The Global Epidemiology of Scleritis: A Systematic Review and Meta-analysis

PURPOSE

Scleritis, a severe inflammatory condition of the sclera, causes significant ocular pain and potential tissue damage. Often linked with systemic diseases, scleritis can be either infectious or noninfectious. Despite its clinical importance, the global incidence and detailed epidemiology of scleritis are poorly understood due to its heterogeneity and rarity. This systematic review and meta-analysis aim to elucidate the worldwide incidence and epidemiological trends of scleritis, examining variations across geographic regions, etiologies, and time periods.

DESIGN

Systematic Review and Meta-analysis.

CLINICAL RELEVANCE

Understanding scleritis epidemiology is crucial for enhancing diagnostic accuracy and treatment, especially concerning systemic illnesses commonly associated with this condition. Identifying epidemiological trends can inform healthcare policies and resource allocation, improving patient outcomes.

METHODS

We systematically reviewed literature across databases, including Embase, PubMed, Virtual Health Library, The Cochrane Library, and medRxiv. Population-based, cohort, case-control, cross-sectional, and claims database studies reporting the frequency, prevalence, or incidence of scleritis diagnosed through clinical or imaging techniques, were included. The screening was based on titles and abstracts, followed by a full-text review. We assessed the risk of bias using standardized tools and systematically extracted data for qualitative and quantitative synthesis. This review is registered with PROSPERO (CRD42022330948).

RESULTS

This review included 74 studies with 169,871 scleritis patients. The incidence was 2.67 per 100,000 in ophthalmological centers and 1.38 per 100,000 in broader population-based studies, both showing a decreasing trend over time. The patient population was predominantly female (67.24%), with an average age of 48.3 years. Epidemiological patterns were significantly influenced by etiology, geographic region, and publication period, with idiopathic cases being the most common. Scleritis was notably associated with systemic diseases such as rheumatoid arthritis, granulomatosis with polyangiitis, Sjögren's syndrome, sarcoidosis, and infectious agents like Mycobacterium tuberculosis and herpes virus.

CONCLUSION

This is the most extensive study on scleritis to date, providing comparative insights across geographic regions, age groups, and genders. Our meta-analysis highlights significant regional differences in scleritis incidence, reflecting variations in medical practice, access to care, and potential genetic and environmental factors. These findings underscore the need for further research to explore these patterns and their global health implications.

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.

Concurrent Large-vessel Vasculitis and Small-vessel Vasculitis Accompanied by Basal Cell Carcinoma: A Case Report

Variable vessel vasculitis is a rare presentation of systemic vasculitis. We herein report a Japanese woman with large- and small-vessel vasculitis accompanied by basal cell carcinoma. The clinical course of our patient suggested paraneoplastic variable vessel vasculitis. Our case suggests that there are two aspects that need to be considered. First, clinicians should consider cancer-related complications when treating variable-vessel vasculitis. Second, the evaluation of variable vessels is needed when treating paraneoplastic vasculitis.

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.

Updates on interstitial lung disease and other selected extra-articular manifestations of rheumatoid arthritis

PURPOSE OF REVIEW

To discuss changes in epidemiology, recent advances in understanding of the pathogenesis and management of selected extraarticular manifestations of rheumatoid arthritis (ExRA).

RECENT FINDINGS

The incidence of ExRA overall and subcutaneous rheumatoid nodules in particular is declining after 2000. These trends reflect improved RA disease activity with early effective immunosuppressive treatments; changing environmental risk factors can be contributing. ExRA continues to carry a two-fold increased mortality risk. RA-associated interstitial lung disease (RA-ILD) is a major contributor to mortality, with no decline in incidence and scant therapeutic options. Individualized risk stratification for RA-ILD based on patient-level risk factors and biomarker profile is evolving with MUC5B as a major genetic risk factor. Clinical trials are underway to evaluate the benefits of novel antifibrotic therapies and targeted therapies for RA-ILD. The risk of cardiovascular disease in RA is generally amendable to treatment with disease-modifying antirheumatic drugs, although cardiovascular risk associated with JAK inhibition is not fully understood.

SUMMARY

Despite reduction in incidence of ExRA overall, the incidence of RA-ILD shows no significant decline and remains a major therapeutic challenge. The use of novel antifibrotics and immunosuppressive drugs shows promise in slowing the progression of RA-ILD.

Decline in Incidence of Extra-Articular Manifestations of Rheumatoid Arthritis: A Population-Based Cohort Study

OBJECTIVE

The focus of this study was to assess changes in the cumulative incidence of extra-articular manifestations of rheumatoid arthritis (ExRAs) and associated mortality risk.

METHODS

This study evaluated trends in occurrence of ExRAs using a population-based inception cohort that included all adult patients with incident rheumatoid arthritis (RA) from 1985 through 2014 meeting the 1987 American College of Rheumatology criteria. Patients were divided into two cohorts based on the incidence date of RA, 1985 to 1999 and 2000 to 2014. The occurrence of ExRAs was determined by manual chart review, and the 10-year cumulative incidence was estimated for each ExRA in both cohorts. Cox proportional hazard models were used to determine associations between specific demographic and RA disease characteristics and ExRAs and between ExRAs and mortality.

RESULTS

There were 907 patients included, 296 in the 1985 to 1999 cohort and 611 in the 2000 to 2014 cohort. The 10-year cumulative incidence of any ExRA decreased significantly between the earlier and later cohorts (45.1% vs 31.6%, P < 0.001). This was largely driven by significant declines in subcutaneous rheumatoid nodules (30.9% vs 15.8%, P < 0.001) and nonsevere ExRAs (41.4% vs 28.8%, P = 0.001). Identified risk factors for the development of any ExRAs include rheumatoid factor positivity (hazard ratio [HR] 2.02, 95% confidence interval [CI] 1.43-2.86) and current smoking (HR 1.61, 95% CI 1.10-2.34). Mortality was increased in patients with either nonsevere (HR 1.83, 95% CI 1.18-2.85) or severe ExRAs (HR 3.05, 95% CI 1.44-6.49).

CONCLUSIONS

The incidence of ExRAs has decreased over time. Mortality remains increased in patients with ExRAs.

Poly-Refractory Rheumatoid Arthritis: An Uncommon Subset of Difficult to Treat Disease With Distinct Inflammatory and Noninflammatory Phenotypes

OBJECTIVE

To investigate the prevalence of poly-refractory rheumatoid arthritis (RA) defined as failure of all biological (b)/targeted synthetic (ts)-disease-modifying drugs (DMARDs). To further investigate whether patients with persistent inflammatory refractory RA (PIRRA) and noninflammatory refractory RA (NIRRA), determined by objective ultrasound (US) synovitis, have distinct clinical phenotypes in both EULAR difficult-to-treat RA (D2T-RA) and poly-refractory RA groups.

METHODS

A cross-sectional study of 1,591 patients with RA on b/tsDMARDs that evaluated D2T-RA criteria and subclassified as poly-refractory if inefficacy/toxicity to at least one drug of all classes. PIRRA was defined if US synovitis in one or more swollen joint and NIRRA if absent. Univariate tests and multivariate logistic regression were conducted to investigate factors associated with poly-refractory, PIRRA, and NIRRA phenotypes.

RESULTS

122 of 1,591 were excluded due to missing data. 247 of 1,469 (16.8%) had D2T-RA and only 40 of 1,469 (2.7%) poly-refractory RA. This latter group had higher disease activity score 28 C-reactive protein (CRP) (median 5.4 vs 5.02, P < 0.05), CRP levels (median 13 vs 5 mg/l, P < 0.01), and smoking (ever) rates (20% vs 4%, P < 0.01) compared with other D2T patients. Smoking was associated with poly-refractory RA (odds ratio 5.067, 95% CI 1.774-14.472, P = 0.002). Of 107 patients with D2T-RA with recent US, 61 (57%) were PIRRA and 46 (43%), NIRRA. Patients with NIRRA had elevated body mass index (median 30 vs 26, P < 0.001) and higher fibromyalgia prevalence (15% vs 3%, P < 0.05), lower swollen joint count (median: 2 vs 5, P < 0.001), and lower CRP levels (5 vs 10, P < 0.01).

CONCLUSION

Only 2.7% of D2T-RA failed all classes of b/tsDMARDs. Among D2T-RA, less than 60% had objective signs of inflammation, representing a target for innovative strategies.

[Secondary vasculitides]

Vasculitides that occur in association with underlying primary diseases are called secondary vasculitides. In the diverse differential diagnostics of vasculitides, a large variety of secondary vasculitides have to be considered. Secondary vasculitides cover the full spectrum of vasculitides, presenting in manifold clinical manifestations. This article provides an overview of systemic diseases and etiological factors, such as infections, drugs, and malignancies, which can be associated with vasculitides. The possible associations with infectious agents are too numerous to be comprehensively covered and are discussed in an exemplary fashion and with a western European focus. Especially in atypical and refractory disease courses, a secondary vasculitis should be considered. In light of the diversity of differential diagnoses and the particular challenges posed by secondary vasculitides, interdisciplinary collaboration is the key for an accurate and early diagnosis as well as for successful treatment management. Treatment of the primary disease should always be prioritized and, if a drug-induced vasculitis is suspected, immediate cessation of the culprit drug is mandatory.

Successful peficitinib monotherapy for the new-onset skin manifestations of rheumatoid vasculitis after long-term treatment with tocilizumab for rheumatoid arthritis

Rheumatoid vasculitis (RV) is a severe extra-articular systemic manifestation of rheumatoid arthritis (RA). Its prevalence has been decreasing for decades because of improved early diagnosis of RA and advances in RA treatment, but it remains a life-threatening disease. The standard treatment for RV has been a glucocorticoid and disease-modifying antirheumatic drugs. Biological agents, including antitumour necrosis factor inhibitors, are also recommended for refractory cases. However, there are no reports of Janus kinase (JAK) inhibitor use in RV. We experienced a case of an 85-year-old woman with a 57-year history of RA who had been treated with tocilizumab for 9 years after receiving three different biological agents over 2 years. Her RA seemed to be in remission in her joints, and her serum C-reactive protein had decreased to 0.0 mg/dL, but she developed multiple cutaneous leg ulcers associated with RV. Because of her advanced age, we changed her RA treatment from tocilizumab to the JAK inhibitor peficitinib in monotherapy, after which the ulcers improved within 6 months. This is the first report to indicate that peficitinib is a potential treatment option for RV that can be used in monotherapy without glucocorticoids or other immunosuppressants.

Autoimmune Axonal Neuropathies

OBJECTIVE

This article reviews autoimmune axonal neuropathies, their characteristic clinical features, disease and antibody associations, appropriate ancillary testing, treatment, and prognosis.

LATEST DEVELOPMENTS

In 2021, the American College of Rheumatology and the Vasculitis Foundation released new summary guidelines for the treatment of antineutrophil cytoplasmic autoantibody-associated vasculitides. In addition, novel autoantibodies have been recently identified; they are often paraneoplastic and associated with axonal neuropathies.

ESSENTIAL POINTS

Recognition of autoimmune axonal neuropathies is important because of the potential for effective treatment to either reverse deficits or slow the progression of disease. It is necessary to properly assess for associations with other systemic disorders (eg, systemic vasculitis, connective tissue disease, neoplasm) so that adequate treatment for both neurologic and non-neurologic aspects of the disease can be initiated.

Rheumatoid vasculitis in 2023: Changes and challenges since the biologics era

BACKGROUND

Significant changes in the epidemiology and natural history of rheumatoid vasculitis (RV) have occurred with the introduction of biological therapies such as TNF inhibitors (TNFi) and rituximab.

PURPOSE

This scoping review aims to address the key current challenges and propose updated criteria for RV. This will aid future descriptive observational studies and prospective therapeutic trials.

METHODOLOGY

The MEDLINE database was searched for eligible articles from inception through December 2022. Articles were selected based on language and publication date after 1998, corresponding to the approval of the first TNFi in rheumatic diseases.

RESULTS

Sixty articles were included in the review. The mean incidence of RV has decreased since the approval of biologic therapies in RA, from 9.1 (95% CI: 6.8-12.0) per million between 1988 and 2000 to 3.9 (95% CI: 2.3-6.2) between 2001 and 2010, probably due to significant improvement in RA severity and a decrease in smoking habits. Factors associated with an increased risk of RV include smoking at RA diagnosis, longer disease duration, severe RA, immunopositivity, and male gender (regardless of age). Homozygosity for the HLA-DRB104 shared epitope is linked to RV, while the presence of HLA-C3 is a significant predictor of vasculitis in patients without HLA-DRB104. Cutaneous (65-88%), neurologic (35-63%), and cardiac (33%) manifestations are common in RV, often associated with constitutional symptoms (70%). Histologic findings range from small vessel vasculitis to medium-sized necrotizing arteritis, but definite evidence of vasculitis is not required in the 1984 Scott and Bacon diagnostic criteria. Existing data on RV treatment are retrospective, and no formal published guidelines are currently available.

CONCLUSION

The understanding of RV pathogenesis has improved since its initial diagnostic criteria, with a wider range of clinical manifestations identified. However, a validated and updated criteria that incorporates these advances is currently lacking, impeding the development of descriptive observational studies and prospective therapeutic trials.

PRIMARY FUNDING SOURCE

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Autoimmune polyneuropathies

The autoimmune peripheral neuropathies with prominent motor manifestations are a diverse collection of unusual peripheral neuropathies that are appreciated in vast clinical settings. This chapter highlights the most common immune-mediated, motor predominant neuropathies excluding acute, and chronic inflammatory demyelinating polyradiculoneuropathy (AIDP and CIDP, respectively). Other acquired demyelinating neuropathies such as distal CIDP and multifocal motor neuropathy will be covered. Additionally, the radiculoplexus neuropathies, resulting from microvasculitis-induced injury to nerve roots, plexuses, and nerves, including diabetic and nondiabetic lumbosacral radiculoplexus neuropathy and neuralgic amyotrophy (i.e., Parsonage-Turner syndrome), will be included. Finally, the motor predominant peripheral neuropathies encountered in association with rheumatological disease, particularly Sjögren's syndrome and rheumatoid arthritis, are covered. Early recognition of these distinct motor predominant autoimmune neuropathies and initiation of immunomodulatory and immunosuppressant treatment likely result in improved outcomes.

Rheumatoid Cerebral Vasculitis in a Patient in Remission

Cerebral vasculitis is a very rare extra-articular complication of rheumatoid arthritis (RA) that is often challenging to diagnose. Elevated titers of rheumatoid factor (RF), anti-cyclic citrullinated peptide antibodies (anti-CCP), and antinuclear antibodies (ANA) have been linked with severe complications. The absence of highly elevated titers of RF, anti-CCP, and ANA can complicate the diagnosis of RA-associated cerebral vasculitis. We report the case of a 59-year-old woman with long-standing arthritis maintained on rituximab and leflunomide who developed sudden headaches and altered level of consciousness. Laboratory work-up revealed normal lymphocyte count and mildly elevated total serum protein and anti-CCP with negative RF and ANA and no evidence for viral or bacterial infections. Cerebrospinal fluid analysis (CSF) showed slightly elevated anti-CCP with normal levels of CXCL-13 and interleukin 6 (IL-6). Brain magnetic resonance imaging (MRI) showed ill-defined lesion of high T2 signal. Using MR angiogram, MR perfusion, and MR spectroscopy, the diagnosis of rheumatoid cerebral vasculitis was confirmed. The patient was treated with intravenous methyl-prednisolone with fast complete improvement. We conclude that adequate immunosuppression in RA might not be able to prevent rare extra-articular manifestations such as rheumatoid cerebral vasculitis.

Treatment of Connective Tissue Disease-Related Intractable Disease with Biological Therapeutics

The treatment of connective tissue disease (CTD) and CTD-related intractable diseases (CTD-IDs) currently depends on the use of steroid therapy. Approximately 20 years have passed since the approval of infliximab for rheumatoid arthritis in 2003. Since then, several biological therapeutics have been marketed and adapted for many CTDs and CTD-IDs other than rheumatoid arthritis. Although conventional treatment for patients with these diseases is rarely used because of their poor prognosis, these cases may benefit from biological therapeutics. However, choosing biological therapeutics is difficult because they have different target molecules compared with conventional therapeutics. In this review, we address the current situation of biological therapeutics for CTD-IDs including Behcet's disease, psoriatic arthritis, ankylosing spondylitis, anti-neutrophil cytoplasmic antibody-related arthritis, and adult Still's disease, as well as the choice of biological therapeutics in clinical practice.

An arm and a leg: A case of rheumatoid vasculitis and antiphospholipid antibody syndrome

Rheumatoid vasculitis is a rare extra-articular complication of rheumatoid arthritis. The most common manifestation is cutaneous; however, it can manifest in various organ systems and is associated with a high degree of morbidity and mortality. Diagnosis is challenging, and there are no validated diagnostic or classification criteria. Most cases should be confirmed with tissue biopsy when possible given the severity of disease and the extent of immunosuppression required to treat this condition. We report the case of a 54-year-old white woman with long-standing, uncontrolled, and seropositive rheumatoid arthritis with a history of elevated anticardiolipin IgG and IgM antibodies who presented with acute stenosis of her left femoral artery which ultimately required a left above-the-knee amputation. Histopathology revealed findings consistent with vasculitis and thrombosis, and subsequent imaging revealed multifocal arterial and venous thromboses. She was diagnosed with rheumatoid vasculitis and antiphospholipid antibody syndrome, and was treated with high-dose glucocorticoids, cyclophosphamide, and warfarin. Rheumatoid vasculitis is a rare but devastating complication of rheumatoid arthritis, and vigilance for this condition must be maintained, especially in patients with long-standing, seropositive disease.

Rheumatoid Vasculitis as an Initial Presentation of Rheumatoid Arthritis

Rheumatoid vasculitis is a rare, extra-articular manifestation that can be seen in long-standing rheumatoid arthritis. Here we present the case of a 51-year-old man who presented with arthralgias, skin rash, dyspnoea and generalized leg swelling and who was diagnosed with rheumatoid arthritis flare.

LEARNING POINTS

Extra-articular manifestations like rheumatoid vasculitis and pericarditis rarely present as initial manifestations of rheumatoid arthritis.A high index of suspicion is required to make the diagnosis, especially in an adult who presents with multiorgan manifestations, rash, and a high titre of rheumatoid factor and anti-CCP antibody levels.

Severe Mononeuritis Multiplex due to Rheumatoid Vasculitis in Rheumatoid Arthritis in Sustained Clinical Remission for Decades

Rheumatoid vasculitis (RV) usually occurs in patients with refractory rheumatoid arthritis (RA). An 80-year-old woman was transferred to our hospital because of muscle weakness and paresthesia in all 4 limbs. She had been diagnosed with RA 30 years ago and achieved sustained clinical remission. At presentation, polyarthritis and drop foot were observed, and rheumatoid factor was prominently elevated. A peripheral nerve conduction test revealed mononeuritis multiplex in her limbs. We suspected that RV had developed rapidly despite RA having been stable for many years and started immunosuppression therapy with steroids combined with azathioprine. The treatment prevented worsening of muscle weakness and paresthesia.

Rheumatoid Vasculitis: Is It Always a Late Manifestation of Rheumatoid Arthritis?

Rheumatoid vasculitis (RV) is an infrequent complication of longstanding severe rheumatoid arthritis (RA). The active vasculitis associated with rheumatoid disease occurs in about 1%-5% of the patient population. RV is a manifestation of "extra-articular" rheumatoid arthritis and involves the small- and medium-sized arteries in the body. Newer RA treatments, including biologic therapies, offer a broader array of potential therapeutic options, although no controlled trials exist to guide treatment. In general, following tissue confirmation of the diagnosis, the severity of organ involvement and disease manifestations can guide treatment decisions. We want to alert clinicians of this unique yet severe complication of RA which has high morbidity and mortality. We describe a thought-provoking case of a 44-year-old male with past medical history (PMH) of hypertension who presented with over three-month history of lower extremity (LE) swelling, discoloration, and ulceration. Arthralgias with constitutional symptoms (fatigue, weight loss), large pericardial effusion, was found to have leukocytoclastic vasculitis along with rheumatoid factor (RF) >650, and anti-cyclic citrullinated peptide (anti-CCP) antibodies >300, low C4 and normal C3. Pericardial fluid appeared serous, exudative, showed histiocytes, multinucleated giant cells and necrotic debris consistent with rheumatoid effusion. Skin, right shin, punch biopsy showed epidermal necrosis from underlying occlusive vasculopathy. Skin, left lower back, punch biopsy showed focal leukocytoclastic vasculitis. The patient was started on high dose steroids with marked improvement in the symptoms, Rituximab was planned awaiting QuantiFERON to be negative. Pan-CT angiography of the whole body was negative for any vascular changes ruling out polyarteritis nodosa (PAN).

Rituximab Therapy for Systemic Rheumatoid Vasculitis: Indications, Outcomes, and Adverse Events

Objective.

To characterize the indication, outcomes, and adverse effects of rituximab (RTX) treatment in a large single-center cohort of patients with systemic rheumatoid vasculitis (RV).

Methods.

We retrospectively reviewed the medical charts of 17 patients treated with RTX for systemic RV from 2000 to 2017. Clinical characteristics, outcomes, and adverse effects were analyzed.

Results.

At RV diagnosis, mean age was 59 years, 59% were female, 94% were white, and 82% had positive rheumatoid factor. At the time of initiating RTX, median Birmingham Vasculitis Activity Score for rheumatoid arthritis was 4.0 (interquartile range 2.0–7.5). RV presented in the skin in 8 patients (47%), as mononeuritis multiplex in 2 (12%), inflammatory ocular disease in 2 (12%), and affected multiple organ systems in 5 (29%). RTX was used for induction therapy in 8 patients (47%), relapsing RV in 4 (24%), second-line therapy in 2 (12%), and salvage therapy or in combination with another agent in 3 (18%). At 3 months, 2 (13%) of 15 patients with available followup information achieved complete remission (CR), and 10 (67%) achieved partial response (PR). At 6 months, 6 patients (40%) achieved CR, 8 (53%) achieved PR, and one had no response. At 12 months, 8 of 13 patients with available records (62%) had CR and 5 patients (38%) had PR.

Conclusion.

Systemic RV is difficult to treat effectively. CR of RV was achieved in 62% and PR in 38% of patients within 12 months of RTX use. Further evidence is needed to inform treatment for patients with RV.

Small vessel multi-organ vasculitis and marantic endocarditis complicating rheumatoid arthritis

Marantic endocarditis is an extremely rare extra-articular complication of rheumatoid arthritis. To date, documented cases typically occurred in the absence of other systemic features of disease activity. We report a rare and exceptional example of marantic endocarditis secondary to fulminant systemic rheumatoid vasculitis with multi-organ disease. Findings from this case and literature review suggest that marantic endocarditis associated with rheumatoid vasculitis displays a tendency to affect the mitral valve with high risk of embolization.

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.

EXTRA-ARTICULAR MANIFESTATIONS OF RHEUMATOID ARTHRITIS

Rheumatoid arthritis (RA) is an immune inflammatory (autoimmune) rheumatic disease of unknown etiology, which is characterized by chronic erosive arthritis and systemic damage to the viscera, and leads to early disability and reduced survival in patients. For its diagnosis, it is currently recommended to use the 2010 ACR/EULAR classification criteria for RA, which should be applied in clinical trials to identify at least one swollen joint, i.e. the presence of arthritis; therefore, the problem of extra-articular manifestations of RA is apparent to stay in the background.

Rheumatoid Vasculitis: A Diminishing Yet Devastating Menace

PURPOSE OF REVIEW

Rheumatoid vasculitis (RV) is an unusual complication of long-standing rheumatoid arthritis, which is characterized by the development of necrotizing or leukocytoclastic vasculitis involving small or medium-sized vessels. In this review, we aim to provide an update on the epidemiology, pathogenesis, clinical presentation, and management of this challenging extra-articular manifestation.

RECENT FINDINGS

RV is heterogenous in its clinical presentation depending on the organ and size of blood vessels involved. The most common organs involved are the skin and peripheral nerve. Based on recent population studies, the incidence has significantly decreased with early recognition and the advent of immunosuppressive drugs and biologics; however, the mortality rates remain high. RV remains a serious extra-articular manifestation of RA that needs to be promptly recognized and treated. No consensus is available on treatment, given the ongoing debate of whether the biologics can trigger or treat RV.

Gastrointestinal and Hepatic Disease in Rheumatoid Arthritis

Gastrointestinal (GI) manifestations of rheumatoid arthritis (RA) are rare, but can be impactful for patients. Some GI processes are directly related to RA, whereas others may be sequelae of treatment or caused by concomitant autoimmune diseases. This article discusses the role of the GI tract in RA pathogenesis; the presentation, epidemiology, and diagnosis of RA-related GI manifestations; concomitant GI autoimmune diseases that may affect those with RA; and GI side effects of RA treatment. The importance of appropriately considering conditions unrelated to RA in the differential diagnosis when evaluating new GI symptoms in patients with RA is noted.

BMC Rheumatology: a home for all rheumatology research within the BMC Series

This editorial accompanies the launch of BMC Rheumatology, a new open access, peer-reviewed journal within the BMC Series portfolio, which considers studies on all aspects of rheumatological diseases. The Journal will also place a special emphasis on manuscripts reporting systemic and inflammatory conditions and connective tissue diseases, along with related comorbidities, including cardiovascular disease, malignancy and infection. Through the publication of a variety of article types, including Research articles, Case reports, Study protocols and Debates, BMC Rheumatology will provide the rheumatology community with an open access avenue to disseminate research into rheumatological diseases, with the ultimate aim of improving patient care.

A Case of Rheumatoid Vasculitis Involving Hepatic Artery in Early Rheumatoid Arthritis

Rheumatoid vasculitis is a rare, but most serious extra-articular complications of long-standing, seropositive rheumatoid arthritis (RA). Vasculitis of hepatic artery is an extremely rare but severe manifestation of rheumatoid vasculitis. A 72-year-old woman who presented with polyarthralgia for 2 months was diagnosed with early RA. Since she had manifestations of livedo reticularis, and liver dysfunction which was atypical for RA patients, a percutaneous needle liver biopsy was performed revealing arteritis of a medium-sized hepatic artery. Extensive investigations did not reveal evidences of other systemic causes such as malignancy or systemic vasculitis. The patient was diagnosed with rheumatoid vasculitis involving hepatic arteries based on Bacon and Scott criteria for rheumatoid vasculitis. With high dose corticosteroid and cyclophosphamide induction and methotrexate and tacrolimus maintenance treatment, she was successfully recovered. Association of rheumatoid vasculitis at very early stages of the disease may represent an early aggressive form of RA.

Severe Extraarticular Manifestations in a Community-based Cohort of Patients with Rheumatoid Arthritis: Risk Factors and Incidence in Relation to Treatment with Tumor Necrosis Factor Inhibitors

Objective.

The aims of this study were to evaluate whether treatment with tumor necrosis factor (TNF) inhibitors in patients with rheumatoid arthritis (RA) affects the risk of developing severe extraarticular rheumatoid arthritis (ExRA) manifestations and to investigate potential predictors for developing ExRA.

Methods.

A dynamic community-based cohort of patients with RA was studied (n = 1977). Clinical records were reviewed and cases of severe ExRA were identified. Information on exposure to TNF inhibitors was obtained from a regional register. Exposure to TNF inhibitors was analyzed in a time-dependent fashion and the incidence of severe ExRA in exposed patients was compared with the incidence in unexposed patients. Cox regression models were used to assess potential predictors of severe ExRA.

Results.

During treatment with TNF inhibitors, there were 17 patients with new onset of severe ExRA in 2400 person-years at risk (PY; 0.71/100 PY, 95% CI 0.41–1.13) compared with 104 in 15,599 PY (0.67/100 PY, 95% CI 0.54–0.81) in patients without TNF inhibitors. This corresponded to an incidence rate ratio of 1.06 (95% CI 0.60–1.78). The age- and sex-adjusted HR for ExRA in anti-TNF–treated patients was 1.21 (95% CI 1.02–1.43), with similar findings in models adjusted for time-dependent Health Assessment Questionnaire and propensity for anti-TNF treatment. Male sex, positive rheumatoid factor (RF), long disease duration, and greater disability were predictors for ExRA.

Conclusion.

This study suggests that patients treated with TNF inhibitors are at a slightly increased risk of developing severe ExRA. RF-positive patients with disabling disease of long duration were more likely to develop severe ExRA.

Vasculitis of the mesenteric circulation

Vasculitis of the mesenteric circulation is an uncommon but life-threatening manifestation of systemic vasculitis. Initial symptoms are frequently non-specific and therefore patients often present to primary care physicians and gastroenterologists with abdominal pain or gastrointestinal bleeding. Given the severity of the conditions associated with mesenteric vasculitis, it is imperative to appropriately diagnose and initiate treatment of suspected cases. This review will focus on diseases commonly associated with vasculitis of the mesenteric vessels. Imaging characteristics and clinical features assisting in diagnosis as well as initial approaches to treatment are emphasized.

Connective Tissue Disorder-Associated Vasculitis

Vasculitides secondary to connective tissue diseases are classified under the category of 'vasculitis associated with systemic disease' in the revised International Chapel Hill Consensus Conference (CHCC) nomenclature. These secondary vasculitides may affect any of the small, medium or large vessels and usually portend a poor prognosis. Any organ system can be involved and the presentation would vary depending upon that involvement. Treatment depends upon the type and severity of presentation. In this review, we describe secondary vasculitis associated with rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, relapsing polychondritis, systemic sclerosis, Sjogren's syndrome and idiopathic inflammatory myositis, focusing mainly on recent advances in the past 3 years.

Häufigkeit und Einteilung kutaner Manifestationen bei rheumatoider Arthritis

HINTERGRUND UND FRAGESTELLUNG

Hautveränderungen bei rheumatoider Arthritis (RA) sind nur in wenigen Studien an größeren Patientenkollektiven untersucht. Deshalb sollen hier die aktuelle Prävalenz und das Spektrum an Hautveränderungen bei RA unter Berücksichtigung von Krankheitsaktivitäts-Scores, Anti-CCP-Antikörpern sowie neueren medikamentösen Therapien erfasst werden.

PATIENTEN UND METHODIK

Zwischen November 2006 und Juli 2007 wurden prospektiv 214 Patienten, die im Funktionsbereich Rheumatologie mit RA behandelt wurden, erfasst.

ERGEBNISSE

Bei 27,5 % der Untersuchten wurden RA-assoziierte Hautveränderungen beobachtet, wobei es sich fast ausschließlich um Rheumaknoten handelte. Signifikant gehäuft traten Rheumaknoten bei längerer Erkrankungsdauer, Nachweis von Rheumafaktoren und Anti-CCP-Antikörpern, aber auch unter Gabe von Leflunomid und TNFα-Blockern auf. Vergleichsweise niedrige Prävalenzen wurden hingegen für die "palisadenförmige neutrophile und granulomatöse Dermatitis" und die "rheumatoide Vaskulitis" ermittelt.

SCHLUSSFOLGERUNGEN

Trotz zunehmend frühzeitiger Therapie der RA und dem Einsatz neuerer Medikamente ist die Prävalenz von Rheumaknoten als wichtigste Manifestation der RA am Hautorgan hoch. Deren verstärkte Ausbildung unter Leflunomid und TNFα-Blockern könnte ein Hinweis dafür sein, dass bei der Entstehung von Rheumaknoten eine pathogenetische Wegstrecke eine Rolle spielt, die von den Therapeutika nur unzureichend beeinflusst wird. Hingegen scheinen die palisadenförmige neutrophile und granulomatöse Dermatitis und die "rheumatoide Vaskulitis" durch neuere Medikamente besser beeinflussbar zu sein.

Incidence and classification of cutaneous manifestations in rheumatoid arthritis

BACKGROUND AND OBJECTIVE

There have only been few studies examining rheumatoid arthritis (RA)-related skin manifestations in larger patient populations. Herein, we present current data on the prevalence and spectrum of cutaneous lesions in RA, addressing disease activity scores, anti-CCP antibodies as well as novel pharmacological approaches.

PATIENTS AND METHODS

Between November 2006 and July 2007, 214 patients with RA treated at the Division of Rheumatology, University Hospital Jena, Germany, were prospectively examined.

RESULTS

27.5 % of patients exhibited RA-related skin manifestations, almost all of which were rheumatoid nodules. These lesions occurred significantly more frequently in patients with longstanding disease, those testing positive for rheumatoid factor and anti-CCP-antibodies, as well as individuals on leflunomide and TNF-alpha antagonists. Comparatively lower prevalence rates were observed for palisading neutrophilic and granulomatous dermatitis and rheumatoid vasculitis.

CONCLUSIONS

Despite increasingly early treatment of RA and use of novel pharmacological agents, there is a high prevalence of rheumatoid nodules, which represent the most common cutaneous manifestation in RA. The higher prevalence of rheumatoid nodules in patients on leflunomide and TNF-alpha antagonists might be an indication that pharmacological treatment has only limited effects on their formation, possibly due to pathogenetic pathways that are only inadequately affected by drug therapies. By contrast, palisading neutrophilic and granulomatous dermatitis and rheumatoid vasculitis appear to respond better to novel pharmacological agents.

Vasculitis and inflammatory arthritis

Vasculitis has been described in most types of inflammatory arthritis. The best described and most widely recognised form is rheumatoid vasculitis. The incidence of systemic rheumatoid vasculitis has declined significantly following the general early use of methotrexate in the 1990s, and it is now a rare form of vasculitis. Treatment of rheumatoid vasculitis is conventionally with glucocorticoids and cyclophosphamide, but there is an increasing role for rituximab similar to that in other types of vasculitis. Despite these developments the mortality of rheumatoid vasculitis remains high. Vasculitis in other types of inflammatory arthritis is less well described and the treatment remains empirical.

Refractory rheumatoid vasculitis

Systemic rheumatoid vasculitis (SRV) can develop in rheumatoid arthritis of long duration and high disease activity. It most commonly manifests as cutaneous vasculitis and mononeuritis multiplex. This can involve any organ of the body and carries very high mortality. We report a case of a young male who had rheumatoid arthritis for the past 15 years and became refractory to standard drugs and anti-TNF agents. He subsequently developed SRV, which started as mononeuritis multiplex. Disease progressed to result in gangrene of hands and feet despite receiving intravenous cyclophosphamide. Intravenous immunoglobulin and rituximab also could not provide any response. Prolonged ICU stay resulted in critical care neuromyopathy. Central nervous system vasculitis developed even after repeated infusions of intravenous immunoglobulins and at last he died of complications. In this case report, we have presented rare and chronic protracted presentation of rheumatoid vasculitis involving skin, nerves, brain and testis, which was refractory to the recommended therapies.

Burning vasculitis

We present the case of a 69-year-old man who was found collapsed close to a heat source and admitted to hospital for severe sepsis. He was also found to have widespread blistering and ulceration of his right leg; however, a history was unobtainable due to reduced consciousness levels. The leg lesions had the initial appearance of mixed depth burns and a management plan was made to transfer the patient to a burns unit for debridement. It was subsequently noted that the patient had a previous diagnosis of seropositive erosive rheumatoid arthritis. A biopsy of the leg lesion was performed and a diagnosis of rheumatoid vasculitis confirmed. Treatment with systemic steroids, intravenous antibiotics and intravenous immunoglobulin therapy for severe hypogammaglobulinaemia was started, and the patient was not transferred for surgical debridement. Rheumatoid vasculitis is a rare and extremely serious complication of rheumatoid arthritis that can manifest in a number of ways, occasionally mimicking other conditions. This case is essential to raise awareness of rare, severe rheumatoid vasculitis and of the potential for its misdiagnosis as a mixed depth burn.

Rheumatoid vasculitis: an update

PURPOSE OF REVIEW

Rheumatoid vasculitis is the most serious extra-articular complication of rheumatoid arthritis, with high morbidity and mortality noted in multiple prior reports. Recent studies have expanded our understanding of this entity in the era of modern immunosuppressive therapy. New clinical predictors and possible protective factors have also been identified.

RECENT FINDINGS

This review provides an update on the epidemiology, clinical correlates, predictors, therapy and outcomes of rheumatoid vasculitis over the past decade. During this time, there has been increasing use of the treat-to-target management practices and incorporation of biologic response modifiers that have revolutionized rheumatoid arthritis treatment with better disease control and overall improved outcomes. The incidence of rheumatoid vasculitis has declined significantly in the past several decades, but morbidity and mortality continue to remain high, despite aggressive treatment with cyclophosphamide or biologic agents. Hydroxychloroquine and low-dose aspirin may have a protective role. There is ongoing debate about the role of newer biological therapies in prevention, treatment or even as a trigger for rheumatoid vasculitis.

SUMMARY

Rheumatoid vasculitis remains a rare yet challenging extra-articular manifestation of rheumatoid arthritis with high morbidity and mortality, despite aggressive use of disease-modifying therapy.

The ying and yang of fever in rheumatic disease

Fevers are relatively common in rheumatic disease, largely due to the fact that the inflammatory process is driven by inflammatory mediators that function as endogenous pyrogens. Since the immune system's sensors cannot accurately distinguish between endogenous and exogenous (pathogen-derived) pyrogens a major challenge for physicians and rheumatologists has been to decipher patterns of clinical signs and symptoms to inform clinical decision making. Here we describe some of the common pitfalls and clinical challenges, and highlight the importance of a systematic approach to investigating the rheumatic disease patient presenting with fever.

The role of KIR2DL3/HLA-C*0802 in Brazilian patients with rheumatoid vasculitis

OBJECTIVES

Rheumatoid arthritis is a polygenically controlled systemic autoimmune disease. Rheumatoid vasculitis is an important extra-articular phenotype of rheumatoid arthritis that can result in deep cutaneous ulcers. The objective of this study was to establish a correlation between the frequency of major histocompatibility complex class I/II alleles and killer immunoglobulin-like receptor genotypes in patients with cutaneous rheumatoid vasculitis.

METHODS

Using the Scott & Bacon 1984 criteria to diagnose rheumatoid vasculitis and after excluding any other causes such as diabetes, atherosclerosis, adverse drug reactions, infection, and smoking, patients who met the criteria were selected. All of the selected rheumatoid vasculitis patients presented deep cutaneous ulcers. Identification of the major histocompatibility complex class I/II and killer immunoglobulin-like receptor genotypes was performed by polymerase chain reaction assays of samples collected from the 23 rheumatoid vasculitis patients as well as from 80 controls (40 non-rheumatoid vasculitis RA control patients and 40 healthy volunteers).

RESULTS

An association between the presence of the HLA-DRB1*1402 and HLA-DRB1*0101 alleles and cutaneous lesions in rheumatoid vasculitis patients and a correlation between the inhibitor KIR2DL3 and the HLA-C*0802 ligand in rheumatoid vasculitis patients were found.

CONCLUSION

An association was found between the presence of the HLA-DRB1*1402 and HLA-DRB1*0101 alleles and the development of cutaneous lesions in rheumatoid vasculitis patients. Additionally, the HLA-C*0802 ligand protects these individuals from developing cutaneous lesions.