Rheumatoid Vasculitis: A Diminishing Yet Devastating Menace

Investigating the causal relationship between rheumatoid arthritis and cardiovascular disease: A Mendelian randomization study

OBJECTIVE

Previous research has revealed a positive correlation between rheumatoid arthritis (RA) and cardiovascular diseases, but the causal relationship is unclear. This study applies Mendelian randomization to examine whether RA causally contributes to the likelihood of various cardiovascular diseases, such as heart failure, coronary artery disease, and atrial fibrillation.

METHODS

Using genome-wide association data, we conducted a univariable MR (UVMR) analysis to evaluate the causal impact of RA on CVD, primarily utilizing the inverse variance weighted method. Additional MR methods were used to test the robustness of the results. Multivariable MR (MVMR) was applied to explore potential confounders.

RESULTS

In the European population, genetically predicted RA had a harmful causal effect on HF, with the IVW analysis indicating an OR of 1.06 (95% CI: 1.02-1.10, P < 0.01) based on 23 SNPs. No causal relationships were found between RA and other CVDs. The MVMR analysis did not identify significant causal impact of rheumatoid arthritis on HF after controlling for traditional risk factors. In the Asian population, RA was associated with an adverse effect on AF, with the IVW method reporting an OR of 1.20 (95% CI: 1.01-1.41, P = 0.03) for 5 SNPs. No other CVD relationships were found.

CONCLUSIONS

Our MR analysis indicates that genetic susceptibility to rheumatoid arthritis increases the likelihood of heart failure in European populations and atrial fibrillation in East Asian populations. However, established CVD risk factors, such as smoking, overweight, and physical inactivity, remain critically important in the management of RA. Key Points • Multiple studies have highlighted a marked increase in the cardiovascular event risk among individuals with RA. However, additional RCTs are needed for confirmation. • We applied Mendelian randomization to explore the potential causal relationship between rheumatoid arthritis and cardiovascular conditions. The findings demonstrated a causal link between RA and heart failure among European populations, as well as an association between RA and atrial fibrillation in East Asian groups. • Further adjustments using multivariable Mendelian randomization to account for the influence of traditional cardiovascular risk factors revealed that the causal association between RA and heart failure disappeared.

Clinical manifestations of rheumatoid arthritis, including comorbidities, complications, and long-term follow-up

Symmetric inflammatory polyarthritis is the most prominent manifestation of rheumatoid arthritis (RA). However, RA can practically affect any organ system, whether hematologic, neurological, cardiac, lung, skin, eyes, or kidneys. Systemic involvement in RA can be severe when there is interstitial lung disease, scleritis, amyloidosis, pure red cell aplasia, or myelodysplasia. Cardiovascular disease is the leading cause of death in patients with RA with a similar cardiovascular risk to that with diabetes mellitus. Patients with RA are at an increased risk of infections or osteoporosis, largely due to treatment-related etiologies. Rheumatoid vasculitis is a devastating long-term complication of RA which is fortunately becoming rarer over time due to better disease activity control. While the risk of mortality overall seems to be reducing over time, the excess mortality risk with RA compared with the general population persists. Fibromyalgia, anxiety, depression, fatigue, and physical inactivity remain important comorbidities associated with RA.

Relationship Between Early and Established Rheumatoid Arthritis Vascular Change of the Dorsalis Pedis Artery Observed with Ultrasound Imaging

BACKGROUND

Despite early treatment of rheumatoid arthritis (RA) being well established to prevent erosive joint damage, studies report persistent moderate to high disease activity. Other pathologies, for example, rheumatoid vasculitis (RV) may contribute symptoms that may not be captured by existing clinical assessment.

OBJECTIVES

To investigate ultrasound-observed changes in the proximal dorsalis pedis artery (DPA) between early (≤ 5 y) and established (>5 y) RA and the RA Disease Activity Index-5 (RADAI-5).

METHODS

Participants with early (n = 20) and established RA (n = 20) were recruited. Five parameters of the DPA were examined with a previously established ultrasound method. Independent t-tests and Cohen d statistics assessed differences and effect size between ultrasound parameters and RADAI-5, and the two groups. Pearson correlation assessed associations between ultrasound parameters and RADAI-5.

RESULTS

Majority of participants (98%) demonstrated arterial wall thickening regardless of disease duration. However, lumen diameter (Cohen's d = 0.972, p = 0.004) and artery diameter (Cohen's d = 0.694, p = 0.034) were decreased in established RA compared to early RA. No strong associations were found between RADAI-5 and ultrasound parameters, except for lumen diameter in early RA demonstrating a fair association to RADAI-5 (r = 0.445). The mean RADAI-5 score indicated moderate to high disease activity with no difference between early and established RA (p = 0.283).

CONCLUSION

Arterial wall thickening of the DPA indicating the precursory changes of RV was observed in most RA participants, with reductions in artery and lumen diameter occurring in established disease. However, the long-standing instrument RADAI-5 may not reflect symptoms and clinical impacts related to vascular changes among people with RA.

Causal association between rheumatoid arthritis and risk of stroke: A Mendelian randomization study

BACKGROUND

Active rheumatoid arthritis (RA) may damage vascular endothelial cells, thereby increasing the likelihood of adverse cardiovascular events. However, it is not yet clearly established whether RA also increases the risk of adverse cerebrovascular events, particularly stroke.

OBJECTIVE

This study was designed to evaluate the likelihood of a causal association between RA and stroke.

METHOD

A two-sample Mendelian randomization (MR) analysis was performed using the inverse variance-weighted (IVW) average, weighted median, and MR-Egger regression methods. The analysis utilized publicly available summary statistics datasets from Genome-wide association studies (GWAS) meta-analyses for RA in individuals of European descent (total n = 484,598; case = 5427, control = 479,171) as the exposure cohort, and from GWAS meta-analyses for "vascular/heart problems diagnosed by doctor: stroke" in individuals included in the UK Biobank (total n = 461,880; case = 7055, control = 454,825, MRC-IEU consortium) as the outcome cohort.

RESULTS

Eight single-nucleotide polymorphisms with genome-wide significance were selected from the GWASs on RA as the instrumental variables. The results of the MR-Egger and weighted median analyses showed no causal association between RA and stroke (OR = 1.081, 95 % CI [0.943-1.240], P = 0.304) vs. OR = 1.079, 95 % CI [0.988-1.179], P = 0.091), respectively. However, the inverse variance-weighted (IVW) analysis results revealed a causal association between RA and stroke (OR = 1.115, 95 % CI [1.040-1.194], P = 0.002). Cochran's Q test and MR-Egger regression revealed no evidence of heterogeneity and horizontal pleiotropy.

CONCLUSION

The MR analysis results indicated that rheumatoid arthritis (RA) may be causally associated with an increased risk of stroke.

Identification and Quantification of Precursory Changes of Rheumatoid Vasculitis in the Dorsalis Pedis Artery

OBJECTIVE

Rheumatoid arthritis (RA) is a systemic connective tissue autoimmune disease that can infiltrate arterial walls. The delay in diagnosis and treatment of rheumatoid vasculitis (RV) in patients with RA may lead to irreversible damage to the arterial walls of small-to-medium vessels, which has serious and devastating consequences, most notably lung and cardiac damage. In this work an ultrasound image-based biomarker was developed to detect precursory changes in RV.

METHODS

The ground truth was initiated from a medical diagnosis of RA, with arterial wall thickening of the proximal dorsalis pedis artery (DPA) indicating precursory changes of RV identified with ultrasound scanning. Ultrasound images of the DPA from 49 healthy subjects in the control group and 46 patients in the RA group were obtained. In total, 187 texture features were extracted from the images, followed by principal component analysis and linear discriminant analysis.

RESULTS

The proposed biomarker detected a significant difference between the two groups (p = 5.74 × 10-18) with an area under the receiver operating characteristic curve of 0.85. Ten major textural features contributing most heavily to the biomarker were identified, with these textures being consistent with clinical observations of RV identified in previous studies. Interscan reproducibility was assessed by computing the biomarker twice based on repeated scans of each ankle. High interscan reproducibility was demonstrated by a strong and significant Pearson's coefficient (r = 0.85, p < 0.01) between the two repeated measurements of the proposed biomarker.

CONCLUSION

The proposed biomarker can discriminate image textural differences seen in images acquired from RA patients, demonstrating precursory changes in RV compared with healthy controls. The major discriminative features identified in this study may facilitate the early identification and treatment of RV.

Rheumatoid Vasculitis in Modern Era: A Case Report and Comprehensive Literature Review

Rheumatoid vasculitis (RV) is a rare extraarticular manifestation of severe seropositive rheumatoid arthritis (RA), affecting small and medium vessels and associated with significant morbidity and mortality. The incidence of RV has significantly decreased in the last three decades due to early diagnosis and better management of RA with biologics. Still, the mortality rate remains high and there are insufficient controlled studies guiding RV treatment. Here, we discussed a case of a 75-year-old male who presented with a non-healing ulcer on lateral malleolus without significant joint pain, the workup showed very high titer rheumatoid factor with erosive joint disease raising high clinical suspicion of RV. Skin biopsy was negative for histologic evidence of vasculitis. He had complete healing of the ulcer with prednisone and methotrexate (MTX). This case highlights the importance of promptly recognizing this rare entity and that a negative biopsy does not rule out RV, and appropriate treatment helps decrease morbidity and mortality.

Methotrexate toxicity complicating a case of rheumatoid arthritis associated Interstitial Lung Disease: Lessons to learn

Rheumatoid arthritis (RA) is one of the most common types of autoimmune arthritis. It can also involve other organs, including vascular structures, and lungs which are affected in 60% to 80% of cases. Other complications may present as airway infections and drug related pulmonary toxicity. We present the case of 75-year-old male patient of North African decent that was hospitalized initially for chronic dyspnea associated with other systemic manifestations, and in whom we confirmed the diagnosis of Rheumatoid arthritis associated interstitial lung disease. The patient was treated with methotrexate (MTX) and later on, he developed a fatal case of methotrexate related pulmonary toxicity.

Ultrasound imaging of the dorsalis pedis artery as an early indicator of the precursory changes for rheumatoid vasculitis: A case series

Introduction

Clinical verification of rheumatoid vasculitis (RV) persists as a mid-to-late diagnosis with medical imaging or biopsy. Early and subclinical presentations of RV, in particular, can remain underdiagnosed in the absence of adequate diagnostic testing. In this study, the research demonstrated the precursory changes for RV in patients with rheumatoid arthritis (RA) using non-invasive ultrasound imaging of a peripheral vessel.

Method

Six participants were recruited: three participants with (RA) and three age- and gender-matched healthy controls. All participants completed a Foot Health Survey Questionnaire (FHSQ), and participants with RA completed a Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5). Bilateral B-mode and Doppler ultrasound of the dorsalis pedis artery (DPA) was performed. The degree of inflammation, lumen and artery diameters, lumen diameter-to-artery diameter ratio and peak systolic velocity in the proximal DPA were compared between the two groups.

Results

The mean RADAI-5 score (5.4 ± 0.8 out of 10) indicated moderate disease activity amongst participants with RA. Inflammation was observed in the DPA wall in all participants with RA, compared to no inflammation observed in the control group (Friedmans two-way analysis: χ2 = 15.733, P = 0.003). Differences between groups for inflammation, lumen diameter and lumen diameter-to-artery diameter ratio were found (P < 0.034), without differences for artery diameter and peak systolic velocity (P > 0.605). DPA wall inflammation did not correlate with FHSQ scores (r = -0.770, P = 0.073).

Conclusion

Despite moderate RA disease activity, this is the first study to demonstrate the use of ultrasound to observe inflammation in small vessel disease. Our findings suggest ultrasound imaging may be a viable screening tool to demonstrate arterial wall inflammation, indicating the precursory changes of RV.

MR and CT angiography in the diagnosis of vasculitides

Vasculitides represent the wide-ranging series of complex inflammatory diseases that involve inflammation of blood vessel walls. These conditions are characterized according to the caliber of the predominantly involved vessels. The work-up of vasculitides often includes imaging to narrow a differential diagnosis and guide management. Findings from CT and MR angiography in conjunction with a thorough history and physical exam are of utmost importance in making an accurate diagnosis. Further, imaging can be used for follow-up, in order to monitor disease progression and response to treatment. This wide-ranging literature review serves as the primary resource for clinicians looking to diagnose and monitor the progression of rare vascular inflammatory conditions. This article provides a comprehensive summary of the main findings on imaging related to each of these vasculitides. For each of the named vasculitis conditions, a thorough overview of the diagnostic modalities and their respective findings is described. Many specific hallmarks of pathology are included in this review article.

Reliability of Ultrasound Imaging in Examining Integrity and Inflammation in the Dorsalis Pedis Artery

OBJECTIVE

Assessment of small vessel inflammatory diseases such as rheumatoid vasculitis is challenging. Small arteries such as the dorsalis pedis artery (DPA) are difficult to assess for changes in the arterial wall with medical imaging. Ultrasound imaging is a viable tool for examining the integrity and inflammatory changes in the arterial wall; however, no empirical data on its reliability have been described.

METHODS

We measured the intra- and inter-rater reliability of ultrasound measurements across five parameters evaluating arterial integrity of the proximal DPA in participants with and without small vessel disease. We recruited 10 participants with rheumatoid arthritis and 10 healthy controls. Two sonographers using ultrasound independently measured DPA lumen diameter, artery diameter, lumen-to-arterial diameter ratio, arterial Doppler velocity and inflammatory changes in the proximal wall of the DPA. The intraclass correlation coefficient (ICC) was used to evaluate 95% confidence intervals within and between raters. Bland-Altman analyses were used to assess limits of agreement and were compared with minimal clinically important differences (MCID).

RESULTS

Four of five selected parameters were found to have excellent intra- and inter-rater reliability within and between raters (ICC = 0.903-0.996). Acceptable reliability was found for measurement of arterial blood flow velocity within raters (ICC = 0.815-0.909), but not between raters (ICC = 0.634). Standard mean errors in all parameters were within minimal clinically important differences.

CONCLUSION

Ultrasound imaging has been found to be a reliable method of assessment of arterial integrity and inflammation of the proximal DPA in people with small vessel disease. Evaluation of arterial blood flow velocity requires cautious interpretation.

Pathogenesis of Extraarticular Manifestations in Rheumatoid Arthritis-A Comprehensive Review

Rheumatoid arthritis (RA) is among the most prevalent and debilitating autoimmune inflammatory chronic diseases. Although it is primarily characterized by destructive peripheral arthritis, it is a systemic disease, and RA-related extraarticular manifestations (EAMs) can affect almost every organ, exhibit a multitude of clinical presentations, and can even be asymptomatic. Importantly, EAMs largely contribute to the quality of life and mortality of RA patients, particularly substantially increased risk of cardiovascular disease (CVD) which is the leading cause of death in RA patients. In spite of known risk factors related to EAM development, a more in-depth understanding of its pathophysiology is lacking. Improved knowledge of EAMs and their comparison to the pathogenesis of arthritis in RA could lead to a better understanding of RA inflammation overall and its initial phases. Taking into account that RA is a disorder that has many faces and that each person experiences it and responds to treatments differently, gaining a better understanding of the connections between the joint and extra-joint manifestations could help to create new treatments and improve the overall approach to the patient.

Rheumatoid Vasculitis Complicated With Acute Inflammatory Demyelinating Polyneuropathy in an Older Female: A Case Report

Rheumatoid vasculitis (RV) causes various complications in the heart, lungs, kidneys, and nerves that require intensive treatment. Rapid RV-related peripheral nerve involvement progression is critical and requires prompt treatment. We report the case of a 73-year-old female with RV, with a chief complaint of difficulty walking without any infectious symptoms for several months. We diagnosed Guillain-Barré syndrome (GBS) accompanied by RV and treated the patient with intravenous immunoglobulin and cyclophosphamide. Previous impairments of activities of daily living (ADLs) were resolved. Diagnosing the neurological manifestations of RV and GBS in older patients with an active RV is challenging because of the various patterns of the progression. For effective management, considering both diseases and implementing immunosuppressive and modulatory treatments is critical to stop the progression of neurological symptoms and prevent the deterioration of ADLs.

Spectrum of Large and Medium Vessel Vasculitis in Adults: Primary Vasculitides, Arthritides, Connective Tissue, and Fibroinflammatory Diseases

PURPOSE OF REVIEW

To provide a comprehensive overview of the spectrum of large and medium vessel vasculitis in adults with primary vasculitides, arthritides, connective tissue, and fibroinflammatory diseases as well as vasculitis mimics, for an efficient differential diagnosis and initial diagnostic approach.

RECENT FINDINGS

Imaging has had a tremendous impact on the diagnosis of medium to large vessel vasculitis, now often replacing histopathologic confirmation and identifying new disease manifestations (e.g., intracranial disease in giant cell arteritis; vascular manifestations of IgG4-related disease). Novel diseases or syndromes involving blood vessels have been described (e.g., VEXAS-Syndrome with polychondritis). The use of the terms "medium" or "large" vessel varies considerably between medical specialties. The differential diagnosis of large and medium vessel vasculitis is becoming increasingly complex as new entities or disease manifestations of known inflammatory rheumatic diseases are regularly identified. A more precise and widely recognized definition of the vessel sizes would make future research more comparable.

Nailfold Videocapillaroscopy for the Evaluation of Peripheral Microangiopathy in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic and refractory autoimmune joint disease that affects multiple organs. Several methods have been applied for the study of microvascular endothelial dysfunction, which is considered an important component of vascular disease in RA. Implementation of nailfold videocapillaroscopy (NVC) represents a viable choice, as the skin is an easily accessible window for the non-invasive, real-time assessment of subtle microcirculation abnormalities. Although NVC is routinely used in the rheumatology field, especially for the diagnostic workout of Raynaud’s phenomenon, accumulating evidence suggests a role in the evaluation of systemic vasculopathy associated with autoimmune rheumatic disorders. The current paper aims to provide an overview of NVC as a valuable clinical aid for the assessment of peripheral microcirculation in RA. Previous studies characterizing the capillaroscopic pattern in RA are summarized, along with associations with disease-related characteristics. Most available reports have mainly focused on the descriptions of non-specific morphological alterations that may reflect endothelial injury over the course of the disease. Still, the exact pattern of structural and functional capillaroscopic alterations and their clinical significance in RA remains a subject of ongoing research.

Rheumatoid Vasculitis, an Uncommon Complication of Non-Deforming Rheumatoid Arthritis: A Case Report

We present an 18-year-old female from South Sudan presented with right fingertips ulceration and black discolouration associated with bilateral wrist/metacarpophalangeal joints pain for five months. The ulceration began at the tip of the right middle finger and gradually progressed to involve the rest of the hand and was associated with agonizing pain. A Doppler study of the right upper limb revealed thrombosis of the antecubital portion of the basilar, ulnar, and part of the distal radial arteries. Blood investigations showed high anti-CCP, doubtful rheumatoid factor titre and ANA titre of 1:320 with coarse and nucleated cells; however, all ANA parameters were negative. A definitive diagnosis of rheumatoid arthritis complicated by rheumatoid vasculitis was made. Unfortunately, the middle finger could not be preserved and ended up amputated, and the patient was commenced on steroids, DMARDs and warfarin. The patient responded very well to the management plan with pain alleviation, ulcers healing and clot resolution.

Constrictive Pericarditis: An Unusual Presentation of Rheumatoid Vasculitis

We describe a case of rheumatoid vasculitis with an atypical presentation of constrictive pericarditis. A 51-year-old man who was previously admitted for diffuse lymphadenopathy, presented with chest pain and a lower extremity rash. Extensive workup including multimodality imaging, serology tests, and biopsy, resulted in the diagnosis of rheumatoid vasculitis.

Acute Neurologic Manifestations of Systemic Immune-Mediated Diseases

Systemic autoimmune diseases can affect the peripheral and central nervous system. In this review, we outline the common inpatient consultations for patients with neurological symptoms from rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, sarcoidosis, immunoglobulin G4-related disease, Behçet's disease, giant cell arteritis, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis, polyarteritis nodosa, and ankylosing spondylitis. We discuss the symptoms, diagnostic strategies, and treatment options.

Rheumatoid Arthritis Associated Episcleritis and Scleritis: An Update on Treatment Perspectives

Episcleritis and scleritis are the most common ocular inflammatory manifestation of rheumatoid arthritis. Rheumatoid arthritis (RA) accounts for 8% to 15% of the cases of scleritis, and 2% of patients with RA will develop scleritis. These patients are more likely to present with diffuse or necrotizing forms of scleritis and have an increased risk of ocular complications and refractory scleral inflammation. In this review we provide an overview of diagnosis and management of rheumatoid arthritis-associated episcleritis and scleritis with a focus on recent treatment perspectives. Episcleritis is usually benign and treated with oral non-steroidal anti- inflammatory drugs (NSAIDs) and/or topical steroids. Treatment of scleritis will classically include oral NSAIDs and steroids but may require disease-modifying anti-rheumatic drugs (DMARDs). In refractory cases, treatment with anti TNF biologic agents (infliximab, and adalimumab) is now recommended. Evidence suggests that rituximab may be an effective option, and further studies are needed to investigate the potential role of gevokizumab, tocilizumab, abatacept, tofacitinib, or ACTH gel. A close cooperation is needed between the rheumatology or internal medicine specialist and the ophthalmologist, especially when scleritis may be the first indicator of an underlying rheumatoid vasculitis.

Frequency of Cardiovascular Manifestation in Patients With Rheumatoid Arthritis

Introduction

Rheumatoid arthritis (RA) is a chronic, inflammatory, systemic autoimmune disease. The increased inflammatory burden in RA may result in atherosclerosis, myocardial infarction (MI), and subsequent mortality. In this study, we will determine the frequency of cardiovascular manifestation in RA patients through history, laboratory workup, and echocardiography.

Methods

This cross-sectional study was conducted in the rheumatology unit of a tertiary care hospital in Pakistan. Three hundred and twenty-two (n=322) participants with a previously confirmed diagnosis of RA were enrolled in this study via consecutive convenient non-probability sampling.

Results

Cardiovascular manifestations were present in 188 (58.3%) participants. More participants had positive rheumatoid factor (82.9% vs. 32.8%; p-value: < 0.0001) in RA patients with cardiovascular manifestation compared to RA patients without cardiovascular manifestation. Patients with cardiovascular manifestations have a significantly higher C-reactive protein (CRP; 10.21 ± 2.81 mg/L vs. 8.17± 2.01 mg/L; p value: < 0.0001) and erythrocyte sedimentation rate (ESR; 16.2 ± 3.14 mg/L vs. 15.1 ± 2.99 mg/L; p value: 0.0017).

Conclusion

In this study, patients with a cardiovascular manifestation had a higher frequency of patients with rheumatoid factor, higher mean values of CRP and ESR. The early diagnosis and management of cardiac manifestations would aid in controlling the severity of the disease and the overall mortality.

A fatal case of diffuse alveolar hemorrhage complicated by rheumatoid arthritis

We describe a fatal case of diffuse alveolar hemorrhage (DAH) complicated by rheumatoid arthritis (RA). A female patient was diagnosed with RA two months earlier and was treated with prednisolone and tacrolimus due to abnormalities in chest images. The patient was admitted to Hamanomachi Hospital for exertional dyspnea and was treated for exacerbation of chronic heart failure. Even after treatment for heart failure, exertional dyspnea remained. Chest CT imaging revealed contractile, patchy consolidations and ground-glass opacities (GGO) with a peribronchial distribution, suggesting an organizing pneumonia (OP) pattern. She was then treated with an additional 25 mg/day of prednisolone following a clinical diagnosis of OP. When the prednisolone dose was tapered, chest imaging showed worsening infiltration. A bronchoscopy was conducted, and bronchoalveolar lavage fluid was sanguineous, indicating DAH. Given that additional workup for the other etiology of DAH was negative, DAH was thought to be related to RA. Intensive treatment, including pulse dose methylprednisolone, failed to halt progression of respiratory failure, leading to a fatal outcome. The clinical presentation proved challenging due to its rarity. DAH might be a differential diagnosis in RA patients with consolidations and GGO in chest CT images. We review past cases of RA-associated DAH and assess potential treatment choices for future cases.

Rheumatoid arthritis: Extra-articular manifestations and comorbidities

Although synovitis is the pathological hallmark of rheumatoid arthritis (RA), many extra-articular manifestations (EMs) and comorbidities likely occur due to the complex, chronic, inflammatory, and autoimmune features of RA. Cardiovascular (CV) disease is the most common cause of death in patients with RA. Compared to the general population, patients with RA have twice the risk of myocardial infarction and up to 50% increased CV mortality risk. Severe and prolonged disease activity, genetics, and inflammation (e.g. CRP, ACPA, cytokines, matrix-degrading enzymes) play important roles in CV disease and atheroscleroticdamage. The second major cause of death in patients with RA is respiratory disease, which occurs in 30-40% of patients. RA may affect the lung interstitium, airways, and pleurae, while pulmonary vascular involvement is less frequent. Central and peripheral nervous system involvement is usually due to small vessel vasculitis, joint damage, or drug toxicity. There is also evidence that microvascular cerebral damage caused by systemic inflammation is associated with the development of Alzheimer's disease and vascular dementia. Some observational studies have hinted how Disease Modified Anti-Rheumatic Drugs and biologics could reduce the incidence of dementia. Primary gastrointestinal and renal involvements are rare and often relate to drug therapy. To minimize morbidity and mortality, physicians must manage RA disease activity (treat-to-target) and monitor risk factors and concomitant conditions (e.g. smoking cessation; weight regulation; monitoring blood pressure, lipids, thyroid hormone, folic acid and homocysteine; screening for depression, anxiety, atlantoaxial instability, and atherosclerosis). This article aims to provide an overview of the most prevalent and important EMs and comorbidities associated with RA.

Endothelial Dysfunction and Extra-Articular Neurological Manifestations in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory autoimmune disease that affects about 1% of the global population, with a female–male ratio of 3:1. RA preferably affects the joints, with consequent joint swelling and deformities followed by ankylosis. However, evidence has accumulated showing that patients suffering from RA can also develop extra-articular manifestations, including cardiovascular disease states, neuropathies, and multiorgan dysfunction. In particular, peripheral nerve disorders showed a consistent impact in the course of the disease (prevalence about 20%) mostly associated to vasculitis of the nerve vessels leading to vascular ischemia, axonal degeneration, and neuronal demyelination. The pathophysiological basis of this RA-associated microvascular disease, which leads to impairment of assonal functionality, is still to be better clarified. However, endothelial dysfunction and alterations of the so-called brain-nerve barrier (BNB) seem to play a fundamental role. This review aims to assess the potential mechanisms underlying the impairment of endothelial cell functionality in the development of RA and to identify the role of dysfunctional endothelium as a causative mechanism of extra-articular manifestation of RA. On the other hand, the potential impact of lifestyle and nutritional interventions targeting the maintenance of endothelial cell integrity in patients with RA will be discussed as a potential option when approaching therapeutic solutions in the course of the disease.

Influence factors of extra-articular manifestations in rheumatoid arthritis

Background and objective

Extra-articular manifestations (EAMs) are serious outcomes or complications of rheumatoid arthritis (RA) with increasing mortality and morbidity. The purpose was to explore the factors influencing EAMs, tissue-specific/systemic EAMs, and the concurrence of several EAMs.

Patients and methods

In total, 519 inpatients with RA were enrolled. The clinical characteristics, laboratory parameters, and medications of RA patients and the details of EAMs were recorded carefully. Differences between groups were examined by a Chi-square test, independent samples t test, one-way analysis of variance, Mann-Whitney U test, and Kruskal-Wallis H test. Binary and ordinal logistic regression analyses were performed to determine the relationship between influential factors and EAMs, tissue-specific/systemic EAMs, and the concurrence of several EAMs.

Results

The morbidity of EAMs was 44.70%. Male sex, age, and traditional Chinese medicine (TCM) were independent influential factors of EAMs, and a number of statistically significant influence factors were found in the multivariate analysis of tissue-specific/systemic EAMs. Finally, age, CRP levels, number of RA-affected types of joints, and TCM were the factors that independently influenced the concurrence of several EAMs.

Conclusion

Influential factors identified in this study could be recommended in clinical work, which is hopeful to decrease the morbidity and mortality of EAMs in RA.

Intracranial and extracranial multiple arterial dissecting aneurysms in rheumatoid arthritis: A case report

OBJECTIVE

We describe a case of intracranial and extracranial multiple arterial dissecting aneurysms in rheumatoid arthritis (RA).

CASE PRESENTATION

A 29-year-old man with a medical history of RA since 18 years of age was admitted to our hospital for vomiting, dysarthria, and conscious disturbance. At 23, he underwent ligation of the left internal carotid artery (ICA) with superficial temporal artery to middle cerebral artery anastomosis because of acute infarct of the left hemisphere caused by arterial dissection of the left ICA. During the current admission, computed tomography (CT) revealed subarachnoid hemorrhage, and digital subtraction angiography (DSA) demonstrated dissecting aneurysms of the left intracranial vertebral artery (VA) and right extracranial VA. We diagnosed him with a ruptured dissecting aneurysm of the left intracranial VA and performed endovascular parent artery occlusion on the left VA. For the right unruptured VA aneurysm, we performed coil embolization simultaneously. At 2 weeks after the endovascular treatment, follow-up DSA revealed that multiple de novo dissecting aneurysms developed on the origin of the left VA and left and right internal thoracic arteries. Those aneurysms were treated with coil embolization. Other remaining aneurysms on the left thyrocervical trunk, right transverse cervical artery, and both common iliac arteries were treated by conservative therapy. While continuing medical treatment for RA, the patient recovered and was discharged to a rehabilitation hospital.

CONCLUSION

Considering that RA-induced vasculitis can be a potential risk of vascular complications including multiple arterial dissections, physicians should carefully perform endovascular interventional procedures for patients with long-term RA.

Clinical characteristics and social productivity levels of patients with malignant rheumatoid arthritis based on a nationwide clinical database in Japan: annual survey from 2003 to 2013

OBJECTIVES

Malignant rheumatoid arthritis (MRA) is defined as rheumatoid arthritis (RA) with systemic vasculitis or other severe extra-articular manifestations. Japan has a nationwide database for MRA. We analyzed the characteristics of Japanese patients with MRA based on data from the Ministry of Health, Labour and Welfare (MHLW).

METHODS

We were permitted to use data on 43,108 patients who were registered in the MHLW database from 2003 to 2013.

RESULTS

Median age was 65 (interquartile range, 57-72) years. Patients consisted of 71% females. Proportions of patients who had or had experienced interstitial pneumonia and pleuritis were increased, episcleritis was stable, and other MRA manifestations were decreased over time. The number of positive symptoms per patient also decreased over time. The median dose of glucocorticoid, percentage of patients undergoing surgery, and use of non-steroidal anti-inflammatory drugs and apheresis decreased year by year. Steinbrocker stage and class improved over time. Median C-reactive protein levels and erythrocyte sedimentation rate also decreased. Regarding social productivity levels of patients with MRA, the proportion of patients who were working or working from home increased and the proportion of patients recuperating or hospitalized decreased.

CONCLUSION

In patients with MRA, disease activity decreased and social productivity improved from 2003 to 2013.

Gastrointestinal Tract Vasculopathy: Clinicopathology and Description of a Possible "New Entity" With Protean Features

Noninfectious gastrointestinal (GI) vasculopathic disorders are rare and are often overlooked in histopathologic examination or when forming differential diagnoses due to their rarity. However, involvement of the GI tract may lead to serious complications, including ischemia and perforation. Since awareness of the types of vasculopathy that may involve the GI tract is central to arriving at a correct diagnosis, we reviewed our institutional experience with GI tract vasculopathy in order to enhance diagnostic accuracy of these rare lesions. We report the clinical and histologic features of 16 cases (excluding 16 cases of immunoglobulin A vasculitis) diagnosed over a 20-year period. Of the 16 patients, 14 presented with symptoms related to the GI vasculopathy (including 2 presenting with a mass on endoscopic examination). The remaining 2 patients presented with incarcerated hernia and invasive adenocarcinoma. The vasculopathy was not associated with systemic disease and appeared limited to the GI tract in 8 patients. Eight had associated systemic disease, but only 6 had a prior diagnosis. The underlying diagnoses in these 6 patients included systemic lupus erythematosus (1), dermatomyositis (2), rheumatoid arthritis (1), eosinophilic granulomatosis with polyangiitis (1), and Crohn disease (1). One patient with granulomatous polyangiitis and 1 patient with systemic lupus erythematosus initially presented with GI symptoms. The 8 cases of isolated GI tract vasculopathy consisted of enterocolic lymphocytic phlebitis (4), idiopathic myointimal hyperplasia of the sigmoid colon (1), idiopathic myointimal hyperplasia of the ileum (1), granulomatous vasculitis (1), and polyarteritis nodosa-like arteritis (1). Isolated GI tract vasculopathy is rare, but appears to be almost as common as that associated with systemic disease. The chief primary vasculopathies are enterocolic lymphocytic colitis and idiopathic myointimal hyperplasia. Although the latter occurs predominantly in the left colon, rare examples occur in the small bowel and likely represent a complex, more protean disorder.

Extra-articular Manifestations and Comorbidity in Rheumatoid Arthritis: Potential Impact of Pre-Rheumatoid Arthritis Prevention

Rheumatoid arthritis (RA) is associated with a wide variety of extra-articular manifestations and comorbidities, several of which can be organ- or even life-threatening. These extra-articular manifestations and comorbidities can also contribute to the physical disability and psychological morbidity of RA that lead to reduced quality of life, higher direct and indirect costs, and societal burden of the disease. Although the expansion of RA treatment options and adoption of treat-to-target approaches has reduced the incidence and severity of several nonarticular manifestations of RA, such as rheumatoid vasculitis and cardiovascular disease events, this does not seem to be shared by all RA comorbidities. Moreover, a number of highly prevalent and impactful RA-driven comorbidities, such as accelerated atherosclerosis, interstitial lung disease, and sarcopenia, can present clinically in the years before the manifestation of joint pain or observable synovitis. A larger proportion of patients with RA have atherosclerosis, myocardial dysfunction, interstitial lung disease, and sarcopenia that is subclinical in the preclinical and earliest clinical phases of RA, emphasizing the importance of targeting the pre-RA phase for the prevention of comorbidities that are often poorly responsive to treatment once they develop. Herein, we review the potential impact of pre-RA prevention on the incidence and burden of extra-articular manifestations and nonarticular comorbidities.

Acute Pulmonary Hypertension Crisis after Adalimumab Reduction in Rheumatoid Vasculitis

Rheumatoid vasculitis is a rare etiology for pulmonary hypertension (PH) in patients with connective tissue disease. We encountered a case of acute PH crisis in a case with rheumatoid vasculitis eight months after undergoing adalimumab reduction. Since no repetition of arthralgia occurred after the adalimumab reduction, we decided to not increase the dose of adalimumab. However, hemodynamic collapse thereafter developed and even though steroid pulse therapy was administered, the patient nevertheless died. The autopsy showed clusters of acute and chronic inflammation around the remodeled pulmonary arteries along with micro-thrombi in the vessel lumen. We should consider the possibility of critical worsening of PH as a phenotype of vasculitis related to immunosuppressive therapy reduction.