Polymyalgia Rheumatica Post-SARS-CoV-2 Infection

There is growing evidence that infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to dysregulation of the immune system and, consequently, the development of autoimmune phenomena. Here, we describe the case of a 75-year-old woman with rheumatic manifestations characterized by intense musculoskeletal pain and stiffness in the neck and shoulders, with sudden onset and with the inability to raise her arms. The patient was admitted with severe pain located in the neck and shoulders. Previously, she had oropharyngeal pain, severe fatigue, and fever; a real-time polymerase chain reaction test for COVID-19 was positive. Two weeks later, the patient presented localized musculoskeletal pain in the neck and shoulders. Relevant laboratory results included an erythrocyte sedimentation rate of 46 mm/hr and a negative rheumatoid factor test; ultrasound findings with bilateral subacromial-subdeltoid bursitis were observed. A diagnosis of polymyalgia rheumatica (PMR) was initially made according to the EULAR/ACR provisional classification criteria for PMR; however, due to C-reactive protein negativity, the diagnosis was established based on symptoms. Management was with prednisone at the dose of 25 mg/day for 4 weeks and progressive reduction until prednisone suspension. The patient showed complete recovery at 6 months of follow-up. In this case, COVID-19 was implicated in the development of autoimmune and inflammatory rheumatic manifestations. PMR is a rare rheumatic condition that should be included in the wide range of rheumatologic manifestations expressed post-SARS-CoV-2 infection.

The High Clinical Burden of Erosive Hand Osteoarthritis is Associated with Clinical Findings, Pain, and Radiographic Severity

Varying reports exist on the clinical impact of erosive hand osteoarthritis (EHOA) in terms of pain and articular function. Few studies have assessed the association of a patient's clinical features with the presence of more severe radiographic disease. The aim was to evaluate clinical and radiographic characteristics in EHOA comparing with non-erosive (NEHOA); to examine pain and functional impairment between EHOA and NEHOA; and correlate functional impairment with clinical findings, pain, and radiographic severity.

METHODS

62 patients with EHOA and 57 with NEHO were included. Pain was assessed through Visual Analogue Scale (VAS) and Australian/Canadian Osteoarthritis Hand Index (AUSCAN) pain subdomain. Functioning was evaluated with the Health Assessment Questionnaire (HAQ) concerning hand function and AUSCAN. Radiographs were scored with the Kallman scale and subchondral erosions with the Verbruggen-Veys method. Student t-tests were used for comparing quantitative data, chi-squared tests for categorical variables, and Pearson or Spearman tests for assessing correlation.

RESULTS

Patients with EHOA reported significantly higher levels of pain on the VAS and AUSCAN (p<0.01). In EHOA, VAS positively correlated with the HAQ and AUSCAN scales (rho=0.68 and 0.77). In NEHOA, Visual Analogue Scale (VAS) positively and strongly correlated with HAQ and AUSCAN (rho=0.84 and 0.89). Nodes, Kallman score and erosions showed a positive but weak correlation with HAQ and AUSCAN in both groups.

CONCLUSION

Both EHOA and NEHOA participants had functional impairment, but the erosive subtype had higher clinical burden and increased joint damage. This higher clinical burden is attributed mainly to pain.

AB0260 ASSOCIATION BETWEEN INFLAMMATION AND DEPRESSIVE SYMPTOMS IN RHEUMATOID ARTHRITIS PATIENTS

Background

Rheumatoid arthritis (RA) is an autoimmune, progressive disease characterized by an inflammatory process mediated by CD4+T lymphocytes leading to damage of the synovial membrane1. Its prevalence is estimated between 0.2 and 1.2% worldwide, affecting women in the fourth and fifth decades2. In 2013, the Mexican College of Rheumatology estimated a 1.6% prevalence3 in Mexico.

RA may affect patients´ social, psychological, economic and physical areas. Among its psychological implications, depression is one of the most important (with a prevalence of 40%) beyond the general population4. Several studies assess either prevalence or prognosis, despite its higher prevalence and a lesser likelihood of remission in these patients. Some investigations looked for a relationship between inflammation and depressive symptoms considering only clinical or biochemical parameters, despite the evidence supporting better results with imaging methods, such as musculoskeletal ultrasound (MSU).

Objectives

To identify the association between MSU demonstrated inflammation and the presence of depressive symptoms in RA patients.

Methods

In 2021 a cross-sectional study on RA patients (according to ACR/EULAR 2010 criteria) was conducted. The subjects were from the Instituto Nacional de Rehabilitación “Luis Guillermo Ibarra Ibarra” and Hospital Juárez de México Rheumatology out-patient clinic. Each patient underwent a clinical (SDAI, CDAI, and EVA), psychological (PHQ9 and InCaViSa questionnaires), and MSU assessment (7 joints score). Data described with central tendency and dispersion measures for quantitative variables and frequencies and proportions for qualitative variables. Kruskal Wallis, U Mann-Whitney and Spearman correlation tests for analysis done.

Results

Fifty-two patients (94% women) were evaluated, with a mean age of 56.06 (±12.31) years and duration of disease 13.66 (±9.44) years. Depression prevalence was 54%. Patients with disease activity had the highest depression scores (p=0.009), those with triggering events in the last six months (p=0.177), the leading event was the death of a close relative in 30% of the patients. A moderate correlation between the depression score (PHQ9) and clinical disease activity scores (SDAI, CDAI, VAS, and painful joints) (rho=0.553 [p<0.001], 0.559 [p<0.001], 0.492 [p<0.001], and 0.57 [p<0.001], respectively) were found. Furthermore, we found a moderate correlation between depression scores and psychological, social and physical quality of life. A mild correlation between MSU synovitis and depression scores (rho=0.315 [p=0.03]) found.

Conclusion

Patients with disease activity reported higher depression scores in comparison to remission patients. We demonstrated a relationship between depressive symptoms, social factors, disease perception and ultrasound synovitis. It is crucial to conduct longitudinal studies with a large number of patients, including a control group, and perform an adequate stratification of the demographic characteristics of the patients and their confounding variables.

References

[1]Karimzadeh H, Karami M, Bazgir N, Karimifar M, Yadegarfar G, Mohammadzadeh Z. Ultrasonographic findings of rheumatoid arthritis patients who are in clinical remission. J Res Med Sci 2018;23(1):38.

[2]García de Yébenes M de J, Loza E. Artritis reumatoide: epidemiología e impacto sociosanitario. Reumatol Clin Supl 2018;14(2):3–6.

[3]Hérnandez L del C, Querol J, De la Garza AL, Férnandez C. Artritis Reumatoide su impacto social y económico. Boletín Epidemiológico 2016;33(12):1–4.

[4]Maldonado G, Ríos C, Paredes C, Ferro C, Intriago MJ, Aguirre C, et al. Depresión en artritis reumatoide. Rev Colomb Reumatol 2017;24(2):84–91.

Disclosure of Interests

None declared

Epistasis Between Two Gene Variants of Leptin and Vascular Endothelial Growth Factor Genes in the Development of Primary Knee Osteoarthritis

BACKGROUND

The association of leptin (LEP) and vascular endothelial growth factor A (VEGFA) genes with the susceptibility to knee osteoarthritis (OA) has been analyzed; however, the epistasis between them has not been investigated.

OBJECTIVE

The objective of the study was to analyze the association of LEP and VEGFA variants and their interaction with primary knee OA in a Mexican Mestizo population.

METHODS

A case-control study was developed. Cases were ≥40 years, BMI ≤27 kg/m², with primary knee OA and radiologic Grade ≥2. Controls were participants with no knee OA and a radiologic Grade < 2. The rs2167270 of LEP and rs2010963 of VEGFA were genotyped. Genotypic association was tested under codominant, dominant, and recessive models. Uni- and multi-variate analyses were developed through non-conditional logistic regression. The multifactor dimensionality reduction algorithm was developed to detect epistasis.

RESULTS

Participants comprised 103 cases and 179 controls. Allelic and genotypic distributions did not show differences between the groups. Notwithstanding, a statistically significant interaction was observed between the LEP and VEGFA genes (p = 0.02) with a testing accuracy of 0.5199 and cross-validation consistency of 10/10. This interaction model confers an increased risk to knee OA (OR [95% CI] = 1.8 [1.1-2.9]).

CONCLUSION

Interaction between LEP and VEGFA is related with genetic susceptibility to developing primary knee OA.

The High Clinical Burden of Erosive Hand Osteoarthritis is Associated with Clinical Findings, Pain, and Radiographic Severity

Varying reports exist on the clinical impact of erosive hand osteoarthritis (EHOA) in terms of pain and articular function. Few studies have assessed the association of a patient's clinical features with the presence of more severe radiographic disease. The aim was to evaluate clinical and radiographic characteristics in EHOA comparing with non-erosive (NEHOA); to examine pain and functional impairment between EHOA and NEHOA; and correlate functional impairment with clinical findings, pain, and radiographic severity.

METHODS

62 patients with EHOA and 57 with NEHO were included. Pain was assessed through Visual Analogue Scale (VAS) and Australian/Canadian Osteoarthritis Hand Index (AUSCAN) pain subdomain. Functioning was evaluated with the Health Assessment Questionnaire (HAQ) concerning hand function and AUSCAN. Radiographs were scored with the Kallman scale and subchondral erosions with the Verbruggen-Veys method. Student t-tests were used for comparing quantitative data, chi-squared tests for categorical variables, and Pearson or Spearman tests for assessing correlation.

RESULTS

Patients with EHOA reported significantly higher levels of pain on the VAS and AUSCAN (p<0.01). In EHOA, VAS positively correlated with the HAQ and AUSCAN scales (rho=0.68 and 0.77). In NEHOA, Visual Analogue Scale (VAS) positively and strongly correlated with HAQ and AUSCAN (rho=0.84 and 0.89). Nodes, Kallman score and erosions showed a positive but weak correlation with HAQ and AUSCAN in both groups.

CONCLUSION

Both EHOA and NEHOA participants had functional impairment, but the erosive subtype had higher clinical burden and increased joint damage. This higher clinical burden is attributed mainly to pain.

Vitamin D receptor gene polymorphisms and susceptibility for primary osteoarthritis of the knee in a Latin American population

BACKGROUND

Primary Osteoarthritis (OA) of the knee is a multifactorial disease that has an important genetic component, and several genes have been associated with its development. The vitamin D receptor has a role in skeletal metabolism that suggests a relationship with OA. The aim of this study was to analyze the association of Vitamin D receptor gene (VDR) polymorphisms in Mexican Mestizo patients.

METHODS

A case-control study was conducted in which 107 cases with primary OA of the knee and 114 controls were included. Cases were patients > 40 years of age with a Body mass index (BMI) of ≤27 and a radiological score for OA of the knee of ≥2. Controls were subjects > 40 years of age with a radiological score of < 2. VDR polymorphisms rs1544410, rs7975232, and rs731236 were analyzed by means of restriction endonucleases, and logistic regression was developed to evaluate risk magnitude.

RESULTS

A significantly increased risk was found of nearly two-fold for the allele T and TT genotypes of rs731236, independently of other well recognized risk factors.

CONCLUSIONS

The rs731236 polymorphism is associated with the risk of primary OA of the knee in Mexican Mestizo population.

D14 repeat polymorphism of the asporin gene is associated with primary osteoarthritis of the knee in a Mexican Mestizo population

BACKGROUND

Asporin is a novel extracellular matrix protein (ECM) with an important role in the development of osteoarthritis (OA), because it has been reported that functional polymorphisms in the aspartic acid repeat (D) of the asporin gene (ASPN) are associated with susceptibility to OA.

AIM

This study was planned to investigate the association of the ASPN polymorphism with primary OA of the knee in a Mexican population, including several countryside regions.

METHODS

We conducted a case-control study in which 93 cases with primary OA of the knee and 118 controls were included. Cases included patients > 40 years of age, with a body mass index (BMI) ≤ 27 and a radiologic score for OA of the knee of ≥ 2. Controls were subjects > 40 years of age with a radiologic score of < 2. The D repeat polymorphism was genotyped and logistic regression was developed to evaluate risk magnitude.

RESULTS

The D14 allele was more common in our cases and was associated with an increased risk for developing OA, while the frequencies of the remaining alleles did not exhibit differences.

CONCLUSION

Our data suggest that the D14 allele of the ASPN polymorphism could exert an influence on primary OA of the knee etiology in a Mexican Mestizo population.

Transculturalization and validation of a Spanish translation of the specific lower limb osteoarthritis and quality of life questionnaire AMICAL: Arthrose des Membres Inférieurs et Qualité de vie AMIQUAL

INTRODUCTION

Several generic questionnaires have been used to measure quality of life in patients with Osteoarthritis (OA) since few instruments have been developed specifically for OA and none was developed for Spanish speaking patients. The purpose of the study was to validate and adapt to Spanish the French questionnaire AMICAL to measure quality of life in patients with hip and knee OA.

METHODS

Transversal, analytical study. The validation process was performed in phases: translation from French to Spanish, translated version analysis by a multidisciplinary expert team, application of a pilot test to patients to evaluate grammatical and content equivalence, blind back translation, and analysis. The questionnaire was applied to hip and knee OA patients, together with the SF-36 questionnaire, as well as the WOMAC and the Lequesne indexes. The reproducibility was evaluated applying the questionnaire after 72hours. The clinimetric analysis was calculated with SPSS 16.0.

RESULTS

One hundred patients with hip OA and 100 patients with knee OA, radiological stages ii-iii, were included to evaluate homogeneity. Sixty-five patients with hip OA and 65 patients with knee OA were included to evaluate consistency. The final sample included 100 hip and 100 patients knee OA patients to estimate homogeneities and 65 patients were evaluated to estimate consistency. Mean (SD) age of patients with hip and knee OA, was 56.34 ± 13 and 60.1 ± 9.2, respectively. Sixty seven percent and 79.8% were female, respectively. Cronbach' alpha for AMICAL was 0.946 and 0.999, for hip OA and knee OA, respectively; and test-retest reliability using the intraclass correlation coefficients was 0.979 and 0.998, respectively. There was also a significant correlation with all the instruments (P<.05), except with the Lequesne index (r-0.383).

CONCLUSIONS

The Spanish version of AMICAL questionnaire keep the clinimetric properties, homogeneity, and consistency, and has a good correlation with other instruments. Consequently, it is reliable, self-applicable, and includes domains beyond the functional capacity that better evaluate the quality of life.

Pseudorheumatoid dysplasia. A rare genetic disorder simulating juvenile idiopathic arthritis

We present the case of a teenage patient with progressive pseudorheumatoid dysplasia, an autosomal recessive disorder that may be initially misdiagnosed as juvenile idiopathic arthritis.

[Arthritis: an unusual and anticipatory clinical presentation of pediatric acute lymphoblastic leukemia. A case report]

BACKGROUND

Acute lymphoblastic leukemia initially shows osteoarticular manifestations. However, it is rare that it shows juvenile idiopathic arthritis (JIA) symptoms.

CLINICAL CASE

A child with acute lymphoblastic leukemia initially misdiagnosed with malignant neoplasia and septic arthritis, and later on with juvenile idiopathic arthritis. The child had persistent articular pain and swelling despite treatment. Six months later, a full blood count revealed leukopenia and neutropenia with lymphocytosis. A bone marrow aspirate confirmed pre-B acute lymphoblastic leukemia with hypodyploidia.

CONCLUSION

This case initially showed typical signs of arthritis, and a diagnosis of acute lymphoblastic leukemia was ruled out, since the those clinical features and hematologic alterations characterizing this hematologic neoplasia.

Disability impact on quality of life in Mexican adults with juvenile idiopathic arthritis and juvenile ankylosing spondylitis

OBJECTIVE

Our aim was to determine the disability impact on quality of life (QOL) in Mexican adults with juvenile idiopathic arthritis polyarticular course (JIAPA) and juvenile ankylosing spondylitis (JAS).

METHODS

A cross-sectional study was performed on 32 adult patients with juvenile idiopathic arthritis. Functional outcome was evaluated using Global Functional Status (GFS) according to American College of Rheumatology (ACR) and Spanish Health Assessment Questionnaire-Disability Index (HAQ-DI) arthritis-specific measurements for functional disability in patients with polyarticular course and Bath Ankylosing Spondylitis Functional Index (BASFI) for those who developed JAS. Quality of life (QOL) was assessed using SF-36 and EuroQol 5D (EQ-5D). Descriptive statistics and associations among clinical, functional, and QOL measurements were examined using Spearman's correlation test. Multiple regression analysis was used to estimate predictor factors for impaired QOL. Differences between groups were evaluated by Fisher exact and Mann-Whitney U tests, and p values of <0.05 were considered statistically significant.

RESULTS

JIAPA and JAS had GFS III/IV in 65 and 50%, respectively. A HAQ-DI score of > 1.5 was found in 35% of JIAPA, and a BASFI score of > 5 in 92% of JAS. Patients with JIAPA and JAS reported lower scores for all physical domains and for mental domains (physical role, social functioning, and emotional role) compared with Mexican population scores (p < 0.005). Health status between both groups studied does not show significant differences (p > 0.05). EQ-5D showed impairment in all five dimensions for both groups studied. Multiple regression analysis showed that GFS was the only variable that affects QOL assessed by SF36.

CONCLUSIONS

In our study population, JIAPA and JAS exhibited a great disability impact on QOL and poor functional outcome during the patients' adult life. GFS has a significant impact on quality of life.

Proxy-reported health-related quality of life of patients with juvenile idiopathic arthritis: The pediatric rheumatology international trials organization multinational quality of life cohort study

OBJECTIVE

To investigate the proxy-reported health-related quality of life (HRQOL) and its determinants in patients with juvenile idiopathic arthritis (JIA).

METHODS

In this multinational, multicenter, cross-sectional study, HRQOL of patients with JIA was assessed through the Child Health Questionnaire (CHQ) and was compared with that of healthy children of similar age from the same geographic area. Potential determinants of HRQOL included demographic data, physician's and parent's global assessments, measures of joint inflammation, Childhood Health Assessment Questionnaire (CHAQ), and erythrocyte sedimentation rate.

RESULTS

A total of 6,639 participants (3,324 with JIA and 3,315 healthy) were enrolled from 32 countries. The mean +/- SD physical and psychosocial summary scores of the CHQ were significantly lower in patients with JIA than in healthy children (physical: 44.5 +/- 10.6 versus 54.6 +/- 4.0, P < 0.0001; psychosocial: 47.6 +/- 8.7 versus 51.9 +/- 7.5, P < 0.0001), with the physical well-being domain being most impaired. Patients with persistent oligoarthritis had better HRQOL compared with other subtypes, whereas HRQOL was similar across patients with systemic arthritis, polyarthritis, and extended oligoarthritis. A CHAQ score >1 and a pain intensity rating >3.4 cm on a 10-cm visual analog scale were the strongest determinants of poorer HRQOL in the physical and psychosocial domains, respectively.

CONCLUSION

We found that patients with JIA have a significant impairment of their HRQOL compared with healthy peers, particularly in the physical domain. Physical well-being was mostly affected by the level of functional impairment, whereas the intensity of pain had the greatest influence on psychosocial health.

Health-related quality of life in juvenile-onset systemic lupus erythematosus and its relationship to disease activity and damage

OBJECTIVE

To assess the health-related quality of life (HRQL) of patients with juvenile-onset systemic lupus erythematosus (JSLE) and its relationship with disease activity and accumulated damage.

METHODS

In this cross-sectional study, HRQL was assessed using the Child Health Questionnaire (CHQ), disease activity using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and accumulated damage using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI).

RESULTS

A total of 297 patients were included. The mean +/- SD physical and psychosocial summary scores of the CHQ were 40.2 +/- 15.0 and 44.8 +/- 10.7, respectively. The most impaired CHQ subscales were global health, general health perceptions, and parent impact-emotional. The SLEDAI score was significantly correlated with both the physical summary score (r = -0.29, P < 0.0001) and psychosocial summary score (r = -0.25, P < 0.0001), whereas the SDI score was significantly correlated only with the physical summary score (r = -0.23, P = 0.0001).

CONCLUSION

We found that patients with JSLE have significant impairment of their HRQL, particularly in the physical domain. HRQL may be affected by both disease activity and accumulated damage, particularly in the renal, central nervous, and musculoskeletal systems.

Assessment of damage in juvenile-onset systemic lupus erythematosus: a multicenter cohort study

OBJECTIVE

To investigate the prevalence of cumulative organ damage in patients with juvenile-onset systemic lupus erythematosus (SLE) and its association with demographic and clinical variables, medication use, and quality of life.

METHODS

The occurrence of organ system damage, as measured by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI), was determined for 387 patients consecutively enrolled in pediatric rheumatology centers from Europe, the US, Mexico, and Japan. Risk factors for damage included demographic variables; clinical manifestations at diagnosis; previous corticosteroid, immunosuppressive, and antimalarial therapies; disease activity; and quality of life.

RESULTS

Overall, 195 (50.5%) patients had damage within a mean of 5.7 years after disease onset. Renal (21.8%) and neuropsychiatric (15.8%) system involvement were observed most frequently, followed by musculoskeletal (11.7%), ocular (10.9%) and skin (9.6%) system involvement, with a mean SDI score of 1.1. In multivariate models, the occurrence of neuropsychiatric manifestations at diagnosis, a longer disease duration, and a greater number of intravenous cyclophosphamide pulses showed the strongest association with the presence of damage.

CONCLUSION

We found evidence of cumulative organ damage, as measured by the SDI, in half of the patients with juvenile-onset SLE. Damage was significantly more likely in patients who had experienced neuropsychiatric manifestations at diagnosis, had a longer disease duration, and had received more intravenous pulses of cyclophosphamide.

Reliability of the articular examination in children with juvenile rheumatoid arthritis: interobserver agreement and sources of disagreement

OBJECTIVE

To assess the interobserver agreement of articular examination in children with juvenile rheumatoid arthritis (JRA) and identify sources of disagreement.

METHODS

Four rheumatologists graded tenderness/pain on motion, swelling, and limitation of motion in the joints of 10 children with JRA, as recommended by the Pediatric Rheumatology Collaborative Study Group, and 17 different joint indices were computed. Agreement was measured by kappa (kappa) and intraclass correlation coefficients (Ri).

RESULTS

All 4 observers detected tenderness in 15.7% of the joints, but they disagreed (2 vs 2) on 4.2% (kappa = 0.71). They detected swelling in 5.2% but disagreed on 6.2% (kappa = 0.47). They found limitation in 4.9%, but disagreed on 8.1% (kappa = 0.54). The tender joint count, and the American Rheumatism Association cooperating clinics and Hart modified Ritchie indices were the most reliable (Ri > 0.93); the swelling severity index fared the worst (Ri = 0.40). There were differences in examination maneuvers and judgment among examiners. Discrepancies were larger in metacarpophalangeal joints and in patients with many involved joints.

CONCLUSION

There was low agreement in the assessment of joint swelling and limitation of motion. Differences in examiners' techniques, patients with severe disease, and the small hand joints were important sources of disagreement.