Nephrotic syndrome due to focal segmental glomerulosclerosis complicating scleroderma: a case report

BACKGROUND

Systemic scleroderma (SSc) is an insidious autoimmune connective tissue disorder with multiorgan involvement. Renal involvement is one of the important causes of morbidity and mortality in scleroderma; however, nephrotic syndrome is reported rarely in association with SSc. We present a patient with SSc who developed focal segmental glomerulosclerosis (FSGS) as a complication of scleroderma.

CASE PRESENTATION

A 59 year old Caucasian female patient, with a known history of diffuse systemic sclerosis from 8 years, presented to our clinic with symptoms of anasarca and weight gain. Her physical examination was unremarkable except for periorbital and extremity edema. Her biochemistry assessment revealed decreased serum albumin levels and elevated serum creatinine levels. A renal biopsy was performed, which showed histopathological patterns of FSGS type of nephrotic syndrome. After administration of high doses of steroid and rituximab in the course of her treatment for 6 months, her symptoms and proteinuria were improved without the occurrence of scleroderma renal crises.

CONCLUSION

SSc is a complex multisystemic autoimmune disorder. SRC is the most prominent renal involvement in SSc, but other renal pathologies may also occur. Each patient should be precisely investigated since managing these renal conditions can differ significantly. Nephrotic syndrome is a rare complication of SSc, which could be managed with prompt diagnosis and steroid administration.

Association between neutrophil/lymphocyte ratio and disease severity in scleroderma patients

Introduction

Systemic sclerosis is a chronic and progressive connective tissue disease with various manifestation. Inflammatory status is developed in early stages and is followed by major organs' dysfunction. Disease severity is evaluated mostly through Medsger scale. There is not any single laboratory test to evaluate disease severity, although some hematologic can reflect disease severity. In this study, we evaluated the association between hematologic indices (specially Neutrophil/Lymphocyte ratio) and Medsger score of disease severity.

Materials and methods

One hundred and twenty-three patients along with the same number of healthy controls were enrolled in this study. Demographic information and past medical records were gathered in first appointment. Hematologic indices were calculated based on the laboratory findings and the association between these indices and Medsger score of disease severity was evaluated.

Results

One hundred and twenty-three patients with mean disease duration of 9.54 and mean Medsger score of 7.42 were investigated in this study. Neutrophil count, erythrocyte sedimentation rate, red cell distribution width and NLR were significantly higher and mean platelets volume was significantly lower in SSc patients in comparison to controls. NLR was significantly correlated with pulmonary and cardiac involvements and Monocyte/Lymphocyte ratio was significantly correlated with the involvement of joint and tendons. We showed that NLR is a predictive factor for the severity of systemic sclerosis. We also found a cut off Value of 1.9 for NLR as a predictor for disease severity in our patients.

Conclusion

Our study shows that SSc and its severity is associated with some hematologic indices like NLR, MLR, platelets and hemoglobin. These indices can also specifically predict the involvement of some organs.

Association of Killer Cell Immunoglobulin-like Receptor (KIR) Genes and their HLA Ligands with Susceptibility to Takayasu Arteritis in the Iranian Population

Takayasu arteritis (TA) is a chronic inflammatory disorder characterized by vascular damage and fibrosis in the intima that commonly occurs in the aorta. In many damaged sites in TA patients, natural killer (NK) cells have been shown to be hyperactivated and produce inflammatory cytokines and toxic components. Killer cell immunoglobulin-like receptors (KIRs) are found on NK cells and interact with human leukocyte antigen (HLA) class I ligands to activate or suppress NK cells. The present study assessed the possible role of KIR and their HLA ligand genes in susceptibility to TA in Iranian patients. This case-control study included 50 TA patients and 50 healthy subjects. DNA was extracted from whole peripheral blood samples, and polymerase chain reaction with sequence-specific primers (PCR-SSP) was performed to recognize the presence or absence of polymorphism in 17 KIR genes and 5 HLA class I ligands in each participant. Among the KIR and HLA genes, a significant decrease was detected in the frequency of 2DS4 (full allele) in TA patients (38%) compared with healthy controls (82%) (OR=0.13, 95% CI=0.05–0.34). However, none of the KIR and HLA genotypes or the interactions between these genes were associated with susceptibility to TA. The KIR2DS4 gene might be involved in the regulation of activation as well as the production of cytotoxic mediators of NK cells in patients with TA.

Comparison of clinicodemographic characteristics and pattern of vascular involvement in 126 patients with Takayasu arteritis: a report from Iran and Turkey

Takayasu arteritis (TA) is an extremely uncommon vasculitis that primarily affects the aorta and its branches. Due to the genetic and ethnicity effect, a diverse array of TA clinical manifestations has been reported worldwide. The purpose of the present study was to compare the clinicodemographic characteristics and pattern of vascular involvement of Iranian and Turkish TA patients. This study was a retrospective, cross-sectional investigation of 126 TA patients in Iran and Turkey. All of the variables analyzed were extracted from historical medical records. In 126 TA patients, the ratio of females to males was 8.6:1, and the average age at onset of disease was 30.5±11.1 years. Fatigue (49.2%) and a weak or absent pulse (79.4%) were the most prevalent symptoms and signs, respectively. The most prevalent angiographic classifications were types V and I in Iranian patients (41.09%) and type I in the Turkish population (47.7%) The left subclavian artery was the vessel most frequently affected by TA (66.6%). Our findings indicated that there were no significant differences between the two countries in terms of clinicodemographic characteristics or vascular involvement. Some clinical manifestations, such as claudication, were more prevalent in the Turkish population due to a higher incidence of occlusive lesions in the right subclavian artery.

Validity and reliability of the Persian version of illness invalidation inventory (3*I) among patients with non-inflammatory rheumatic painful disorders

BACKGROUND

The Invalidation Illness Inventory (3*I) is an instrument that assesses invalidation (including discounting and lack of understanding dimensions) experienced by patients with rheumatic disorders. This study aimed to translate and validate the 3*I in Iran.

METHODS

Following translation of the 3*I into the Iranian language (Persian), a cross-sectional study was conducted. A consecutive sample of females with chronic non-inflammatory rheumatic painful diseases completed the questionnaire. Patients also completed the Revised Symptom Impact Questionnaire (SIQR) and the Short Form Health Survey-12 (SF-12). To examine convergent validity, the correlation between the 3*I, the SIQR, and the SF-12 was assessed. The reliability of the 3*I was examined by internal consistency (the Cronbach's alpha coefficient) and intraclass correlation coefficient (ICC).

RESULTS

In all 196 patients participated in the study. The mean (SD) age of patients was 45.62 ± 10.70 years. Several significant correlations between the Invalidation Illness Inventory (discounting/lack of understanding) with the symptom impact (SIQR) and the short form health survey (SF-12) were observed lending support to the convergent validity of the 3*I. The Cronbach's alpha coefficients were acceptable for most dimensions and sources, ranging from 0.52 to 0.88. Most ICC values for the dimensions of 3*I were above 0.75.

CONCLUSIONS

The findings indicated that the Persian version of Illness Invalidation Inventory (3*I) is a valid instrument for invalidation assessment in patients with chronic pain. Given the high frequency of perceived invalidation among patients with rheumatic painful disorders, serious attention is needed to the issue in clinical and research settings.

Effects of curcumin supplementation on metabolic parameters, inflammatory factors and obesity values in women with rheumatoid arthritis: A randomized, double-blind, placebo-controlled clinical trial

Rheumatoid arthritis (RA) is a chronic inflammatory disease that leads to cartilage damage with mostly accompanied by metabolic disorders. This study aimed to investigate the effects of curcumin supplementation on metabolic parameters (lipid profile and glycemic indices), inflammatory factors, visfatin levels, and obesity values in women with RA. This randomized, double-blind, placebo-controlled clinical trial was conducted on 48 women with RA. The patients were treated with curcumin (500 mg once a day) or placebo for 8 weeks. Fasting blood samples, anthropometric measurements, dietary intakes, and physical activity levels of subjects were collected at baseline and the end of the study. Curcumin supplementation significantly decreased homeostatic model assessment for insulin resistance (HOMA-IR), erythrocyte sedimentation rate, serum levels of high-sensitivity C-reactive protein and triglycerides, weight, body mass index, and waist circumference of patients compared with the placebo at the end of the study (p < .05 for all). HOMA-IR and triglyceride levels significantly increased within the placebo group. Changes in fasting blood sugar, insulin, other lipids profile, and visfatin levels were not significant in any of the groups (p > .05). These results support the consumption of curcumin, as a part of an integrated approach to modulate metabolic factors, inflammation, and adiposity in women with RA.

Coats'-like Response Associated with Linear Scleroderma

Purpose

To present a case of linear scleroderma known as "en coup de sabre" associated with Coats'- like response.

Case Report

A 12-year-old boy presented with subacute painless vision loss in the ipsilateral side of the patient's en coup de sabre lesion. Ocular examination revealed vitreous hemorrhage with severe exudation of the posterior pole and telangiectatic vessels. Fundus fluorescein angiography indicated multiple vascular beadings and fusiform aneurysms with leakage which was consistent with a Coats'-like response. The patient was subsequently treated with intravitreal bevacizumab and targeted retinal photocoagulation. Twelve months' follow-up showed marked resolution of macular exudation with significant visual improvement.

Conclusion

Physicians should be aware of the possible ophthalmic disorders accompanying en coup de sabre and careful ophthalmologic examinations should be performed in these patients. As presented in the current case, treatment with intravitreal anti-VEGF agents and laser photocoagulation may be a beneficial option for patients with coats'-like response.

Anticyclic citrullinated peptide antibody in rheumatoid arthritis:a cross-sectional study in Iran

BACKGROUND/AIM

Studies have shown that anticyclic citrullinated peptide antibody (anti-CCP) titers can be useful in the diagnosis of rheumatoid arthritis (RA). We evaluate the association between anti-CCP antibody titers and the demographic, clinical, and laboratory characteristics of RA patients. Moreover, we explore whether there is any relation between joint destruction and demographic and clinical characteristics of RA patients.

MATERIALS AND METHODS

One hundred and four RA patients with positive anti-CCP titers were compared to 104 RA patients with negative anti-CCP titers. The activity of RA was evaluated using the Disease Activity Score 28 (DAS28). Joint destruction was assessed in the subjects by X-rays of the wrists. Blood samples were collected for assessment of anti-CCP, rheumatoid factor (RF), and erythrocyte sedimentation rate.

RESULTS

Forty-eight (23.0%) males and 160 (76.9%) females were included in this study. RF, DAS28, and joint destruction were significantly different between patients with and without anti-CCP (P < 0.0001). DAS28, duration of disease, hospitalizations, and occupation differed significantly between patients with and without joint destruction (P < 0.0001).

CONCLUSION

This study indicates that anti-CCP is correlated with a high disease activity index and more joint destruction in RA patients and it may be used as a prognostic factor for RA.

Serum Vitamin D Status in Iranian Fibromyalgia Patients: according to the Symptom Severity and Illness Invalidation

Background

This study was designed to assess serum vitamin D status (25-OHD) in the fibromyalgia (FM) patients and to compare it with a healthy control group. It also aimed to investigate the correlation of serum vitamin D level with FM symptom severity and invalidation experiences.

Methods

A total of 74 consecutive patients with FM and 68 healthy control participants were enrolled. The eligible FM patients completed the Illness Invalidation Inventory (3^*I), the Revised Fibromyalgia Impact Questionnaire (FIQR) and a short-form health survey (SF-12). Venous blood samples were drawn from all participants to evaluate serum 25-OHD levels. Mann-Whitney tests and multiple logistic regression analyses were performed and Spearman's correlations were calculated.

Results

88.4% of FM patients had low levels of serum 25-OHD. FM patients had significantly higher level of serum 25-OHD than the control group (17.24 ± 13.50 and 9.91 ± 6.47 respectively, P = 0.0001). There were no significant correlations between serum 25-OHD levels and the clinical measures of disease impact, invalidation dimensions, and health status. Multiple logistic regression analyses revealed that an increased discounting of the disease by the patient's spouse was associated with a 4-fold increased risk for vitamin D deficiency (OR = 4.36; 95% CI, 0.95–19.87, P = 0.05).

Conclusions

This study showed that although high rates of vitamin D insufficiency or deficiency were seen among FM patients and healthy non-FM participants, but it seems there was no intrinsic association between FM and vitamin D deficiency. Addressing of invalidation experience especially by the patient's spouse is important in management of FM.

Cardiac involvement in rheumatoid arthritis: A cross-sectional study in Iran

BACKGROUND

Cardiovascular disease is one of the extra-articular manifestations of rheumatoid arthritis (RA) that is the most common cause of death in these patients. So we decided to evaluate RA patients in terms of history, clinical examination, electrocardiography, and echocardiography to determine the prevalence of types of cardiac involvements in these patients.

METHODS

100 consecutive patients, diagnosed with RA, referred to rheumatology clinic in Razi referral hospital of Rasht, Iran, were enrolled. Complete physical examination of the joints was performed in all subjects to evaluate the remission of disease. Signs and symptoms of possible cardiac involvement were evaluated in patients by taking history and erythrocyte sedimentation rate test; moreover, an expert cardiologist performed complete cardiovascular examination in all participants. Then, all subjects were referred to a same center for electrocardiography and echocardiography. Finally, analysis was performed by using chi-square and t tests.

RESULTS

23 (23%) males and 77 (77%) females were included in this study. Tachycardia, dyspnea, and chest pain were the most cardiac signs and symptoms of patients. 32 subjects had abnormal findings in electrocardiogram. The most abnormal findings in patient's ECG were ST interval and T wave changes. Abnormal findings in echocardiography were observed in 74 participants. Pericardial involvement and ventricular dysfunction were the most abnormal findings in patient's echocardiography. We found a significant relation between duration of RA disease and abnormal echocardiography findings (p<0.05).

CONCLUSION

This study indicates the high prevalence of cardiac involvement in RA patients.

Pulmonary involvement in rheumatoid arthritis: A cross-sectional study in Iran

Background:

Interstitial lung disease (ILD) is a type of pulmonary manifestation in patients with rheumatoid arthritis (RA). Mostly RA-ILD has no symptoms and is only diagnosed by clinical examination, pulmonary function test (PFT), and high-resolution computed tomography (HRCT); hence it seems that the diagnosis of pulmonary involvement in early stages of RA is of great importance. Therefore, we decided to answer this question whether the evaluation of RA patients without pulmonary symptoms using methods such as PFT and HRCT are justifiable and reasonable or not.

Methods:

We conducted a cross-sectional study in a referral rheumatology clinic in Razi hospital of Rasht, Iran. Forty-four consecutive patients, diagnosed with RA, were enrolled. Physical examination of the joints was performed by an rheumatologist. The activity of RA was evaluated in all patients by Disease Activity Score 28. An expert pulmonologist performed the respiratory examination in all participants. Then, all subjects were referred for chest X-ray, PFT, and HRCT of lungs.

Results:

Patients included in this study, 9 (20.45%) males and 35 (79.55%) females, were 21–73 years old and their mean age was 49 ± 13 years. Significant relation between PFT and respiratory complaints was observed (P = 0.016). PFT had significant relation with respiratory examinations (P = 0.009). Our results indicated a significant relation between disease activity rate and PFT (P = 0.038). While HRCT had any significant relation with above items.

Conclusion:

We concluded, using PFT in the respiratory assessment of RA patients can be limited to persons with high disease activity, respiratory complaints, and positive findings in the clinical respiratory examination.

Change in Bone Mineral Density in Post Menopausal Women with Rheumatoid Arthritis

Introduction: Low bone mass is a serious complication of post menopausal women with rheumatoid arthritis. We determined the Change in Bone Mineral Density in postmenopausal women with rheumatoid arthritis. Methods: This retrospective cohort study was carried out on consecutive postmenopausal women with rheumatoid arthritis who were referred to the Azar 5th teaching hospital affiliated to Golestan University of Medical Sciences, North of Iran in 2009. The required data were gathered from the patients’ medical records. The data were analyzed using SPSS software and statistical tests. Results: We studied 98 postmenopausal women with rheumatoid arthritis. Mean number of years since menopause and mean duration of disease were 9.39 and 5.13 respectively. T Score mean in femoral neck and lumbar spines was -1.45±1.26 and -2.45±1.44 respectively. The overall prevalence of osteoporosis at both the lumbar spine and femoral neck was 13.3. We have found a significant correlation between age, duration of disease, duration of menopause and bone mineral density (P-Value<0.01). Conlusion: Our results indicate a negative effect of age, number of years since menopause and duration of disease on bone mineral density. So, BMD should be measured in high risk women prior to the implementation of any treatment or prevention program. Bangladesh Journal of Medical Science Vol. 12 No. 02 April’13 Page 158-163 DOI: http://dx.doi.org/10.3329/bjms.v12i2.14944

Endothelin-1 in systemic sclerosis

INTRODUCTION

Scleroderma is a systemic disorder with unknown etiology most notably characterized by skin thickening and organ damage. Endothelin-1 (ET-1) plays a role in skin fibrosis. The aim of this study was survey and comparison of ET-1 level in Systemic Sclerosis (SSc) patients with and without digital ulcer.

MATERIAL AND METHODS

A cross-sectional analytical study conducted among the 95 patients with scleroderma in 2006 who were referred to the Rheumatology clinic in Shariati hospital of Tehran. The questionnaire was completed for every patient. Plasma level of endothelin-1 was also measured in all of them. The data was analyzed using SPSS software and statistical tests.

RESULTS

The result indicated, relationship among digital ulcers and digital pitting scars with plasma level of ET-1 were significant (P value < 0.05). We could not find any significant relationship between age and plasma level of ET-1.

CONCLUSION

These data indicate plasma level of ET-1 in scleroderma patients with digital ulcer was higher than patients without digital ulcer. Thus, increase in plasma level of ET-1 could be effective in vascular damage, fibrosis, and skin thickness.