POS1101 DAPSA CORRECTED FOR PsAID12 IMPROVES ITS CONCORDANCE WITH MINIMAL DISEASE ACTIVITY

Background

Psoriatic arthritis (PsA) is a chronic inflammatory disease of highly variable presentation, which determines a physical and psychological deterioration, with a negative impact on the quality of life of patients and knowing the patient’s perception of their health status is very important for a good management of PsA.

Objectives

To assess an adjustment of the DAPSA according to the status of the PsAID-12 (Impact of the disease in psoriatic arthritis) and to analyze its relation in clinical practice with the minimal activity of the disease (Minimal Disease Activity or MDA) in psoriatic arthritis.

Methods

Multicenter cross-sectional study, which recruited 200 patients, who met the criteria for Classification of Psoriatic Arthritis (CASPAR), in six Spanish rheumatology centers. At the time of the visit, demographic, clinical, laboratory data, HAQ (0-3) and PsAID12 (0-10) self-questionnaires were collected. Disease activity was measured using DAPSA (with its cut-off points), MDA status was obtained, and the PsAID12 index was calculated. When a PsAID≤4 was not reached, the DAPSA was scaled to a higher interval (DAPSA corrected) obtaining a new index, DAPSA-PsAID. All analyzes were performed using SPSS23 software. Differences were considered statistically significant if p < 0.05.

Results

Of the total number of patients, 55% were men, with an age of 55.2 ± 11.6 years; 75% had only peripheral involvement and 25% had pure or mixed axial involvement. 43% were on biological treatment (18% join to csDMARDs). The patients who reached the MDA were 102 (51%), 62.7% in men vs 37.3% in women (p 0.025). With the PsAID-corrected DAPSA, the proportion of patients in low activity-remission who did not reach the MDA was lower than with the standard DAPSA (see Table 1), 16.3% vs 27.6% (Kappa 0.750 vs 0.688). In the binary regression analysis for MDA status, adjusted for sex, an OR (95% CI) for DAPSA and DAPSA corrected for PsAID of 8.12 (1.88-35.04) and 12.31 (3.74-40.50), respectively, was obtained.

Table 1.MDA N=102No MDA N= 98pHAQ≤0.5, n (%)82 (92.0)31 (36.5)<0.0001DAPSA REM/LDA, n (%)98 (96.1)27 (27.6)<0.0001PsAID≤4, n (%)92 (90.2)45 (45.9)<0.0001DAPSA-PsAID REM/LDA, n (%)93 (91.2)16 (16.3)<0.0001

Conclusion

A PsAID-corrected DAPSA could be a more reliable alternative to MDA than conventional DAPSA and facilitate clinician decisions in daily practice.

References

[1]Schoels MM, et al. Ann Rheum Dis 2016;75(5):811-8.

[2]Gossec L, et al. Ann Rheum Dis. 2020 Jun;79(6):700-712.

Acknowledgements

To SOGARE

Disclosure of Interests

Guillermo Gonzalez Arribas: None declared, Carlota Laura Iñíguez: None declared, Francisco Maceiras-Pan Speakers bureau: Janssen, Novartis, Lilly, Abbvie, UCB, Víctor Quevedo Vila: None declared, Luis Fernández-Dominguez Speakers bureau: Janssen, Novartis, UCB, José Antonio Mosquera Martínez: None declared, Carlos García-Porrúa Speakers bureau: Janssen, Novartis, Lilly, Abbvie, UCB, Jose L. Guerra-Vazquez: None declared, Jose Antonio Pinto Tasende Speakers bureau: Janssen, Novartis, Lilly, Abbvie, UCB, Celgene, Consultant of: Novartis, Janssen

AB0959 The activity of psoriatic arthritis with axial involvement correlates with PsAID12

Background

Patients with psoriatic arthritis (PsA) show an impact on the physical and psychological aspect of the disease and it can be measured with the PsA Impact of Disease (PsAID) questionnaire, and it is expected that the impact of the disease improves when the patient is in remission or low disease activity.

Objectives

To determine the rate of low impact of the disease in patients with PsA in daily clinical practice, and to evaluate its relationship with its axial activity.

Methods

A cross-sectional study was conducted in consecutive patients who met the CASPAR criteria, with positive clinical (DLI) and positive axial radiology, with or without peripheral involvement, and who were treated according to standard clinical practice (EULAR recommendations). Demographic, clinical, analytical data, HAQ index (0-3) and PsAID12 (0-10) were also collected. Patients were divided into 2 groups: those with a PsAID above 4 (high impact) or below 4 (low impact). Continuous variables are shown as median (Q1-Q3) and categorical variables as percentages and frequencies. The analyzes were performed using SPSS23 software. Differences were considered statistically significant if p < 0.05.

Results

Of the 269 patients evaluated with PsA, 72 patients with axial involvement were included, 40 men (55.6%), with a median age of 54.1 years (45.0-62.0) and disease duration of 7 years (2-11). Obesity (BMI>29.99) affected 28.3% and serum CRP level was 0.45 mgr/dl (0.08-1.10). The treatments of the patients were: NSAIDs 43.1%, corticosteroids 21.6%, csDMARD 52.9% and biological therapy 51.9%. The BASDAI was 4.2 (2.0-6.2) and the ASDAS-PCR was 2.4 (1.5-3.2), with 39.6% being in low activity or remission. The median PsAID total score was 3.9 (1.6-5.4), evaluated in 61 patients. The patients who achieved a PsAID12 ≤4 was 63% (see Table 1), more men and with a lower CRP. In addition, the low impact measured by the PsAID12 was associated with a lower BASDAI and ASDAS-PCR.

PsAID≤4n=39PsAID>4n=22pAge, years54 (42-62)54 (49-66)0.284Male gender, n %28 (70)10 (43.5)0.038Disease duration, years7 (3-10)5 (1.2-9.5)0.432CRP, mgr/dl0.30 (0.04-0.79)1.04 (0.07-2.44)0.03BSA, %0.2 (0-1)0.5 (0-1.5)0.594BASDAI2.1 (0.8-4.0)6.1 (4.4-6.9)<0.001ASDAS-PCR1.5 (1.1-2-4)3.1 (2.3-3.4)<0.001

Conclusion

Almost two thirds of patients with PsA with axial involvement in daily clinical practice had a low impact of the disease measured by PsAID12 and correlated with low activity in the BASDAI and ASDAS-PCR.

References

[1]Gossec L, et al. Annals of the Rheumatic Diseases 2014;73:1012-1019.

Acknowledgements

to Galician Rheumatology Society (SOGARE)

Disclosure of Interests

Carlota Laura Iñíguez: None declared, Guillermo Gonzalez Arribas: None declared, Francisco Maceiras-Pan Speakers bureau: Abbvie, Novartis, Janssen, Lilly, Jose L. Guerra-Vazquez: None declared, Víctor Quevedo Vila: None declared, Luis Fernández-Dominguez Paid instructor for: Janssen, Novartis, BMS, Carlos García-Porrúa Speakers bureau: Abbvie, Novartis, Janssen, Lilly, José Antonio Mosquera Martínez: None declared, Jose Antonio Pinto Tasende Speakers bureau: Abbvie, Novartis, Janssen, Lilly, Celgene, Consultant of: Janssen, Novartis

AB0577 METABOLIC SYNDROME IN PSORIATIC ARTHRITIS SEEMS ASSOCIATED TO INFLAMMATORY STATUS OF THE DISEASE

Background:

Evidence suggests that inflammation plays a causal role in the development of Metabolic Syndrome (MetS) and elevated peripheral levels of proinflammatory mediators, such as C-reactive protein (CRP) confering cardiovascular and metabolic risk.

Objectives:

The objective of this study was to evaluate Metabolic Syndrome among patients with PsA naïve to biologics and to evaluate its association with inflammatory activity status previous start them.

Methods:

We performed a retrospective cross-sectional study of a cohort of patients ≥18 years of age, all patients with a diagnosis of PsA (CASPAR criteria), included in the Sueiro Cohort. Patients were managed according to a standard protocol adopted at the Rheumatology outpatient clinic of six hospitals and they were patients on follow-up for at least 6 months. Collected variables included age and gender, blood biochemistry, blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), HLA-B27 and rheumatoid factor, glucocorticoid, NSAID and conventional or biologic DMARD, smoking habit, hyperuricemia, type 2 diabetes mellitus, obesity (BMI kg/m2). MetS was defined by a combination of abdominal obesity, impaired fasting glucose, atherogenic dyslipidemia, and elevated blood pressure. Status of disease activity was supported by tender and swollen joint counts (TJC68 and SJC66) from patients who were going to start treatment with biologics and Patient-reported outcome measure were collected with Patient Global Assessment (0-10 cm) and Patient Pain Assessment (0-10 cm). Remission and low disease activity status was obtained by DAPSA score and its defined cut-off. Tests were two-tailed with a significance level of 5%. Data were analyzed using SPSS V21.0 statistical software (IBM Corp. NY, USA).

Results:

A total of 416 were included in the study: 222 PsA patients treated with csDMARD kept in remission or low disease activity and 194 patients needed to be treated with bDMARD. The mean age of the patients was 53.0 years (SD: 11.8). Two hundred and twenty-eight were males (56.2%).

Fifty-six patients had MetS (13.8%) and it was more frequent in patients who were in clinical activity and they needed biologics (17.9% vs 10.4%, p 0.028) with mean (SD) of DAPSA of 16.7 (11.1). Patients starting treatment with biologics and with MetS had more proportion of patients older than 50 years (24.2 % vs 8.3%, p 0.006) and CRP >5 mgr/L (71.4% vs 52.6%, p 0.042) and DAPSA had higher values than in patients without MetS (18.6 vs 16.2) but there were not significant statistical differences. Binary regression analysis showed increased risk of MetS for age > 50 years old (OR 3.287 [95%CI: 1.258-8.591], p 0.015) and CRP > 5 mgr/L (OR 2.684 [95%CI: 1.141-6.313], p 0.024) but not for gender (OR 2.136 [95%CI: 0.932-4.893], p 0.073) neither for DAPSA>14 (OR 1.539 [95%CI: 0.695-3.409], p 0.288).

Conclusion:

Patients with PsA active despite csDMARD had more prevalence of MetS and this was associated with those patients over 50 years old and CRP higher than normal values. DAPSA was higher in patients with MetS but without reaching significant statistical difference.

References:

[1]Lee YH, Pratley RE. The evolving role of inflammation in obesity and the metabolic syndrome. Current Diabetes Reports. 2005;5:70–75

Acknowledgements:

I have acknowledgements to SOGARE.

Disclosure of Interests:

None declared.

AB0771 DAPSA REMISSION/LOW DISEASE ACTIVITY IS ASSOCIATED WITH LOW PSAID12 IN PSORIATIC ARTHRITIS

Background:

Psoriatic arthritis (PsA) has a prevalence of 0.17% in North-Western of Spain and patients suffer this disease have significant impact on daily life due to articular, dermatological and psychological symptoms. DAPSA VLDA/LDA (≤14) is a therapeutic goal recommended by EULAR for clinical practice.

Objectives:

Our aim was to assess the relationship between DAPSA index and PsAID questionnaire in routine clinical practice.

Methods:

We performed a cross-sectional study of patient and physician reported outcomes. We obtained clinical information of patients with PsA attending clinic from October 2018 to October 2019. Data were collected from clinical records concerning age, gender, disease duration, joint counts, dactylitis, enthesitis, body surface area (BSA) of psoriasis, laboratory results (ESR and CRP), HAQ, PsAID12, pain and global assessment from patient with numerical rating scale (NRS) and DAPSA index. Data were analysed using SPSS21. Logistic regression was used to assess patient reported outcomes which were associated with DAPSA VLDA/LDA.

Results:

Data were available for 210 patient visits, 43% females. DAPSA≤14 was in 143 patients (68.1%) and was associated with higher disease duration, OR 1.079 (1.020-1.142, 95% CI), p 0.008. DAPSA index was not associated with BSA (r 0.126, p 0.176).

PsAID12 was evaluated in 156 patients and we saw that patients with DAPSA≤14 had significantly lower PsAID12 (mean 1.7 ± SD 1.7 vs. 3.9 ± 2.1), p< 0.0001. PsAID12 of less than 4 is considered a good outcome and all items of PsAID12 (Figure 1, mean values for NRS) were less than 4 in patients with DAPSA≤14. All components of PsAID12 except item 3 (skin problems) were associated with DAPSA≤14 on univariate analysis but only pain remained independent predictor on multiple regression analysis (p< 0.0001).

Conclusion:

In these PsA patients, DAPSA VLDA/LDA was associated with higher disease duration and with lower PsAID12. Pain is dominant symptom in patients with psoriatic arthritis, even in those with DAPSA≤14, and skin problems are not good represented in DAPSA index.

References:

[1]Gossec L, Ann Rheum Dis. 2014;73(6):1012–1019.

[2]Di Carlo, et al: PsAID-12 in clinical setting. J Rheum 2017; 44:3

Acknowledgments:

SOGARE

Disclosure of Interests:

Carlos García-Porrúa: None declared, Luis Fernández-Dominguez: None declared, Jose L. Guerra-Vazquez: None declared, José Antonio Mosquera Martínez: None declared, Jose Pinto-Tasende Consultant of: Janssen, Novartis, Speakers bureau: Lilly, Janssen, Novartis, BMS, Pfizer, Celgene

AB0823 MINIMAL DISEASE ACTIVITY IN PSORIATIC ARTHRITIS IS ASSOCIATED WITH LOW IMPACT OF DISEASE ON PSAID12 QUESTIONAIRE

Background:

Psoriatic arthritis (PsA) has a prevalence of 0.58% in Spain and patients suffer this disease have significant impact on daily life due to articular, dermatological and psychological symptoms. To reach minimal disease activity (MDA) is a therapeutic goal recommended by EULAR for clinical practice.

Objectives:

Our aim was to assess the relationship between MDA and PsAID questionnaire in routine clinical practice.

Methods:

We performed a cross-sectional study of patient and physician reported outcomes. We obtained clinical information of patients with PsA attending clinic from October 2018 to October 2019. Data were collected from clinical records concerning age, gender, disease duration, joint counts, dactylitis, enthesitis, body surface area (BSA) of psoriasis, laboratory results (ESR and CRP), HAQ, PsAID12, pain and global assessment from patient with numerical rating scale (NRS) and MDA status. Data were analysed using SPSS21. Logistic regression was used to assess patient reported outcomes which were associated with achieving MDA.

Results:

Data were available for 210 patient visits, 57% males. MDA 5/7 was reached in 118 patients (56.2%) and MDA7/7 in 58 (27.6%). Age and gender were not associated with reach MDA. Higher disease duration was associated with MDA, OR 1.062 (1.012-1.114, 95% CI), p 0.015.

PsAID12 was evaluated in 156 patients and all components were associated with reach MDA. Patients in MDA had significantly lower PsAID12 than those were not in MDA (mean 1.5 ± SD 1.5 vs. 3.8 ± 2.1), p< 0.0001. PsAID12 of less than 4 is considered a good outcome and individual components of PsAID12 (Figure 1, mean values for NRS) were less than 4 in patients with MDA.

Figure 1.

All components of PsAID12 were associated with MDA on univariate analysis but only pain and functional capacity remained independent predictors on multiple regression analysis (p< 0.0001 and p0.008 respectively).

Percentage of BSA was associated with skin component of PsAID12 (p<0.0001) and with shame component (p0.001).

Conclusion:

In these PsA patients, MDA was reached mainly in patients with higher disease duration. MDA is a relevant treatment target in PsA, with markedly lower PsAID12 in patients in MDA. Pain and functional discapacity are dominant symptoms in patients with psoriatic arthritis, even in those in MDA. Skin affection is associated with skin and shame components on the PsAID12.

References:

[1]Queiro R et al. Arthritis Res Ther. 2017 Mar 29;19(1):72.

Acknowledgments:

SOGARE

Disclosure of Interests:

José Antonio Mosquera Martínez: None declared, Carlos García-Porrúa: None declared, Luis Fernández-Dominguez: None declared, Jose L. Guerra-Vazquez: None declared, Jose Pinto-Tasende Consultant of: Janssen, Novartis, Speakers bureau: Lilly, Janssen, Novartis, BMS, Pfizer, Celgene

Tuberculous spondylitis: epidemiologic and clinical study in non-HIV patients from northwest Spain

OBJECTIVES

To study the epidemiology, clinical features, and outcome of non-human immunodeficiency virus (HIV) patients diagnosed with tuberculous spondylitis (TS) in a well-defined region of northwestern Spain.

METHODS

Retrospective chart review of patients older than 14 years of age diagnosed with TS at two contiguous areas between 1986 and 1999.

RESULTS

Thirty-seven patients (19 men; mean age 60.3 years) were diagnosed with TS. The average annual incidence rate of TS was 0.55/100,000 population 15 years of age and older. The thoracic and lumbar regions were affected in most cases. The mean duration of symptoms before diagnosis was 28 weeks (range 3-129). Active or healed pulmonary tuberculosis was observed in only 30%. The tuberculin skin test was negative in 24%. The most common findings at the time of diagnosis were back pain and elevated ESR (either 89%). Of note, only 19% had fever. On admission plain radiographs disclosed the presence of spondylitis in 84% of the patients. Computed tomography scan and magnetic resonance imaging yielded conclusive diagnostic data in the cases with normal radiographs, and were very useful in the visualization of abscesses and intraspinal compression. Cultures of material from percutaneous needle aspiration and open bone biopsy were positive for Mycobacterium tuberculosis in 79% and 77% of the cases, respectively. Antituberculous therapy was given to all patients (mean duration of treatment 44 weeks). Surgical procedures were performed in 12 cases, in 7 of them to remove paraspinal and/or epidural abscesses, and in 5 because of neurological complications. Local pain and neurological deficits were the mostfrequent sequelae (16 and 8 cases, respectively). One patient died during the course of treatment due to a co-morbid disease. None of the patients had relapses of tuberculosis.

CONCLUSION

TS is a major cause of morbidity. There is a long delay to the diagnosis in most patients. Awareness of its clinical features and early therapy are required to reduce severe complications.

Epidemiology of the vasculitides

In summary, systemic vasculitides constitute a heterogeneous group of overlapping diseases that are somewhat more common than previously considered. Although the causes of vasculitis are largely unknown, epidemiologic studies have implicated geographic, genetic, and environmental factors. Ethnicity, various genes such as those of the MHC, gender, and environmental factors seem to account for the different incidence rates of these syndromes. GCA is the most common vasculitis in elderly people from Western countries. Small-sized cutaneous vasculitides, particularly HSP in children and HV in adults, are also common diseases. Increased physician awareness and the routine use of ANCA tests may contribute to an increase in the recognition of conditions such as WG and MPA.

Predictive factors for renal sequelae in adults with Henoch-Schönlein purpura

OBJECTIVE

To examine the outcome and risk factors for renal sequelae in an unselected population of adults with Henoch-Schonlein Purpura (HSP).

METHODS

Retrospective study of adult patients (> 20 years) with biopsy proved cutaneous vasculitis diagnosed as having HSP seen at a single center between 1984 and 1998. Patients were classified as having HSP according to proposed criteria. Only those patients with a followup of at least 1 year were included in this study of renal sequelae.

RESULTS

Twenty-eight patients with a mean followup of 5.5 years fulfilled the inclusion criteria. When the study was concluded, 10 patients (36%) had renal sequelae and 2 (7%) had renal insufficiency. Men outnumbered women. However, neither a previous history of drugs, gender, nor age at disease onset was associated with a higher risk of permanent renal involvement. Patients with hematuria at disease onset or renal involvement during the course of the disease more commonly developed renal sequelae (p < 0.001). The presence of anemia (p = 0.05) at the time of diagnosis and the onset in summer (p < 0.05) were also more common in those with permanent renal involvement (renal sequelae). Patients with relapses had also a higher trend to develop renal sequelae (p = 0.07). All patients who fulfilled more than 2 of these 5 risk factors developed permanent renal involvement. With this model we were able to predict renal sequelae in 8 of the 10 patients who had this complication. The Goodman-Kruskal gamma test value was 0.92 (95% CI 0.78-1.00).

CONCLUSION

In unselected adults with HSP, permanent renal involvement (renal sequelae) is not uncommon. Hematuria at disease onset and persistence of renal manifestations during the course of the disease are significant indicators of possible development of renal sequelae. These manifestations plus other features such as onset in summer, anemia at disease onset, or relapses of the disease may predict the development of renal sequelae in most patients.

Hypersensitivity vasculitis in adults: a benign disease usually limited to skin

OBJECTIVES

To examine the clinical spectrum of hypersensitivity vasculitis (HV) in an unselected population of adults and establish differences between patients with HV limited to the skin and those with systemic involvement.

METHODS

Retrospective study of adult patients (> 20 years) with biopsy-proven cutaneous leukocytoclastic vasculitis diagnosed as having HV, who were seen at the single hospital serving a well defined population between 1984 and 1998. Patients were classified as having HV according to the criteria of Michel et al. (9). To examine outcome and relapses of the disease only those patients with a follow-up of at least 1 year were included in this study.

RESULTS

64 patients with a mean follow-up of 4.9 +/- 3.5 (range: 1.1-13.6) years were studied. Ten (15.6%) had visceral involvement (3 gastrointestinal and 7 renal manifestations) during the course of the disease. The remaining patients had a leukocytoclastic vasculitis limited to the skin. When the study was concluded persistent hematuria and proteinuria was only observed in 1 patient and none developed renal insufficiency. Patients with a history of drug treatment and elevated ESR had more systemic complications but the difference was not statistically significant. The outcome was excellent in both patients with HV limited to the skin and in those with systemic complications during the course of the disease.

CONCLUSIONS

In unselected adults HV is generally a benign disease confined exclusively to the skin. In those patients with systemic manifestations, visceral involvement is generally mild and transient.

Rheumatic manifestations of infective endocarditis in non-addicts. A 12-year study

Infective endocarditis (IE) is due to a microbial infection of the heart valves or of the endocardium in close proximity to either congenital or acquired cardiac defects. This infection is associated with a high risk of complications. Rheumatic manifestations are known to be frequent complications of IE. Controversy, however, frequently exists about the actual incidence of these complications. This may be due to the small number of series describing the frequency and type of rheumatic manifestations, the absence of uniform criteria used for the diagnosis of IE, and the fact that some studies on rheumatic manifestations in IE have been described from tertiary referral centers, which implicates associated problems of referral bias and uncertainty of denominator population. To investigate further the incidence, clinical spectrum, and outcome of patients with IE and rheumatic manifestations, we examined the features of patients diagnosed with clinically definite IE according to the Duke classification criteria at the single reference hospital for a defined population in northwestern Spain during a 12-year period. Between 1987 and 1998, 100 consecutive patients had 110 episodes of clinically definite IE. Rheumatic manifestations were observed in 46 of the 110 episodes (41.8%). As in other western countries, they occurred more commonly in men aged in their 50s. The most frequent valve involved was the aortic (43.5%) followed by the mitral valve (30.4%). Myalgia was a frequent symptom. Peripheral arthritis, generally as monoarthritis, was clinically evident in 15 cases (13.6%), and sacroiliitis in 1 patient. Low back pain was described in 14 cases (12.7%). Septic discitis was observed in 2 cases, and biopsy-proved cutaneous leukocytoclastic vasculitis was found in 4 cases. Other conditions such as trochanteric bursitis and polymyalgia were observed in 2 and 1 case, respectively. Apart from a significantly higher frequency of hematuria and a trend to lower serum complement levels in patients with rheumatic complications, no differences in clinical features, laboratory tests, or microbiologic blood culture results were found between cases with IE with or without rheumatic manifestations. Also, although patients with rheumatic manifestations had more embolic complications, the inhospital mortality rate in patients with rheumatic manifestations was not significantly different from that of the rest of the patients. The present study supports the claim that rheumatic complications are frequent in patients with clinically definite IE from southern Europe. The presence of musculoskeletal or vasculitic manifestations may be of some help, as warning signs, for the recognition of patients with severe disease who require rapid diagnosis and therapy.

Association between HLA-DRB1*15 and secondary Sjögren's syndrome in patients with rheumatoid arthritis

OBJECTIVE

To examine the relationship between HLA-DRB1 alleles and the clinical expression of the secondary form of Sjogren's syndrome (SS) in patients with rheumatoid arthritis (RA).

METHODS

Typing of HLA-DRB1 alleles was carried out by molecular based techniques on DNA obtained from a population of patients with RA from Lugo in northwestern Spain. Patients were diagnosed according to the 1987 American College of Rheumatology criteria for RA, and comprised 137 seropositive and 42 seronegative individuals. Secondary SS was defined by xerostomia and keratoconjunctivitis sicca, supported by ophthalmologic examination. Patients were compared with 145 ethnically matched controls.

RESULTS

Twenty-two (12.3%) of the patients with RA also had secondary SS. The majority of these (19/22) were rheumatoid factor positive. Eleven (57.9%) of the seropositive patients with secondary SS carried an HLA-DRB1*15 allele compared with 28 (23.7%) seropositive patients without secondary SS (OR 4.4, 95% CI 1.5-13.6, pc = 0.014). In contrast, the frequency of DRB1*04 was reduced in seropositive patients with secondary SS compared to those without secondary SS, although this did not achieve significance after correction for multiple testing (OR 0.28, 95% CI 0.09-0.88, pc = 0.08). Of note, in individuals lacking the RA shared epitope (SE), DRB1*15 was found to be associated (OR 2.3, 95% CI 1.0-5.1, pc = 0.03) with RA in the absence of secondary SS. No differences were found between DRB1*15 positive and negative patients in terms of erosive disease, nodules, or rheumatoid factor positivity.

CONCLUSION

Secondary SS is associated with an increased frequency of HLA-DRB1*15 in seropositive patients with RA from northwestern Spain. HLA-DRB1*15 is also associated with RA in SE negative individuals without secondary SS, although the possibility that such patients will later develop SS cannot be ruled out. Further studies are needed to confirm whether the HLA-DRB1*15 association with secondary SS in RA is common to Spanish and other ethnic populations.

Polymyalgia manifestations in different conditions mimicking polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is a generally benign syndrome involving the neck, shoulder, and hip girdles in the elderly. However, none of the clinical and laboratory findings are specific for this syndrome. Different diseases may present with features suggesting PMR. The consideration of other conditions which in some cases resemble PMR is very important, as their therapy and prognosis differ completely from that of PMR. Four patients presenting with typical PMR manifestations, who were finally diagnosed as having conditions very different from PMR, are described. The importance of the differential diagnosis in patients presenting with polymyalgia symptoms is underlined.

Visual manifestations of giant cell arteritis. Trends and clinical spectrum in 161 patients

Giant cell (temporal) arteritis (GCA) is the most common systemic vasculitis in Western countries. It involves large and medium-sized vessels with predisposition to the cranial arteries in the elderly. Cranial ischemic complications, in particular permanent visual loss, constitute the most feared aspects of this vasculitis. Although the use of corticosteroids and a higher physician awareness may have contributed to a decrease in the frequency of severe ischemic complications, permanent visual loss is still present in 7%-14% of patients. To investigate further the incidence, trends, and clinical spectrum of visual manifestations in patients with GCA, we examined the features of patients with biopsy-proven GCA diagnosed at the single reference hospital for a defined population in northwestern Spain during an 18-year period. Predictive factors for the development of any visual manifestation, not only permanent visual loss, were also examined. Between 1981 and 1998, 161 patients were diagnosed with biopsy-proven GCA. Visual ischemic complications were observed in 42 (26.1%), and irreversible blindness, mainly due to anterior ischemic optic neuropathy and frequently preceded by amaurosis fugax, was found in 24 (14.9%). Despite a progressive increase in the number of new cases diagnosed, there was not a significant change in the proportion of patients with visual manifestations during the study period (p = 0.37). Patients with visual ischemic complications had lower clinical and laboratory biologic markers of inflammation. Indeed, during the last years of the study, anemia was associated with a very low risk of visual complications. Also, HLA-DRB1*04-positive patients had visual manifestations more commonly. Patients with other ischemic complications developed irreversible blindness more frequently. The best predictors of any visual complication were HLA-DRB1*04 phenotype (odds ratio [OR] 7.47) and the absence of anemia at the time of admission (OR for patients with anemia = 0.07). The best predictors of irreversible blindness (permanent visual loss) were amaurosis fugax (OR 12.63) and cerebrovascular accidents (OR 26.51). The present study supports the claim that ocular ischemic complications are still frequent in biopsy-proven GCA patients from southern Europe. The presence of other ischemic complications constitutes an alarm for the development of irreversible blindness. In contrast, a higher inflammatory response may be a protective factor against the development of cranial ischemic events.

Association of giant cell arteritis and polymyalgia rheumatica with different tumor necrosis factor microsatellite polymorphisms

OBJECTIVE

To determine whether giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are associated with different tumor necrosis factor (TNF) microsatellite polymorphisms.

METHODS

Typing of TNF microsatellite polymorphisms was carried out by molecular-based techniques on DNA obtained from a population sample of residents from Lugo, northwestern Spain. A case-control approach was used to compare 136 patients with GCA and/or PMR with 147 ethnically matched controls. The association of disease with TNF microsatellite polymorphisms was investigated using chi-square tests and multivariate logistic regression analyses.

RESULTS

Different TNF microsatellite associations were found with GCA and PMR. In patients with isolated GCA, the primary association was with TNFa2, which was independent of the GCA associations with HLA-DRB1*0401 and *0101. A negative association was found with TNFa10. In patients with isolated PMR, there was a positive association with TNFb3. This was found to be independent of the HLA-DRB1*13/*14 association in isolated PMR. TNFd4 was negatively associated with isolated PMR. Forward stepwise logistic regression analyses indicated that the strongest association with GCA was provided by the TNFa2 allele, although DRB1*0401 and *0101 were still associated. PMR was primarily associated with TNFb3. A direct comparison of TNF allele frequencies between isolated GCA and isolated PMR indicated that the main difference between these conditions occurred in the frequency of TNFa10.

CONCLUSION

GCA and PMR in individuals from northwestern Spain are associated with different TNF microsatellite polymorphisms. The primary TNF associations (TNFa2 and TNFb3) appear to influence susceptibility to these conditions independent of any HLA-DRB1 association.

RANTES gene polymorphism in polymyalgia rheumatica, giant cell arteritis and rheumatoid arthritis

OBJECTIVE

To investigate whether a biallelic polymorphism (A or G) occurring within the promoter region of the RANTES gene (position-403) is associated with polymyalgia rheumatica (PMR), giant cell arteritis (GCA) and rheumatoid arthritis (RA).

METHODS

A PCR-RFLP method was used to genotype cases and controls for this polymorphism. 3 groups of patients were examined; these comprised GCA patients who did not exhibit features of PMR (n = 30), PMR patients who did not exhibit features of GCA (n = 53) and RA patients (n = 99). All patients and controls (n = 65) originated from the area surrounding Lugo, Galicia, NW Spain.

RESULTS

A significant increase in the frequency of allele A was found in PMR patients compared with normal controls. A marginal increase of this allele frequency was observed in RA but not in GCA patients.

CONCLUSION

This is the first report of an association of a RANTES gene polymorphisms with PMR and RA. Our data suggest a possible role for of RANTES in the development of both PMR and RA.

Different gene loci within the HLA-DR and TNF regions are independently associated with susceptibility and severity in Spanish rheumatoid arthritis patients

The aim of this study was to investigate whether polymorphisms in the tumor necrosis factor (TNF) and HLA-DRB1 gene regions are independently associated with rheumatoid arthritis (RA) in a population from Lugo region of northwestern Spain. RA patients (n=179) attending hospital outpatient clinics in Lugo, northwestern Spain and matched controls (n=145) were recruited. RA susceptibility in this population was predominantly associated with DRB1*0401, while erosive disease was associated with HLA-DRB1*0101 and DRB1*04. The increase in DRB1*04 was accounted for by an increase in DRB1*0404 and *0405 but not *0401 frequencies. In contrast, *0401 frequency was significantly increased in seropositive patients. The rheumatoid arthritis shared epitope (SE) was associated with increased risk for seropositive and erosive disease and this appeared to operate in a dose-dependent manner. Logistic regression analyses revealed that the TNF microsatellite markers TNFc1 and b3 were associated with RA independently of DRB1*04 and the SE. Carriage of a TNF c1 allele provided an increased risk of RA in SE-negative and SE-heterozygous individuals. TNFc1 and TNFb3 were not associated with erosive or seropositive disease. In contrast, TNF a2 was significantly associated with erosive disease which was independent of DRB1*04 and the SE. Further studies will be needed to establish why (TNFc1) polymorphism seemingly associated with low TNFalpha production, is a risk factor for RA.

Epidemiologic and clinical aspects of Behçet's disease in a defined area of Northwestern Spain, 1988-1997

OBJECTIVE

To assess the frequency and clinical manifestations of Behçet's disease (BD) during the past 10 years in a defined area of Northwestern Spain.

METHODS

The charts of all the patients diagnosed as having BD at the Hospital Xeral-Calde from 1988 through 1997 were reviewed. All the patients were residents of Lugo. Patients were followed from the time of diagnosis until either the patient's death or July 1, 1998. By that time patients were classified as having complete BD if they fulfilled the International Study Group Criteria (ISG) for BD. Patients with recurrent oral ulcerations plus one of the remaining 4 criteria of the ISG were classified as having an incomplete form of BD.

RESULTS

Sixteen patients (9 men/7 women) were diagnosed as having complete BD and 7 (3 men) as having incomplete BD. The average annual incidence rate of complete BD in the Lugo region of Northwestern Spain was 0.66/100,000. Oral ulcerations with or without genital ulcerations were the most common initial manifestations. Neurological involvement was relatively frequent in men with complete BD. In contrast, a positive pathergy test was less common. Two patients with neurological involvement and 3 with uveitis had severe sequelae. However, there was a single death, apparently not related to BD.

CONCLUSION

In Northwestern Spain, BD is more common than was expected and is a nonfatal disease. However, central nervous system involvement and severe ocular complications overshadow the good prognosis observed in the majority of patients.

Erythema nodosum: etiologic and predictive factors in a defined population

OBJECTIVE

To examine the frequency and features of erythema nodosum (EN), establish disease associations, and identify the optimal set of predictors for the occurrence of secondary EN.

METHODS

We performed a retrospective study of an unselected population of patients 14 years and older with biopsy-proven EN diagnosed at a referral hospital between 1988 and 1997. Patients were classified as having either idiopathic EN or EN secondary to other diseases if the skin nodules occurred in the context of a well-defined disease, or if there was a precipitating event in close temporal proximity to the onset of EN.

RESULTS

One hundred six patients (82 women) were diagnosed as having biopsy-proven EN. At the time of diagnosis, no precipitating events or underlying diseases were identified in 36.8% of patients. Sarcoidosis and nonstreptococcal upper respiratory tract infections (URI) were the most common conditions associated with secondary EN. Only 1 of 35 patients with an initial diagnosis of idiopathic EN and a followup of at least 1 year was finally diagnosed as having secondary EN. The best predictive model of secondary EN included an abnormal results on a chest radiograph, a previous history of nonstreptococcal URI, and a significant change in antistreptolysin O (ASO) titer in 2 consecutive determinations performed in a 2-4-week interval. Also, the presence of peripheral synovitis, a positive tuberculin skin test, and a history of diarrhea suggested the presence of secondary EN. This model showed high sensitivity and specificity.

CONCLUSION

Idiopathic EN is common. A basic procedure including careful medical history-taking, a physical examination for peripheral synovitis, 2 consecutive ASO determinations, a tuberculin skin test, and chest radiography may be sufficient to diagnose EN.

The clinical spectrum of osteoarticular tuberculosis in non-human immunodeficiency virus patients in a defined area of northwestern Spain (1988-1997)

OBJECTIVE

To examine the frequency and clinical manifestations of osteoarticular tuberculosis in non-human immunodeficiency virus (HIV) patients during the past 10 years in a northwestern area of Spain.

METHODS

The charts of all patients older than 14 years of age, not HIV-infected, and diagnosed as having osteoarticular tuberculosis at the Xeral-Calde Hospital from 1988 through 1997 were reviewed. All patients were residents of the region of Lugo. The diagnosis of osteoarticular tuberculosis was made on the basis of a positive culture for Mycobacterium tuberculosis from synovial fluid, joint tissue or paravertebral abscess or by histological findings of caseating granulomas in biopsied tissue.

RESULTS

Thirty-two HIV-negative patients (20 men and 12 women) were diagnosed with osteoarticular tuberculosis. The average annual incidence rate of osteoarticular tuberculosis in the combined (male and female) non-HIV population > or = 15 years of age was 15.68/million (95% CI: 10.25; 21.11); males 20.02/million (95% CI: 11.25; 28.79); females 11.52/million (95% CI: 5.00; 18.03). The age at the time of diagnosis was 60.8 +/- 17.5 years. Peripheral monoarthritis was observed in 16 of the 32 cases. The knee was the most frequent site of peripheral tuberculous arthritis (31%), but involvement of the non-weight-bearing joints (50%) was also common. Spondylitis involving the lower thoracic and upper lumbar vertebrae (31%) and unilateral sacroiliitis (19%) were less commonly observed. In general, patients with osteoarticular tuberculosis had a long duration of symptoms of the disease prior to the diagnosis (median: 5.5 months). The tuberculin skin test was negative in 3 cases. Chest radiograph was abnormal in only 6 of 32 patients (19%). The ESR (mean +/- SD) at the time of diagnosis was 55.7 +/- 29.0 mm/hr. Computed tomography was very useful in detecting early involvement of the sacroiliac joints and in defining the extent of the abscesses and the severity of the involvement in patients with spondylitis. All patients received chemotherapy for tuberculosis. None of them suffered relapses of tuberculosis.

CONCLUSION

Tuberculosis is a major source of osteoarticular complications in northwestern Spain. The prevailing low level of clinical suspicion may explain the long delay to the diagnosis in most patients. A greater awareness of the possibility of this severe complication, especially in the elderly people or in high-risk populations, would be advisable.

Drug associated cutaneous vasculitis in adults in northwestern Spain

OBJECTIVE

To examine the incidence and clinical features of adults with biopsy proven cutaneous vasculitis (CV) associated with drugs.

METHODS

Retrospective study of an unselected population of adults (age >20 years) with biopsy proven leukocytoclastic CV from 1988 through 1997. Drug associated CV was considered if CV was confirmed by a skin biopsy and there was a history of drug use within one week before the development of CV. Drug associated CV was classified by American College of Rheumatology (ACR) criteria. To differentiate Henoch-Schonlein purpura (HSP) from hypersensitivity vasculitis (HV), the traditional criteria proposed by Michel, et al were used (J. Rheumatol. 1992;19:721-8).

RESULTS

Thirty-three of 138 patients (23.9%) presenting with biopsy proven CV were diagnosed with drug associated CV. The annual incidence rate of biopsy proven drug associated CV in adults was 17.49 cases/million (95% CI 11.53-23.46): men 25.10/million (95% CI 14.85-35.36), women 10.31/million (95% CI 3.92-16.70). Antibiotics (n = 13), especially amoxicillin, and analgesics or nonsteroidal anti-inflammatory drugs (n = 11) were the drugs more commonly associated with CV. All adults with drug associated CV met the ACR classification criteria for HV or HSP. Based on Michel's criteria 26 patients (78.8%) were classified as having HV and 7 HSP. No patient met ACR criteria for other systemic vasculitides. Complete recovery with no sequelae was observed in most cases.

CONCLUSION

Among patients with CV, drug associated disease is common and usually has a good clinical outcome.

Systemic vasculitis in adults in northwestern Spain, 1988-1997. Clinical and epidemiologic aspects

The vasculitides constitute a heterogeneous group of diseases characterized by blood vessel inflammation and necrosis with different but frequently overlapping clinical and pathologic manifestations. The incidence of these conditions is frequently controversial. To further investigate the incidence and clinical manifestations of vasculitides, we reviewed the spectrum of these diseases in an unselected population of adults (age > 20 years) from northwestern Spain during a 10-year period. From January 1988 through December 1997, 267 adults were diagnosed as having vasculitis. The overall average annual incidence rate of vasculitis in the region of Lugo, Spain, between 1988 and 1997 for the population older than 20 years was 141.54/million. Primary vasculitis (115.04/million for the population older than 20 years; 81.3%), especially giant cell arteritis (GCA) was the most common group. Small vessel primary vasculitis (hypersensitivity vasculitis and Henoch-Schönlein purpura) was the second most common group. Both GCA and small vessel primary vasculitis had a good outcome. However, although less common, patients with medium and small vessel primary vasculitis, in particular those with polyarteritis nodosa, had a high mortality related to the systemic manifestations of the disease or to the immunosuppressive therapy. Among the group of adults with secondary vasculitis (26.51/million; 18.7%), rheumatic diseases and specifically those occurring in the context of rheumatoid arthritis were the most common group. Patients with secondary vasculitis had clinical or laboratory data that may suggest the presence of an underlying disease. In summary, systemic vasculitides are somewhat more common than previously considered. As in other western countries, GCA constitutes the most common type of vasculitis in northwestern Spain. Better physician awareness may contribute to the progressive increase in the recognition of these conditions.

Bacterial infection presenting as cutaneous vasculitis in adults

OBJECTIVE

To examine the frequency and clinical features of patients with bacterial infection presenting with biopsy-proven leukocytoclastic cutaneous vasculitis (CV) in a well-defined area of southern Europe (northwestern Spain).

METHODS

A retrospective study of an unselected population of adult patients (age > 20 years) with biopsy-proven leukocytoclastic CV diagnosed at the Hospital Xeral-Calde (Lugo, Spain) was carried out from January 1988 through December 1997. Cutaneous vasculitis related to bacterial infection was considered if the vasculitis was confirmed by a skin biopsy showing leukocytoclastic vasculitis, if no drug intake was registered prior to the development of CV, and if bacteriologic evidence of infection was obtained.

RESULTS

Four of 138 patients (2.9%) presenting with biopsy-proved CV were diagnosed with leukocytoclastic CV related to bacterial infection. Three patients (2 with bacterial endocarditis and 1 with meningococcemia) met the ACR criteria for the classification of hypersensitivity vasculitis. Another patient with bacterial endocarditis met the criteria for mixed cryoglobulinemia. All of them presented with palpable purpura, high or low grade fever, an elevated erythrocyte sedimentation rate and leukocytosis.

CONCLUSION

Cutaneous vasculitis may be the presenting manifestation of bacterial infection. In this respect, rheumatologists should be aware of possible infectious causes of vasculitis, even though they are not common.

Comparative clinical and epidemiological study of hypersensitivity vasculitis versus Henoch-Schönlein purpura in adults

OBJECTIVES

To assess the incidence and clinical features of adults with hypersensitivity vasculitis (HV) and Henoch-SchOnlein purpura (HSP) in a well-defined population.

METHODS

Retrospective study of an unselected population of adult patients (>20 years) with biopsy-proven cutaneous vasculitis diagnosed as having HV or HSP who presented at a primary hospital between 1988 and 1997. Patients with cutaneous vasculitis secondary to collagen vascular diseases, neoplasia, severe infections, and those with other well-defined clinical entities were excluded. Patients were classified as having either HV or HSP according to the criteria proposed by Michel et al (J Rheumatol 1992;19:721-28).

RESULTS

Fifty-six adults (35 men/21 women), were classified as having HV and 27 adults as having HSP (19 men/8 women). The annual incidence rate for HV was 29.7/million and 14.3/million for HSP. At the onset of the disease, adults with HSP were younger than those with HV (46+/-18 years versus 59+/-18 years in HV; P = .005). Precipitating events were found in 50% of HV and in 30% of HSP patients. A history of drug therapy before the onset of vasculitis was found in 46% of HV and in 26% of HSP (P = .074). At disease onset, skin lesions were the most common manifestation in both groups. During the disease course, adults with HSP had joint manifestations more commonly (59% in HSP v25% in HV; P < .003) and more gastrointestinal (82% v 5% in HV; P < .001) and renal complications (48% v 5% in HV; P < .001). HSP subjects required more aggressive therapy consisting of steroids (P < .001) or cytotoxic agents (P < .001). After 37+/-28 (median, 31) months, complete recovery was observed in 98% of adults with HV. After 40+/-27 (median, 36) months, complete recovery was observed in only 67% of adults with HSP (P < .001). Renal insufficiency was observed in 8% of adults with HSP.

CONCLUSIONS

In adults, HV and HSP as defined by these criteria, behave as two well-differentiated diseases. HV has a milder course and lack of severe complications, and HSP a higher risk of gastrointestinal and renal complications.

The spectrum of polymyalgia rheumatica in northwestern Spain: incidence and analysis of variables associated with relapse in a 10 year study

OBJECTIVE

To examine patients presenting with polymyalgia rheumatica (PMR) during a 10 year period in Northwestern Spain and to assess disease incidence and the frequency of relapses in patients diagnosed as having either isolated ("pure") PMR or PMR associated with giant cell arteritis (GCA).

METHODS

Clinical records of patients with PMR diagnosed at the Hospital Xeral Lugo from January 1987 through December 1996 were reviewed. Patients with PMR were categorized into 2 subgroups depending on the presence or absence of associated GCA. Other conditions presenting with polymyalgia symptoms or mimicking isolated PMR were excluded. These patients were followed from the time of diagnosis until either patient's death or January 1, 1998.

RESULTS

One hundred eighty-five patients were studied. The average annual incidence rates of the total group of PMR and isolated PMR were 18.67 x 10(-5) and 13.52 x 10(-5), respectively, in a population aged 50 years or older. Relapses were frequent in both isolated PMR and PMR associated with GCA. In general, they occurred when the dose of prednisone was < 7.5 mg/day or it had been discontinued. Rate of steroid tapering was significantly higher in patients with isolated PMR who had relapses. Patients with HLA-DRB1*0401 had a higher frequency of relapses. As reported in patients with PMR associated with GCA, the adjusted mortality rate in patients with isolated PMR showed no difference compared to the Spanish population aged 50 years or older.

CONCLUSION

In Northwestern Spain, PMR is a nonfatal disease with a low incidence and frequent relapses. A possible influence of HLA-DRB1*04 alleles in the development of more severe disease, with greater tendency to relapses, is suggested.

The clinical spectrum of severe septic bursitis in northwestern Spain: a 10 year study

OBJECTIVE

To assess the clinical and microbiological characteristics of septic bursitis in those cases that required treatment at the hospital during the past 10 years in a northwestern area of Spain.

METHODS

The charts of all patients diagnosed as having septic bursitis at Hospital Xeral-Calde, Lugo, Spain, from October 1987 through September 1997 were reviewed based on published criteria and graded according to severity.

RESULTS

Sixty-nine patients diagnosed with definite and 6 with probable septic bursitis met the criteria for severe septic bursitis. Sixty-two were male (82.7%). The mean age at the time of diagnosis was 51 years. The most frequently involved sites were olecranon (47%) and prepatellar (44%) bursae. Among predisposing factors, the presence of prepatellar bursitis was correlated with a job that involved frequent trauma on the bursae. The main clinical and laboratory findings were cellulitis and/or erythema (94.7%), fever (77.3%), and leukocytosis (72%). Noninflammatory synovial fluid (SF, < 2,000 leukocytes/mm3) was observed in 4/32 (12.5%) cases. Positive SF cultures were obtained in 69 of 75 patients (92%). Staphylococcus aureus was the most common pathogen (84%). Blood cultures were positive in 12 of 62 patients (19.4%). Three patients had osteomyelitis. This complication was associated with a longer delay to diagnosis from the onset of symptoms (> 3 weeks vs 9.3+/-13.3 days for the group as a whole). Apart from these 3 cases, overall outcome was excellent.

CONCLUSION

Severe septic bursitis is a common disease. Local trauma is the most common risk factor for this infection. Although the most common pathogen is S. aureus, other pathogens such as Brucella abortus play an important role in this infection in our area.

Osteoarticular complications of brucellosis in an Atlantic area of Spain

OBJECTIVE

To assess the frequency and clinical manifestations of osteoarticular brucellosis in an Atlantic area of Spain.

METHODS

The case histories of all patients older than 14 years of age with active brucellosis diagnosed at the Hospital Xeral-Calde, Lugo, Spain, between October 1979 and October 1997 were reviewed. Diagnosis of brucellosis was by one of the following criteria: isolation of brucella species in blood or other fluids or tissue samples; or a clinical picture compatible with brucellosis in the presence of raised titers of specific antibodies by seroagglutination or Rose-Bengal plate agglutination tests.

RESULTS

Forty-four patients (34 men, 10 women) of the 158 patients diagnosed with brucellosis (27.8%) had osteoarticular complications. Spondylitis (20/44; 45.5%) and sacroiliitis (15/44; 34.1%) were the most common complications. Patients with spondylitis were older and had a more chronic disease course than those with sacroiliitis or peripheral arthritis. Brucella abortus was the pathogenic strain responsible for human brucellosis in this region of Spain.

CONCLUSION

In the Lugo region of Northwestern Spain osteoarticular brucellosis principally affects males and mainly involves spine and sacroiliac joints.