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  Access statistics : Table of Contents
   2018| September  | Volume 13 | Issue 3  
    Online since August 21, 2018

 
 
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REVIEW ARTICLES
Role of myositis-specific autoantibodies in personalized therapy
Anand N Malaviya, Sanjiv Kapoor
September 2018, 13(3):186-194
DOI:10.4103/injr.injr_135_17  
In a landmark breakthrough in 1976, Reichlin and Mattioli discovered the first myositis-specific antibody (MSA) called anti-Mi2 antibody that identified a specific clinical phenotype characterized by pathognomonic skin rash of dermatomyositis, typical proximal muscle weakness, good response to treatment, and the absence of interstitial lung disease and cancer. The discovery firmly placed inflammatory muscle diseases among the group of systemic rheumatic autoimmune diseases. Over the next four decades, a large number of additional MSAs have been discovered in this group of patients called “idiopathic inflammatory myopathy” (IIM). It is becoming clear that the increasing numbers of autoantibodies being discovered may necessitate a name change to “autoimmune myositis” (AIM), as recently suggested by a French-Canadian group. In the light of these discoveries, it was evident that a new classification system based on the combination of clinical phenotypes and the associated autoantibodies would soon be propounded. Preliminary report on such a classification was published in 2016 by the Swedish Group from Karolinska Institute led by Prof. Ingrid Lundberg. In October 2017, the European League Against Rheumatism and the American College of Rheumatology published the provisional classification criteria for IIM with the aim to categorize patients in uniform subgroups of clinical phenotype for meaningful drug trials. These are exciting times for clinicians, for research scientists, and for the patients with inflammatory myositis with reasons to be optimistic about a bright future. This short review provides a summary of the present knowledge with emphasis on its clinical implications.
  5,921 599 1
ORIGINAL ARTICLES
Anxiety and depression are common in fibromyalgia patients and correlate with symptom severity score
Gurmeet Singh, Sheetal Kaul
September 2018, 13(3):168-172
DOI:10.4103/injr.injr_52_18  
Background: Anxiety and depression are seen commonly in fibromyalgia patients. We conducted this study to find out the prevalence of anxiety and depression in fibromyalgia and correlate anxiety and depression with symptom severity (SS) scale. Methods: Eighty fibromyalgia patients and 72 controls were included in this cross-sectional study. Hospital anxiety and depression scale were used to assess anxiety and depression. SS scale was used to assess SS of fibromyalgia. Quality of life (QOL) was measured using the World Health Organization QOL-BREF. The severity of pain, fatigue, and disturbed sleep were measured by 10 centimeter long visual analog scale. Results: Fibromyalgia patients when compared to controls had higher prevalence of both anxiety (87.5% vs. 23.6%, P < 0.0001) and depression (72.5% vs. 5%, P < 0.0001). Both anxiety and depression had positive correlation with SS scale score, (r = 0.51, P < 0.0001) and (r = 0.42, P < 0.0001), respectively. Patients with anxiety and depression had poor QOL, more pain, and more disturbed sleep as compared to patients without anxiety and depression. Gender, disease duration, fatigue, and tender points had no association with anxiety and depression in fibromyalgia patients. Patients with depression had higher age as compared to patients without depression (P = 0.02). Conclusion: Anxiety and depression are common in fibromyalgia patients and correlate with the SS scale score. Fibromyalgia patients with anxiety and depression have poor QOL, more pain, and disturbed sleep.
  4,827 475 5
Diagnostic value of procalcitonin for differentiation between bacterial infection and noninfectious inflammation in febrile children with systemic autoimmune diseases
Sathishkumar Loganathan, Sathish Kumar
September 2018, 13(3):173-177
DOI:10.4103/injr.injr_54_18  
Objectives: The objective of this study is to determine the diagnostic value of procalcitonin (PCT) for differentiation between bacterial infection and noninfectious inflammation in febrile children with systemic autoimmune disease. Methods: It was a cross-sectional study and children with systemic autoimmune disease such as systemic lupus erythematosus (SLE) and juvenile idiopathic arthritis (JIA) presenting with fever (>38°C) were recruited. Results: Out of 24 children included, 16 had SLE (11 in disease flare group and 5 in infection group) and 8 had disease flare of Systemic JIA. Two children in SLE infection group died. Mean PCT was 92.2 ng/ml in SLE infectious group and 3.50 ng/ml in SLE flare group which was statistically significant (P = 0.009). However, the mean C-reactive protein was 98 mg/dl in SLE infectious group and 52 mg/dl in SLE flare group which was not statistically significant (P = 0.25). PCT concentration cutoff value >1.2 ng/ml has the sensitivity of 83% (95% confidence interval [CI] 43.6–0.97) and specificity of 72% (95% CI 49.1–87.5), positive predictive value of 50% (95% CI 23.6–76.3) and negative predictive value 93% (95% CI 68.5–98.7). Conclusions: PCT levels >1.2 ng/ml in febrile SLE patients should point to a bacterial infection, whereas PCT levels <1.2 ng/ml might indicate disease flare that could reduce unnecessary antibiotic use. PCT may serve as a useful marker for the detection of systemic bacterial infection in patients with the systemic autoimmune disease.
  3,876 330 -
REVIEW ARTICLES
Multicentric reticulohistiocytosis: A clinicoradiological review
Anindita Sinha, Santosh Dhungana, Dipankar De , Mahesh Prakash, Shefali Khanna Sharma, Ashim Das
September 2018, 13(3):195-201
DOI:10.4103/injr.injr_151_17  
Multicentric reticulohistiocytosis is a rare systemic disease described as a lipoid dermato-arthritis. Characteristic involvement includes multiple skin nodules and progressive arthritis. Involvement of skin, mucosa, and internal organs has been described. Predominant involvement of the distal interphalangeal joint occurs in the hands. Other joints involved are knee, shoulder, and hips. Rarely, vertebral involvement may also occur. A significant association with underlying solid organ as well as hematologic malignancies warrants a thorough workup and imaging screening. Diagnosis is based on histopathologic findings of histiocytic infiltration with multinucleated giant cells. Radiographic manifestations in the multiple joints are characterized by symmetrical destructive and erosive arthritis. Ultrasound of the hands may be helpful in detecting the nodules in characteristic periarticular distribution in early presentations. We describe the common and uncommon clinical and imaging features of early and late manifestations of the disease.
  3,903 277 1
ORIGINAL ARTICLES
Evaluation of gait speed over time in adults with arthritis: Data from the osteoarthritis initiative
Vishal Vennu, Harsh Misra
September 2018, 13(3):154-158
DOI:10.4103/injr.injr_34_18  
Objective: In this longitudinal study across four clinical sites in the United States, gait speed (GS) over time in adults with arthritis was examined. Methods: We performed a secondary analysis using data from the osteoarthritis initiative. A sample of 4450 adults aged 45 years and older, regardless of sex or ethnicity, were included in the analysis. Based on the response to self-reported questionnaires about arthritis, adults were classified into two groups: without arthritis and with arthritis. GS in m/s was assessed using the 20-m-walk test at baseline and over time. A general linear mixed model was used to examine the GS over time in adults with arthritis. Results: The rate of decrease in GS per year was 0.006 m/s after adjusting for age, sex, race, depressive symptoms, and body mass index. In adults, having arthritis was significantly associated with lower GS (β = −0.039, standard error = 0.007, P <.001) compared to those without arthritis. The interaction between arthritis, GS, and time was also significant (β = −0.0013, SE = 0.005, P = 0.017), indicating that the slope changed over time due to the continuous decline in GS (0.006 m/s/year). Conclusions: In adults, having arthritis is associated with lower GS and declined over time compared to those without arthritis, even after controlling for all covariates.
  3,589 320 3
Safety and efficacy of abatacept among patients with refractory rheumatoid arthritis: Experience from a North Indian Tertiary Care Hospital
MN Arjun, Arun Hegde, Krishnan Shanmuganandan, Darshan S Bhakuni, Kavita Singh, Abhishek Kumar
September 2018, 13(3):163-167
DOI:10.4103/injr.injr_37_18  
Background: T-cells are pathogenic in rheumatoid arthritis (RA) and have an important role in persistent synovitis, even in established disease. Modulation of T-cell activity by blocking of costimulatory signals has been known to suppress inflammation and improves prognosis in RA. This study aims to assess the effect of costimulation blockade with Abatacept in patients with RA who were refractory to conventional synthetic/biological disease modifying anti-rheumatoid drugs (csDMARDs, bDMARDs). Methods: In this prospective study, 63 patients with active disease, measured by the European League Against Rheumatism (EULAR) disease activity score (DAS28-erythrocyte sedimentation rate [ESR]) ≥3.2, who had failed conventional therapy with at least 2 csDMARDs and/or antitumour necrosis factor (anti-TNF) agents (Infliximab/Etanercept) either standalone, or in combination, were initiated on Abatacept in fixed doses, which was given on days 1,15, and 29 and repeated every 28 days for 11 months, after taking informed consent. Biomarkers comprising ESR and DAS28-ESR score were measured at baseline and repeated at the end of 3, 6, and 12 months. The primary end-point was the achievement of remission as defined by DAS28-ESR score ≤ 2.6. Results: Sixty-three patients completed 6 monthly follow-up whereas 57 patients completed 12 months follow-up (90% follow-up rate). DAS28-ESR declined significantly at 3 months (P = 0) and improvements were sustained at 6th and 12th month. Treatment was discontinued in three patients due to inadequate response, and three patients were lost to follow-up. Nearly 52.6% patients achieved primary end-point. Most common adverse effects reported during the study period were headache (14.2%) and upper respiratory tract infection (9.5%). Conclusions: Abatacept is an effective and well-tolerated treatment option for Indian RA patients with an inadequate response to csDMARDs and TNF antagonists.
  3,540 272 1
Comparison of the performance of three classification criteria for Behçet's Disease in a single centre cohort from South India
Vishnu S Chandran, Suma Balan
September 2018, 13(3):159-162
DOI:10.4103/injr.injr_50_18  
Background: A new International Paediatric criteria for Behçet's disease (PEDBD) 2015 has been introduced in the presence of existing revised International Criteria for Behçet's Disease (ICBD) and the International Study Group (ISG) criteria. In this study, we compared the performance of the new PEDBD criteria with the existing criteria in the pediatric group of Behçet's disease. Methods: In this retrospective study eligible patients were identified from a database and their already recorded characteristics were analyzed. A total of 25 patients who visited the pediatric rheumatology clinic were included in the cohort. Performance of the ISG, revised ICBD, and PEDBD 2015 was evaluated in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), negative likelihood ratio (NLR), positive likelihood ratio (PLR), diagnostic odds ratio (DOR), accuracy, and Youden's index (YI). Results: The revised ICBD has the maximum sensitivity (88.24%) when compared to PEDBD (64.71%) and ISG (47.05%). ISG had 100% specificity, with a comparable value in revised ICBD (87.5%) and PEDBD (87.5%). PPV was similar in all the three criteria with ISG 100%, revised ICBD 93.75%, and PEDBD 91.67%. NPV in revised ICBD was 77.78%, ISG was 47.06%, and PEDBD 53.85%. PLR of revised ICBD was 7.06 and PEDBD was 5.18. NLR was detected to be 0.53 in ISG as it was 0.40 in PEDBD and 0.13 in revised ICBD. The DOR in revised ICBD was 52 and PEDBD was 12.83. YI was 0.47 in ISG, 0.76 in revised ICBD, and 0.52 in PEDBD. The accuracy was best for revised ICBD 88% and PEDBD 72%. Conclusion: Revised ICBD criteria hold a higher statistical significance in the diagnosis of the Behçet's disease even in the pediatric age group. PEDBD has a comparable sensitivity and PPV although the NPV and specificity are very low in comparison to the other criteria. It was observed that oral aphthosis, despite being the most common manifestation in the Behçet's disease pediatric group, other features, mainly vascular involvement was the most common presenting complaint.
  3,377 311 -
IMAGES IN RHEUMATOLOGY
Alkaptonuria
Dillibabu Ethiraj, Venkatraman Indiran, Kanakaraj Kannan, Thirumalasetty Ramachandra Prasad
September 2018, 13(3):209-210
DOI:10.4103/injr.injr_67_18  
  3,131 243 -
Inflammatory polyarthritis: It's Not always about the Joints!
Kavitha Mohanasundaram, Peramanathan Nithyananthan, R Vimalchander, E Yogalakshmi, Sonti Sulochana, A Gowrishankar
September 2018, 13(3):207-208
DOI:10.4103/injr.injr_40_18  
  2,838 245 -
Pulmonary Artery Pseudoaneurysm in a Patient of Rheumatoid Arthritis
Sudipta Mohakud, Arshdeep Singh, Suprava Naik, Nerbadyswari Deep
September 2018, 13(3):202-203
DOI:10.4103/injr.injr_31_18  
  2,812 201 -
BRIEF REPORTS
Serum vascular endothelial growth factor levels as a marker of skin thickening, digital ischemia, and interstitial lung disease in systemic sclerosis
Chinnadurai Saranya, Ramamoorthy Ramesh, Mahendran Bhuvanesh, Chilukuri Balaji, Selvakumar Balameena, Sankaralingam Rajeswari
September 2018, 13(3):182-185
DOI:10.4103/injr.injr_132_17  
Background: Vascular injury is the initial event in the pathogenesis of systemic sclerosis (SSc) and potent proangiogenic mediators such as vascular endothelial growth factor (VEGF) are overexpressed in the skin and circulation of patients with SSc. The objective of this study was to determine the serum levels of VEGF in patients with SSc and to correlate it with the severity of skin thickening, digital ischemia, and interstitial lung disease (ILD). Methods: Serum VEGF levels were measured in 55 patients with SSC who fulfilled 2013 ACR/EULAR classification criteria for scleroderma and 30 healthy age- and gender-matched controls by ELISA. All patients underwent detailed clinical examination, baseline blood investigations, chest X-ray, electrocardiogram, and pulmonary function tests. Echocardiography and high-resolution computed tomography scan of lungs were done wherever necessary. Results: Median serum VEGF in SSc patients was higher than in the controls (675 pg/ml [interquartile range (IQR): 395–920] vs. 180.5 pg/ml [IQR: 155–215], respectively; P = 0.00001). No statistically significant difference was observed between diffuse (662.5 pg/ml [IQR: 441.25–942.5]) and limited SSc (680 pg/ml [IQR: 325–850]) (P = 0.412). Serum VEGF levels correlated significantly with higher modified Rodnan skin scores (r = 0.7168) (P < 0.0001) and lower forced vital capacity (r = −0.6771) (P < 0.0001). Median VEGF levels were higher in patients with digital ischemia (digital pitted scars, digital ulcers, and gangrene) compared to those without ischemic changes (P = 0.001). Patients with ILD (n = 21) had significantly higher median VEGF levels when compared to those without ILD (n = 34) (870 pg/ml [IQR: 592.5–1000] vs. 467.5 pg/ml [IQR: 297.5–760]; P = 0.001). There was no significant difference in serum VEGF levels between early (650 pg/ml [IQR: 375–885]) and late stages (890 pg/ml [IQR: 530–1000]) of disease (P = 0.197). Conclusion: Serum VEGF levels were elevated in SSc and they correlated with the severity of skin thickening, digital ischemia, and presence of ILD.
  2,668 238 1
Enhancement of knowledge and skills in laboratory techniques for autoantibody evaluation: Utility of a single-day hands-on workshop
Durga Prasanna Misra, Krushna Chandra Pani, Sajjan N Shenoy, Anupam Wakhlu, Parasar Ghosh, Pravin Hissaria, Vikas Agarwal
September 2018, 13(3):178-181
DOI:10.4103/injr.injr_153_17  
Background: Laboratory tests evaluating autoantibodies form a key part of rheumatology practice, yet this remains the least emphasized part of rheumatology training. Methods: We conducted a single-day autoantibody workshop to train young rheumatologists in the principles of autoantibody testing as well as provide hands-on exposure to conduct these tests. We assessed the efficacy of this workshop by pretest and posttest questionnaires evaluating three domains – Antigen–antibody interactions and laboratory techniques other than immunofluorescence (Domain 1); immunofluorescence (Domain 2); and clinical relevance of autoantibodies (Domain 3). In addition, we also sought unstructured feedback from participants. Results: There was a baseline knowledge deficit regarding autoantibody estimation and evaluation among the participants. Comparison of pre- and posttest questionnaires revealed that the 1-day workshop was effective in improving overall knowledge about autoantibody testing as well as in Domain 1 and 2 but not Domain 3. Hands-on exposure and basic level discussion of laboratory techniques were appreciated by attendees. Conclusion: A single-day workshop is effective in enhancing knowledge of attendees about autoantibody testing. In-depth discussions about these laboratory techniques in rheumatology, the immune mechanisms involved and association with clinical scenarios require workshops of longer duration.
  2,627 190 -
EDITORIALS
Anxiety and depression in fibromyalgia: Are we putting the cart before the horse?
Sakir Ahmed, Able Lawrence
September 2018, 13(3):150-151
DOI:10.4103/0973-3698.239516  
  2,418 329 4
Classification criteria of paediatric Behcet's disease: An evolving area of study
Sathish Kumar
September 2018, 13(3):152-153
DOI:10.4103/0973-3698.239517  
  2,439 264 -
LETTERS TO EDITOR
Comments on: Antineutrophil cytoplasmic autoantibody associated vasculitis-Clinical profile and outcomes
Rohini Handa
September 2018, 13(3):212-213
DOI:10.4103/injr.injr_81_18  
  2,307 216 1
IMAGES IN RHEUMATOLOGY
Childhood polyarteritis nodosa presenting with posterior reversible encephalopathy syndrome
Mahesh Janarthanan, Sangeetha Geminiganesan, Jacquilyne Kharlukhi, Saji James
September 2018, 13(3):204-206
DOI:10.4103/injr.injr_38_18  
  2,248 209 -
FROM THE EDITORS DESK
From the editor's desk
Vinod Ravindran
September 2018, 13(3):149-149
DOI:10.4103/0973-3698.239518  
  2,193 247 -
LETTERS TO EDITOR
Branding in rheumatoid arthritis: A harmful practice
Prasanta Padhan, Ipsita Mohanty
September 2018, 13(3):211-211
DOI:10.4103/injr.injr_11_18  
  2,216 205 -