useful patient outcome measure and improved compliance (long term follow up).

Methotrexate induced pneumonitis (MTX-P) is an uncommon, but potentially serious and life-threatening adverse event. The dose, duration of treatment and route of administration of methotrexate bear no relationship to MTX-P. Many risk factors have been studied but no definitive risk factor is identified. Pre-existing pulmonary disease may be associated with increased risk of MTX-P. Several sets of criteria have been proposed for diagnosis of MTX-P but none are validated. Diagnosis is mainly clinical and requires a high degree of suspicion. Treatment is mainly supportive along with discontinuation of methotrexate. Most patients recover. Mortality up to 17% has been reported in literature. Reintroduction of methotrexate after recovering from MTX-P is generally avoided. This article focuses on the epidemiology, clinical presentation, pathology, laboratory features and management of MTX-P.

Biologic disease modifying anti-rheumatic drugs (DMARD) have revolutionized the management of several rheumatic disorders, especially those with autoimmune inflammatory etiology. A decade of experience has further endorsed their efficacy and unraveled safety issues. Treat to target remission is the current mantra. Infections remain the single most important complication. However, the access to biologics has been severely restricted by their exorbitant cost. Several biologics will lose their patent in the imminent future. An exact replica of a protein molecule is difficult if not impossible. Molecules seemingly similar to biologics called biosimilars or 'follow on biologics' are likely to flood the markets world wide at a challenging and affordable price. However, the acceptability of biosimilars will be driven by several contentious issues connected with manufacture, standardization, extent of validation (compared to source innovator biologic), interchangeability (with biologic), regulatory issues, and other patient centric socioeconomic issues. India is likely to provide a fertile field for biosimilar drugs and patients stand to gain from an expanded access and newer treatment paradigms. The fierce competition between several pharmaceutical companies (Indian and multinationals) to gain supremacy will fuel better affordability, equity and access to medicine while upholding the science of quality drugs. The stage is now set for this next big revolution in therapeutics.

Dyskeratosis congenita, an inherited disorder of telomere accretion primarily affects ectoderm, manifesting as skin, nail and mucosal changes. We here present a novel association of dyskeratosis congenita with systemic lupus erythematosus in a 10-year-old female. The patient had classical triad of lacy reticular skin pigmentations, nail dystrophy and mucosal leukoplakia. Also, she had pancytopenia, blepharitis, nasolacrimal duct obstruction, dental decay with gingival recession, tooth loss, hirsutism and atrophic scarring of palms. On funduscopy, pre-retinal and superficial flame shaped haemorrhages were present. Anti-double stranded DNA antibody and antinuclear antibodies were positive. On treatment with steroids, partial response was seen. It is further emphasized the need to investigate for markers of systemic lupus erythematosus in every case presenting as dyskeratosis congenita to establish the causal relationship between dyskeratosis congenita and systemic lupus erythematosus.

Thirty five year old female presented with severe joint pain involving knees, elbows, wrists, small joints of hands and lumbosacral spine for 3 years along with multiple skin colored, asymptomatic nodules scattered over her body for last 6 months. On examination, there were multiple discrete but grouped, firm, skin colored, non tender papules and nodules, ranging in size from 2 mm to 2 cm over multiple sites mainly involving trunk and bilateral upper limbs. Systemic examination was within normal limits. Routine blood investigations were normal except for raised Eryth- rocyte sedimentation rate (31 mm/h). Radiographs of bilateral hands showed erosive arthritis in left index, left middle, right index and right little finger. Punch biopsy from a nodule over dorsum of hand on histopathological examination showed circumscribed large focus of diffuse dense infiltrate of large histiocytes and histiocytic giant cells with the scattering of lymphocytes and few neutrophils. Thus the diagnosis of Multicentric Reticulohistiocytosis was confirmed. The patient was started on 30 mg prednisolone with 15 mg of methotrexate orally once a week. The patient noticed improvement in the joint symptoms but there was no improvement in cutaneous lesions.

Subacute Cutaneous Lupus Erythematosus (SCLE) is a distinct subset of Systemic Lupus Erythematosus (SLE). The papulosquamous subtype of SCLE may mimic psoriasis. We describe one such case of SLE with SCLE with psoriasiform lesions.