Validation of the Portuguese Version of the Scleroderma Health Assessment Questionnaire

The Health Assessment Questionnaire Disability Index (HAQ-DI) was completed with five visual analog scales to assess systemic sclerosis (SSc) called Scleroderma HAQ (SHAQ). We performed a validation of the European Portuguese version of SHAQ for patients with SSc. Patients with different forms of SSc from five Hospital Centers were invited. The reliability of the Portuguese SHAQ was evaluated by internal consistency and by test-retest reliability. Content validity was checked by two rheumatologists and by a panel of patients. Construct validity was assessed by structural validity and by known-groups hypothesis tests. Criterion validity was addressed with selected dimensions from the UCLA GIT 2.0, the SF-36v2, and the EuroQoL EQ-5D-5L. A total of 102 SSc patients agreed to participate, 31 of which answered to the retest. HAQ-DI demonstrated high internal consistency reliability (α = 0.866) and SHAQ also showed high test-retest reliability (ICC 0.61-0.95). We evidenced the unidimensionality of all VASs. HAQ-DI scores were worse in males, patients older than 65 years, and individuals with a diffuse form of SSc. Criterion validity was mainly evidenced through the correlation between the HAQ-DI and SF-36v2 physical summary measure (r = -0.688) and EQ-5D-5L index score (r = -0.723). Likewise, the SHAQ overall disease severity VAS was also correlated with SF-36v2 physical summary measure (r = -0.628). Mental score correlations were smaller. With the exception of the Raynaud's VAS, all the other VASs correlated well with similar clinical variables. This paper provides evidence to demonstrate how reliable and valid the European Portuguese version of SHAQ is, to be used in SSc patients to assess the clinical severity under the perspective of patients.

The idiopathic inflammatory myopathies module of the Rheumatic Diseases Portuguese Register

AIMS

To characterise the idiopathic inflammatory myopathies (IIM) module of the Rheumatic Diseases Portuguese Register (Reuma.pt/myositis) and the patients in its cohort.

METHODS

Reuma.pt is a web-based system with standardised patient files gathered in a registry. This was a multicentre open cohort study, including patients registered in Reuma.pt/myositis up to January 2022.

RESULTS

Reuma.pt/myositis was designed to record all relevant data in clinical practice and includes disease-specific diagnosis and classification criteria, clinical manifestations, immunological data, and disease activity scores. Two hundred eighty patients were included, 71.4% female, 89.4% Caucasian, with a median age at diagnosis and disease duration of 48.9 (33.6-59.3) and 5.3 (3.0-9.8) years. Patients were classified as having definite (N=57/118, 48.3%), likely (N=23/118, 19.5%), or possible (N=2/118, 1.7%) IIM by 2017 EULAR/ACR criteria. The most common disease subtypes were dermatomyositis (DM, N=122/280, 43.6%), polymyositis (N=59/280, 21.1%), and myositis in overlap syndromes (N=41/280, 14.6%). The most common symptoms were proximal muscle weakness (N=180/215, 83.7%) and arthralgia (N=127/249, 52.9%), and the most common clinical signs were Gottron's sign (N=75/184, 40.8%) and heliotrope rash (N=101/252, 40.1%). Organ involvement included lung (N=78/230, 33.9%) and heart (N=11/229, 4.8%) involvements. Most patients expressed myositis-specific (MSA, N=158/242, 65.3%) or myositis-associated (MAA, 112/242, 46.3%) antibodies. The most frequent were anti-SSA/SSB (N=70/231, 30.3%), anti-Jo1 (N=56/236, 23.7%), and anti-Mi2 (N=31/212, 14.6%). Most patients had a myopathic pattern on electromyogram (N=101/138, 73.2%), muscle oedema in magnetic resonance (N=33/62, 53.2%), and high CK (N=154/200, 55.0%) and aldolase levels (N=74/135, 54.8%). Cancer was found in 11/127 patients (8.7%), most commonly breast cancer (N=3/11, 27.3%). Most patients with cancer-associated myositis had DM (N=8/11, 72.7%) and expressed MSA (N=6/11) and/or MAA (N=3/11). The most used drugs were glucocorticoids (N=201/280, 71.8%), methotrexate (N=117/280, 41.8%), hydroxychloroquine (N=87/280, 31.1%), azathioprine (N=85/280, 30.4%), and mycophenolate mofetil (N=56/280, 20.0%). At the last follow-up, there was a median MMT8 of 150 (142-150), modified DAS skin of 0 (0-1), global VAS of 10 (0-50) mm, and HAQ of 0.125 (0.000-1.125).

CONCLUSIONS

Reuma.pt/myositis adequately captures the main features of inflammatory myopathies' patients, depicting, in this first report, a heterogeneous population with frequent muscle, joint, skin, and lung involvements.

Touraine-Solente-Gole syndrome: pathogenic variant in SLCO2A1 presented with polyarthralgia and digital clubbing

BACKGROUND

Primary Hypertrophic Osteoarthropathy (PHO), also known as Touraine-Solente-Gole Syndrome, is a rare, multisystemic autosomal recessive disorder caused by pathogenic variants in the 15-hydroxyprostaglandin dehydrogenase (HPGD) or Solute Carrier Organic Anion Transporter Family Member 2A1 (SLCO2A1) genes. However, autosomal dominant transmission has also been described in some families with incomplete penetrance. PHO usually starts in childhood or adolescence, presenting with digital clubbing, osteoarthropathy, and pachydermia. We described a complete form of the syndrome in a male patient with a homozygous variant in the SLCO2A1 gene (c.1259G > T).

CASE PRESENTATION

A 20-year-old male was referred to our Pediatric Rheumatology Clinic with a five-year history of painful and swollen hands, knees, ankles and feet, prolonged morning stiffness and relief with non-steroidal antiinflammatory drugs. He also reported late onset facial acne and palmoplantar hyperhidrosis. Family history was irrelevant and parents were non-consanguineous. On clinical examination, he presented clubbing of the fingers and toes, moderate acne and marked facial skin thickening with prominent scalp folds. He had hand, knee, ankles and feet swelling. Laboratory investigations showed elevated inflammatory markers. Complete blood count, renal and hepatic function, bone biochemistry were normal, as well as immunological panel. Plain radiographs revealed soft tissue swelling, periosteal ossification and cortical thickening of the skull, phalanges, femur and toe acroosteolysis. Due to the absence of other clinical signs suggesting a secondary cause, we suspected PHO. A genetic study revealed a likely pathogenic variant, c.1259G > T(p.Cys420Phe), in homozygosity in the SLCO2A1 gene, thus confirming the diagnosis. The patient started oral naproxen with significant clinical improvement.

CONCLUSIONS

PHO should be kept in the differential diagnosis of inflammatory arthritis affecting children, often misdiagnosed as Juvenile Idiopathic Arthritis (JIA). To the best of our knowledge, this is the second genetically confirmed case of PHO in a Portuguese patient (first variant c.644 C > T), both made at our department.

Assessment of calcinosis in Portuguese patients with systemic sclerosis - a multicenter study

INTRODUCTION/OBJECTIVES

The study aims to define the clinical and subclinical calcinosis prevalence, the sensitivity of radiographed site and clinical method for its diagnosis, and the phenotype of Portuguese systemic sclerosis (SSc) patients with calcinosis.

METHOD

A cross-sectional multicenter study was conducted with SSc patients fulfilling Leroy/Medsger 2001 or ACR/EULAR 2013 classification criteria, registered in the Reuma.pt. Calcinosis was assessed through clinical examination and radiographs of hands, elbows, knees, and feet. Independent parametric or non-parametric tests, multivariate logistic regression, and sensitivity calculation of radiographed site and clinical method for calcinosis detection were performed.

RESULTS

We included 226 patients. Clinical calcinosis was described in 63 (28.1%) and radiological calcinosis in 91 (40.3%) patients, of which 37 (40.7%) were subclinical. The most sensitive location to detect calcinosis was the hand (74.7%). Sensitivity of the clinical method was 58.2%. Calcinosis patients were more often female (p = 0.008) and older (p < 0.001) and had more frequently longer disease duration (p < 0.001), limited SSc (p = 0.017), telangiectasia (p = 0.039), digital ulcers (p = 0.001), esophageal (p < 0.001) and intestinal (p = 0.003) involvements, osteoporosis (p = 0.028), and late capillaroscopic pattern (p < 0.001). In multivariate analysis, digital ulcers (OR 2.63, 95% CI 1.02-6.78, p = 0.045) predicted overall calcinosis, esophageal involvement (OR 3.52, 95% CI 1.28-9.67, p = 0.015) and osteoporosis (OR 4.1, 95% CI 1.2-14.2, p = 0.027) predicted hand calcinosis, and late capillaroscopic pattern (OR 7.6, 95% CI 1.7-34.9, p = 0.009) predicted knee calcinosis. Anti-nuclear antibody positivity was associated with less knee calcinosis (OR 0.021, 95% CI 0.001-0477, p = 0.015).

CONCLUSIONS

Subclinical calcinosis high prevalence suggests that calcinosis is underdiagnosed and radiographic screening might be relevant. Multifactorial pathogenesis may explain calcinosis predictors' variability. Key Points • Prevalence of subclinical calcinosis in SSc patients is substantial. • Hand radiographs are more sensitive to detect calcinosis than other locations or clinical method. • Digital ulcers were associated with overall calcinosis, esophageal involvement and osteoporosis were associated with hand calcinosis, and late sclerodermic pattern in nailfold capillaroscopy was associated with knee calcinosis. • Anti-nuclear antibody positivity may be a protective factor for knee calcinosis.

Severe infections in Portuguese patients with rheumatoid arthritis under biologic treatment - a multicenter, nationwide study (SIPPRA-B Study)

INTRODUCTION

Despite years of experience with biological disease modifying anti-rheumatic drugs (bDMARD) in rheumatoid arthritis (RA), little is known about differences in infectious risk among bDMARDs. The aim of this study was to assess the incidence and type of infections in RA patients on bDMARDs and to determine possible predictors.

METHODS

A retrospective multicenter cohort study that included patients registered in the Rheumatic Diseases Portuguese Registry (Reuma.pt) with RA, and exposed to at least one bDMARD until April 2021. RA patients under bDMARD and with at least one episode of severe infection (SI), defined as infection that requires hospitalization, use of parenteral antibiotics or that resulted in death, were compared to patients with no report of SI. Demographic and clinical data at baseline and at the time of each SI were collected to establish comparisons between different groups of bDMARDs. Comparisons between different bDMARDs were assessed and logistic regression was performed to identify predictors of SI.

RESULTS

We included 3394 patients, 2833 (83.5%) female, with a mean age at RA diagnosis of 45.5±13.7 years. SI was diagnosed in 142 of the 3394 patients evaluated (4.2%), totaling 151 episodes of SI. At baseline, patients with SI had a significantly higher proportion of prior orthopedic surgery, asthma, interstitial lung disease, chronic kidney disease and corticosteroid use, higher mean age and longer median disease duration at first bDMARD. Nine patients died (6.0%). Ninety-two SI (60.9%) occurred with the first bDMARD, the majority leading to discontinuation of the bDMARD within 6 months (n=75, 49.7%), while 65 (43.0%) restarted the same bDMARD and 11 (7.3%) switched to another bDMARD (6 of them to a different mechanism of action). In the multivariate analysis, we found that chronic kidney disease, asthma, infliximab, corticosteroid use, interstitial lung disease, previous orthopedic surgery, higher Health Assessment Questionnaire and DAS284V-ESR are independent predictors of SI.

CONCLUSION

This study described the incidence and types of SI among Portuguese RA patients on biologics, identifying several predictors of SI, both globally and with different bDMARDs. Physicians should be aware of the real-word infectious risk in RA patients on bDMARDs when making treatment decisions.

Predictors of cardiac involvement in idiopathic inflammatory myopathies

Objectives

Idiopathic inflammatory myopathies (IIM) are a group of rare disorders that can affect the heart. This work aimed to find predictors of cardiac involvement in IIM.

Methods

Multicenter, open cohort study, including patients registered in the IIM module of the Rheumatic Diseases Portuguese Register (Reuma.pt/Myositis) until January 2022. Patients without cardiac involvement information were excluded. Myo(peri)carditis, dilated cardiomyopathy, conduction abnormalities, and/or premature coronary artery disease were considered.

Results

230 patients were included, 163 (70.9%) of whom were females. Thirteen patients (5.7%) had cardiac involvement. Compared with IIM patients without cardiac involvement, these patients had a lower bilateral manual muscle testing score (MMT) at the peak of muscle weakness [108.0 ± 55.0 vs 147.5 ± 22.0, p=0.008] and more frequently had oesophageal [6/12 (50.0%) vs 33/207 (15.9%), p=0.009] and lung [10/13 (76.9%) vs 68/216 (31.5%), p=0.001] involvements. Anti-SRP antibodies were more commonly identified in patients with cardiac involvement [3/11 (27.3%) vs 9/174 (5.2%), p=0.026]. In the multivariate analysis, positivity for anti-SRP antibodies (OR 104.3, 95% CI: 2.5-4277.8, p=0.014) was a predictor of cardiac involvement, regardless of sex, ethnicity, age at diagnosis, and lung involvement. Sensitivity analysis confirmed these results.

Conclusion

Anti-SRP antibodies were predictors of cardiac involvement in our cohort of IIM patients, irrespective of demographical characteristics and lung involvement. We suggest considering frequent screening for heart involvement in anti-SRP-positive IIM patients.

Creation and Validation of a Portuguese Version of the UCLA Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument

(1) Background: The UCLA GIT 2.0 questionnaire has been recognized as a feasible and reliable instrument to assess gastrointestinal (GI) symptoms in systemic sclerosis (SSc) patients and their impact on quality of life. The aim of this study was to create and validate UCLA GIT 2.0 for Portuguese patients with SSc. (2) Methods: A multi-center study was conducted enrolling SSc patients. UCLA GIT 2.0 was validated in Portuguese using reliability (internal consistency, item -total correlation, and reproducibility) and validity (content, construct, and criterion) tests. Criterion tests included EQ-5D and SF-36v2. Social-demographic and clinical data were collected. (3) Results: 102 SSc patients were included, 82.4% of them female, and with a mean sample age of 57.0 ± 12.5 years old. The limited form of SSc was present in 62% of the patients and 56.9% had fewer than five years of disease duration. Almost 60% presented with SSc-GI involvement with a negative impact on quality of life. The means for SF-36v2 were 39.3 ± 10.3 in the physical component summary and 47.5 ± 12.1 in the mental component summary. Total GI score, reported as mild in 57.8% of the patients, was highly reliable (ICC = 0.912) and the Cronbach's alpha was 0.954. There was a high correlation between the total GI score and EQ-5D-5L and SF-36v2 scores. (4) Conclusion: The Portuguese version of UCLA GIT 2.0 showed good psychometric properties and can be used in research and clinical practice.

Concomitant ischemic stroke and myocarditis as the initial clinical presentation of Takayasu arteritis

Tayakasu arteritis (TA) is a chronic large-vessel systemic vasculitis more frequent in women. The pathogenesis of TA is not fully understood. Due to its silent and heterogenous nature, it is a challenging diagnosis, with no specific diagnostic tests. We report the case of a 45-year-old woman presenting with a concomitant ischemic stroke and myocarditis as an atypical presentation of Takayasu arteritis, revealing its heterogeneous nature. The pre-existent myocardial scar and dilated cardiomyopathy are is a reminder of how silent yet aggressive this vasculitis can be and the need of for high level of suspicion to detect and treat Takayasu arteritis early, avoiding late consequences. Corticosteroids (0.5-1.0mg/kg/day) are the mainstay treatment associated with steroid-sparing drugs, such as methotrexate or azathioprine.

A Rare Cause of Low Back Pain: A Challenging Diagnosis

One of the rarest causes of low back pain is septic arthritis of a lumbar facet joint. We report the case of a 92-year-old diabetic woman with a history of four days of back pain, dysuria, and fever. Due to a sudden worsening of lumbar pain, she went to the emergency department. Physical exam revealed pain with pressure over the D12 vertebral apophyses and the lower-left paraspinal musculature. Laboratory data showed a normochromic normocytic anemia with a hemoglobin of 9.3 g/dL, white cell count of 14.61x10e3/µL (83.1% neutrophils), serum creatinine 1.46 mg/dL and C-reactive protein of 32.11 mg/dL. In urinalysis, nitrites and leukocyturia were identified. CT scan showed an acute D12 fracture and fat stranding at L5, with no irregularities in the discs or in other lumbar spaces. Escherichia coli was isolated in blood culture. Lumbar MRI confirmed the diagnosis of septic arthritis of an L5-S1 facet joint and L5 vertebrae osteomyelitis. The patient was successfully treated with intravenous ceftriaxone for eight weeks. As far as we know, this is the second report of septic arthritis of the facet joint caused by Escherichia coli.

POS0901 INTERSTITIAL LUNG DISEASE IN MIXED CONNECTIVE TISSUE DISEASE: CLINICAL AND SEROLOGICAL ASSOCIATIONS

Background

Mixed connective tissue disease (MCTD) is a rare systemic rheumatic disease characterized by the expression of autoantibodies targeting the U1-ribonucleoprotein and overlapping clinical features of systemic sclerosis, systemic lupus erythematosus, and inflammatory myopathies. Interstitial lung disease (ILD) is present in 47% to 78% of patients and has been associated with higher mortality rates. Associations of ILD with Raynaud’s phenomenon, dysphagia, anti-Ro52 antibodies, and a scleroderma pattern on nailfold capillaroscopy have been reported in MCTD patients.

Objectives

This study aims to identify clinical and serological associations and independent predictors of ILD for patients with MCTD.

Methods

Multicenter retrospective study using data collected from clinical records. Adult patients who underwent lung computed tomography (CT) and met at least one of four MCTD diagnostic criteria (Sharp, Alarcón-Segovia, Kasukawa, or Kahn criteria) were included. Univariate analysis was performed using Chi-Square, Fischer’s Exact, and Mann-Whitney tests, as appropriate. Multivariate analysis was performed using binary logistic regression modelling. The linearity of the continuous variables concerning the logit of the dependent variable was assessed via the Box-Tidwell procedure. Cases with missing information and outliers were excluded from the multivariate analysis to fulfil all assumptions necessary to assure the validity of the regression.

Results

Fifty-seven patients, of whom 37 were Caucasian (64.9%) and 48 were females (84.2%), with a mean age of 39.4±14.0 years, were included. Twenty-seven patients had ILD (47.4%), of whom 22 had nonspecific interstitial pneumonia (81.5%), 4 had usual interstitial pneumonia (14.8%), and 1 had lymphoid interstitial pneumonia (3.7%) pattern on CT. Among patients with ILD, 13 were asymptomatic (48.1%), while 14 had respiratory symptoms (51.9%), including dyspnea (N=13, 48.1%), cough (N=7, 25.9%), and pleuritic chest pain (N=1, 3.7%). Pulmonary function tests were performed in 22 patients (81.5%), 20 of whom had a restrictive pattern (90.9%).

In the univariate analysis, lymphadenopathy at disease onset (22.2% vs 3.3%, p=0.045) and esophageal involvement at any time point (40.7% vs 16.7%, p=0.043), were associated with ILD.

The binary logistic regression model predicting ILD included 56 patients, and the model explained 36.5% (Nagelkerke R2) of the variance in ILD and correctly classified 75% of all cases. Older age at diagnosis (OR 1.10/year, 95%CI: 1.00-1.12, p=0.046) and lymphadenopathy at disease onset (OR 19.65, 95%CI: 1.91-201.75, p=0.012) were identified as predictors of ILD in MCTD patients, irrespective of sex and esophageal involvement.

Conclusion

Older age at diagnosis and lymphadenopathy at disease onset were independent predictors of ILD in MCTD. Therefore, these factors should be considered when evaluating MCTD patients, especially at the time of diagnosis. To the best of our knowledge, this is the largest study ever describing predictors of ILD for MCTD patients.

References

[1]Fagundes MN, Caleiro MT, Navarro-Rodriguez T, Baldi BG, Kavakama J, Salge JM, Kairalla R, Carvalho CR. Esophageal involvement and interstitial lung disease in mixed connective tissue disease. Respir Med. 2009 Jun;103(6):854-60. doi: 10.1016/j.rmed.2008.12.018. Epub 2009 Feb 6. PMID: 19201182.

[2]Gunnarsson R, Aaløkken TM, Molberg Ø, Lund MB, Mynarek GK, Lexberg AS, Time K, Dhainaut AS, Bertelsen LT, Palm O, Irgens K, Becker-Merok A, Nordeide JL, Johnsen V, Pedersen S, Prøven A, Garabet LS, Gran JT. Prevalence and severity of interstitial lung disease in mixed connective tissue disease: a nationwide, cross-sectional study. Ann Rheum Dis. 2012 Dec;71(12):1966-72. doi: 10.1136/annrheumdis-2011-201253. Epub 2012 May 1. PMID: 22550317

Disclosure of Interests

None declared

AB0655 Clinical and immunological features of a Portuguese cohort of Mixed Connective Tissue Disease

Background

Various nationwide studies have been already published to better understand Mixed Connective Tissue Disease (MCTD) (1,2). However, Portuguese data is not available.

Objectives

To characterize clinical and immunological features of a Portuguese cohort of patients with MCTD.

Methods

Retrospective, multicenter study including adult-onset patients with clinical diagnosis of MCTD and fulfilling at least one of the following classification criteria: Sharp, Kasukawa, Alarcón-Segovia or the Kahn’s criteria. Positivity to other autoantibodies besides anti-U1-RNP were allowed. SPSS was used for statistical analysis and significance level was defined as 2-sided p<.05.

Results

A total of 98 patients were included, with a mean age at diagnosis and disease duration of 40.5±13.7 and 7.0±6.5 years, respectively. Most patients were female (87.8%) and Caucasian (70.4%). Raynaud’s phenomenon (96.9%), arthralgia/arthritis (94.9/74.5%) and puffy fingers (60.2%) were the most common and early manifestations. Gastroesophageal (GE), respiratory and muscular involvement were also prevalent, mostly during the follow up, affecting 30.6%, 34.7% and 43.9% of the patients, respectively. Clinical and immunological characteristics are described in Table 1. Males were older at symptom’s onset (65.0 VS 46.7, p=.035), having more respiratory involvement (OR=4.5, 95% CI 1.3-16.4), and positivity to anti-ACPA (OR=20.0, 95% CI: 3.1-129.4). GE involvement occurred more often in Caucasian patients (OR=3.8; 95% CI: 1.0-14.1), while anemia of chronic diseases (OR=2.7; 95% CI: 1.0-7.2), myositis (OR=3.6; 95% CI: 1.3-9.9) and constitutional symptoms (OR=3.2; 95% CI: 1.2-8.3) were more frequent in Afro-American patients, whose were also younger at disease (34.1 VS 50.6, p=.01). After a median follow-up time of 4 (IQR 8) years, 4 deaths occurred (4.1%), mostly (75%) due to infectious complications.

Table 1.

Clinical and immunological characteristics

Clinical ManifestationsAt presentationFollow-upMucocutaneous systemRaynaud’s phenomenon, n (%)85 (86.7)95 (96.9)Puffy hands, n (%)48 (49.0)59 (60.2)SSc-like, n (%)43 (44.8)59 (60.8)SLE-like, n (%)28 (28.9)35 (35.7)Musculoskeletal systemArthralgia/Arthritis, n (%)/n (%)81 (82.7) / 56 (57.1)93 (94.9) / 73 (74.5)Myositis, n (%)26 (25.6)43 (43.9)Hematological system, n (%)46 (46.9)70 (71.4)Respiratory system, n (%)14 (14.3)34 (34.7)Cardiovascular system3 (3.1)4 (4.1)Pulmonary hypertension*2 (2.0)15 (15.3)Gastroesophageal involvement, n (%)11 (11.2)30 (30.6)Renal involvement, n (%)2 (2.0)10 (10.2)Neurological involvement, n (%)6 (6.3)14 (14.3)Constitutional symptoms, n (%)26 (26.5)30 (30.6)Immunological characteristicsAnti-dsDNA, n (%)21 (21.4)Anti-smith antibody, n (%)21 (21.4)Anti-Ro/SSA, n (%)31 (31.6)Anti-La/SSB, n (%)7 (7.1)Anti-centromere, n (%)3 (4.1)Rheumatoid Factor, n (%)39 (39.8)Anti- anti-citrullinated protein antibodies, n (%)6 (6.1)Antiphospholipid antibodies, n (%)7 (7.1)Myositis antibodies, n (%)9 (9.2)Complement activation, n (%)27 (27.6)Hypergammaglobulinemia, n (%)51 (52.0)

Legend: Anti-dsDNA: anti-double stranded deoxyribonucleic acid antibody; SLE: systemic lupus erythematosus, SSc: systemic sclerosis. *No information regarding cardiac catheterism, then compatible alterations in the echocardiogram.

Conclusion

Raynaud’s phenomenon, puffy fingers and arthritis were the most common manifestations in Portuguese patients, with similar proportions found in literature (1,2). However, we reported some differences in mucocutaneous, renal and serosa involvement and higher prevalence of probable pulmonary hypertension (1,2), which may be explained by the heterogeneity of the inclusion criteria. Except for respiratory, myositis, GE and constitutional symptoms, there were no differences regarding gender and ethnicity.

Here, we characterize the largest cohort of MCTD in Portugal.

References

[1]Cappelli S, et al. Semin Arthritis Rheum. 2012 Feb;41(4):589–98.

[2]Alves MR et al. Clin Exp Med. 2020 May;20(2):159–66.

Disclosure of Interests

None declared

POS0891 REUMA.pt/MYOSITIS – THE PORTUGUESE REGISTRY OF INFLAMMATORY MYOPATHIES

Background

The idiopathic inflammatory myopathies (IMM) module of the Rheumatic Diseases Portuguese Register (Reuma.pt/Myositis) is a tool used to systematically evaluate IIM patients.

Objectives

To clinically characterise the Reuma.pt/Myositis cohort.

Methods

Multicentre open cohort study, including IIM patients registered in Reuma.pt up to January 2022. Data collected included demographic, clinical, and treatment data and patient-reported outcomes. Data were presented as frequencies and median (interquartile range) for categorical and continuous variables, respectively.

Results

280 patients were included, 71.4% female, 89.4% Caucasian, with a median age at diagnosis and disease duration of 48.9 (33.6-59.3) and 5.3 (3.0-9.8) years, respectively. Patients were classified as having definite (N=57/118, 48.3%; N=35/224, 15.6%), likely (N=23/118, 19.5%; N=50/224, 22.3%), or possible (N=2/118, 1.7%; N=46/224, 20.5%) IIM by 2017 EULAR/ACR and Bohan-Peter criteria, respectively. Disease subtypes included dermatomyositis (DM, N=122/280, 43.6%), polymyositis (N=59/280, 21.1%), myositis in overlap syndromes (N=41/280, 14.6%), clinically amyopathic DM (N=17/280, 6.1%), nonspecific myositis (N=13/280, 4.6%), mixed connective tissue disease (N=12/280, 4.3%), immune-mediated necrotizing myositis (N=9/280, 3.2%), and inclusion bodies myopathy (N=7/280, 2.5%). Over the course of the disease, the most common symptoms were proximal muscle weakness (N=180/215, 83.7%), arthralgia (N=127/249, 52.9%), erythema (N=63/166, 38.0%), fatigue (N=47/127, 37.0%), Raynaud’s phenomenon (N=76/234, 32.5%), and dysphagia (N=33/121, 27.3%), and the most common clinical signs were Gottron’s sign (N=75/184, 40.8%), heliotrope rash (N=101/252, 40.1%), Gottron’s papules (N=93/237, 39.2%), and arthritis (N=38/98, 38.8%). Organ involvement included lung (N=78/230, 33.9%), oesophageal (N=40/221, 18.1%), and heart (N=11/229, 4.8%) involvements. Most patients expressed myositis-specific (MSA, N=158/242, 65.3%) and/or myositis-associated (MAA, 112/242, 46.3%) antibodies. The most frequent antibodies were anti-SSA/SSB (N=70/231, 30.3%), anti-Jo1 (N=56/236, 23.7%), and anti-Mi2 (N=31/212, 14.6%). Most patients had a myopathic pattern on electromyogram (N=101/138, 73.2%), muscle oedema in magnetic resonance (N=33/62, 53.2%), and high CK (N=154/200, 55.0%) and aldolase levels (N=74/135, 54.8%) at diagnosis, with median highest CK levels of 1308 (518-3172) and aldolase of 42 (12-121) mg/dL. Neoplasia was found in 11/127 patients (8.7%), most commonly breast (N=3/11, 27.3%), non-melanoma skin (N=2/11, 18.2%), and colorectal (N=2/11, 18.2%) cancer (Table 1). Most patients with cancer-associated myositis had DM (N=8/11, 72.7%) and expressed MSA (N=6/11) and/or MAA (N=3/11). The most used drugs over the course of disease were glucocorticoids (N=201/280, 71.8%), methotrexate (N=117/280, 41.8%), hydroxychloroquine (N=87/280, 31.1%), azathioprine (N=85/280, 30.4%), mycophenolate mofetil (N=56/280, 20.0%), intravenous immunoglobulin (N=55/280, 19.6%), and rituximab (N=45/280, 16.1%). At the last follow-up, there was a median MMT8 of 150 (142-150), modified DAS skin of 0 (0-1), global VAS of 10 (0-50) mm, and HAQ of 0.125 (0.000-1.125).

Table 1.

Autoantibodies in cancer-associated myositis

CancerIIMAutoantibodiesBreastDM (3)Mi2, SRP (+ SSA/SSB), Pm/SclSkin (non-melanoma)Clinically amyopathic DM, PMJo1, SAE1 (+SSA/SSB)ColorectalDM (2)Mi2 (2)KidneyDM-LungDM-LymphomaInclusion bodies myopathy-UnknownDM-

Conclusion

Reuma.pt/Myositis adequately captures the main features of inflammatory myopathies’ patients, depicting in this first report a heterogeneous population, with frequent muscle, joint, skin and lung involvements. Of interest, most patients reached low disease activity at the last follow-up appointment.

Disclosure of Interests

None declared

AB0688 Predictors of muscle involvement in Portuguese patients with mixed connective tissue disease

Background

Mixed connective tissue disease (MCTD) is a rare heterogeneous disease, characterized by overlapping features of classic connective tissue diseases. Myositis may be present in up to two-thirds of patients with MCTD and it is included in all diagnostic criteria available. Although some possible associations have been reported, to the best of our knowledge, no independent predictors of MCTD-related myositis have been described.

Objectives

To identify clinical and laboratorial predictors for muscular involvement in a cohort of Portuguese patients with MCTD.

Methods

Multicentre retrospective cohort study including adult-onset patients with a clinical diagnosis of MCTD and fulfilling at least one of the following diagnostic criteria: Sharp, Kasukawa, Alarcón-Segovia or Kahn criteria. Myositis was defined as proximal muscle weakness, creatine kinase elevation, electromyography (EMG) suggestive changes or a positive muscular biopsy. Univariate analysis was performed using Chi-Square, Fischer’s Exact Test and Mann-Whitney Test, as appropriate. Multivariate analysis was performed using binary logistic regression modelling. The linearity of the continuous variables concerning the logit of the dependent variable was assessed via the Box-Tidwell procedure. Cases with missing information and outliers were excluded from the multivariate analysis to fulfil all assumptions necessary to assure the validity of the regression.

Results

A total of 98 patients were included, 43 (44.3%) of whom had muscular involvement at any time of the disease course. Concerning patients with MCTD-related myositis, the mean age at diagnosis was 34.8±12.5 years and the mean disease duration of 4.1±4.9 years. The majority of patients were female (90.7%) and of European ancestry (66.7%).

EMG was performed in 24 patients, of whom 10 (41.7%) had a myopathic pattern. Seventeen patients were submitted to a muscular biopsy, of whom 8 (47.1%) had histological myositis features. Capillaroscopy was performed in 24 patients and 12 (50%) had a scleroderma pattern.

African ancestry and leukopenia were positively associated with myositis at disease onset. Furthermore, fever at the onset of disease, younger age at diagnosis and shorter disease duration were positively associated with the occurrence of myositis at any phase of the disease.

The multivariate analyses predicting myositis at diagnosis included 54 patients and at any time of the disease included 90 patients. These models explained 37.8% and 26.9% (Nagelkerke R2) of the variance in myositis and correctly classified 79.6% and 73.3% of all cases, respectively.

African ancestry (OR 8.39, 95%CI: 1.43-49.37, p=0.019), leukopenia (OR 6.24, 95%CI: 1.32-29.48, p=0.021) and younger age at diagnosis (OR 1.07/year, 95%CI: 1.01-1.14, p=0.035) were identified as independent predictors of myositis at diagnosis. Fever (OR 6.51, 95%CI: 1.23-34.37, p=0.027) was an independent predictor of muscular involvement at any time of the disease in MCDT patients.

Conclusion

African ancestry, leukopenia and younger age at diagnosis are independent predictors of myositis at presentation in MCTD patients, while fever is an independent predictor of myositis at any time of the disease. While evaluating patients with MCTD, these predictive factors should be considered.

References

[1]Ciang NCO, Pereira N, Isenberg DA. Mixed connective tissue disease-enigma variations? Rheumatol. 2017 Mar 1;56(3):326–33.

[2]Hall S, Hanrahan P. Muscle involvement in mixed connective tissue disease. Rheum Dis Clin North Am. 2005 Aug;31(3):509–17, vii.

Disclosure of Interests

None declared

AB0416 THE IMPACT OF FATIGUE ON SYSTEMIC SCLEROSIS PATIENTS

Background:

Fatigue is a frequent and commonly undervalued symptom among rheumatic disease, including Systemic Sclerosis (SSc).1,2

Objectives:

To determine the prevalence of severe fatigue in a SSc cohort and to evaluate how it correlates with disability, quality of life and mental illness.

Methods:

A cross-sectional study was conducted evaluating a cohort of SSc patients. Fatigue was evaluated using Functional Assessment Chronic Illness Therapy (Fatigue) (FACIT-F) questionnaire. A value < 30 was defined as severe fatigue. Health Assessment Questionnaire (HAQ), Scleroderma HAQ (SHAQ), 36-Item Short Form Health Survey (SF-36), EuroQol-5D (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) questionnaires were also filled. Clinical data was obtained and analysed.

Results:

We included 20 patients, 17 females [n = 17 (85%)], median (min, max) age was 52.5 (28, 75) years-old. Regarding disease classification, 13 (65%) had limited SSc, 4 (20%) had diffuse SSc and 3 (15%) had early SSc. The median FACIT-F score was 34 (3, 48). The prevalence of severe fatigue was 40% (n = 8). Fatigue had a moderate negative correlation with HAQ (τ = -0.641; p < 0.001) and a weak negative correlation with lung (τ = -0.345; p = 0.039) and gastrointestinal (τ = -0.419; p = 0.011) involvements and with patient global assessment (τ = -0.325; p = 0.047) subtopics of SHAQ. A moderate positive correlation was found between FACIT-F and EQ-5D (τ =0.625; p < 0.001) and physical functioning (τ = 0.560; p = 0.001) and vitality (τ = 0.777; p < 0.001) domains of SF-36. The remaining SF-36 domains had a weak positive correlation with FACIT-F (Table 1). Regarding mental illness, there was a moderate negative correlation between FACIT-F and HADS-D (τ = -0.638; p < 0.001) and HADS-A (τ =-0.535; p = 0.001).

Conclusion:

Severe fatigue is frequent among SSc patients. The greater the fatigue, the greater the disability, the lower the quality of life and the worse the score on the scale of depression and anxiety.

References:

[1]F. Basta, A. Afeltra, D.P.E. Margiotta. Fatigue in systemic sclerosis: a systematic review. Clin Exp Rheumatol 2018; 36 (Suppl. 113): S150-S160

[2]Sarah Hewlett, Emma Dures, And Celia Almeida. Measures of Fatigue. Arthritis Care & Research Vol. 63, No. S11, November 2011, pp S263–S286

Table 1.

Correlation of FACIT-F with measures of disability, quality of life and mental illness

VariablesKendall’s τ coefficientp-valueHAQ-0.6410.000SHAQ - GI involvement-0.3450.039 - Lung involvement-0.4190.011 - Vascular involvement-0.2150.192 - Digital ulcers0.1020.549 - Patient global assessment-0.3250.047EQ-5D0.6250.000SF-36 - Physical functioning0.5600.001 - Role physical0.4910.003 - Bodily pain0.4630.006 - General health0.3410.045 - Vitality0.7770.000 - Social functioning0.4430.009 - Role emotional0.3500.041 - Mental health0.3760.024HADS-D-0.6380.000HADS-A-0.5350.001

Disclosure of Interests:

None declared

AB0415 ANXIETY AND DEPRESSION IN SSc – ASSESSING FUNCTION, QUALITY OF LIFE AND GASTROINTESTINAL INVOLVEMENT

Background:

Systemic Sclerosis (SSc) is a chronic disease with multi-organ manifestations that may contribute to disability and low quality of life.1 Therefore, anxiety and depression are more frequent in SSc patients than in general population.2

Objectives:

To assess the prevalence of anxiety and depression in a SSc cohort and to evaluate its correlation with function, quality of life and assessment of gastrointestinal (GI) involvement scores.

Methods:

A cross-sectional study was conducted evaluating a cohort of SSc patients. All patients answered to the Hospital Anxiety and Depression Scale (HADS) questionnaire. A cut-off score < 8 was considered normal. Health Assessment Questionnaire (HAQ), Scleroderma HAQ (SHAQ), 36-Item Short Form Health Survey (SF-36), EuroQol-5D (EQ-5D) and University Of California, Los Angeles, Scleroderma Clinical Trials Consortium Gastrointestinal Scale (UCLA SCTC GIT) 2.0 questionnaires were also obtained. Clinical data was obtained and analyzed.

Results:

We included 20 patients, 17 females [n = 17 (85%)], median (min, max) age was 52.5 (28, 75) years-old. Regarding disease classification, 13 (65%) had limited SSc, 4 (20%) had diffuse SSc and 3 (15%) had early SSc. A score ≥ 8 was found in 14 (70%) patients on HADS-A [median (min, max) = 9 (2, 19)] and in 12 (60%) patients on HADS-D [median (min, max) = 8 (1, 15)]. Depressive patients had significantly worst scores on the measures of function, such as HAQ and lung and gastrointestinal involvements and patient global assessment of SHAQ, of quality of life, such as EQ-5D and physical functioning, role physical, bodily pain, vitality, social functioning and mental health domains of SF-36, and on the UCLA SCTC GIT 2.0 scale. Anxious patients had significantly worst scores on social functioning and mental health domains of SF-36 and on the UCLA SCTC GIT 2.0 scale (Table 1).

Conclusion:

The prevalence of depression and anxiety on SSc patients is high and should not be neglected. Overall disability and multiorgan manifestations, particularly GI involvement, may contribute to a low quality of life and consequently to depression and anxiety.

References:

[1]Firestein & Kelley’s Textbook of Rheumatology 2-Volume Set, 11th Edition

[2]Brett D. Thombs et al. Depression in Patients With Systemic Sclerosis: A Systematic Review of the Evidence. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 57, 2007, pp 1089–1097

Table 1.

Function, quality of life and gastrointestinal (GI) involvement assessment according to HADS score.

Results, median [min, max]HADS-D ≥ 8 (n = 12)HADS-D < 8 (n = 8)P-valueHADS-A ≥ 8 (n = 14)HADS-A < 8 (n = 6)P-valueSHAQ- GI involvement26.5 [0, 90]2 [0, 40]0.00918.5 [0, 90]2.5 [0, 40]0.091- Lung involvement48.5 [5, 90]2.5 [0, 30]0.00118 [0, 90]3 [0, 65]0.126- Patient global assessment67.5 [30, 100]4 [0, 85]0.01153.5 [2, 100]41.5 [0, 85]0.509HAQ1.375 [0.5, 2]0.1875 [0, 1]0.0011.25 [0, 2]0.875 [0, 1.125]0.147EQ5D0.3667 [-0.0573, 0.6937]0.6752 [0.2870, 1]0.0060.4640 [-0.0573, 0.7667]0.6752 [0.287, 1]0.075SF36- Physical functioning25 [15, 75]75 [50, 100]0.00140 [15, 100]72.5 [25, 85]0.106- Role physical31.25 [0, 75]72.875 [31.25, 100]0.02537.5 [0, 100]65.625 [31.25, 100]0.214- Bodily pain41 [0, 74]68 [20, 88]0.01141 [0, 88]61.5 [20, 74]0.428- Vitality25 [0, 43.75]65.625 [25, 75]0.00137.5 [0, 75]65.625 [12.5, 75]0.135- Social functioning37.5 [12.5, 87.5]87.5 [50, 100]0.00250 [12.5, 100]87.5 [87.5, 100]0.003- Mental health45 [25, 80]65.7 [51.4, 85]0.01245 [25, 75]77.5 [51.4, 85]0.005UCLA SCTC GIT 2.0- Reflux0.38 [0, 1.25]0 [0, 1.25]0.0240.25 [0, 1.25]0 [0, 1]0.139- Distension1 [0.5, 2]0.25 [0, 1.5]0.0171 [0.25, 2]0.125 [0, 1]0.024- Total0.44[0.1, 0.99]0.04 [0, 0.97]0.0100.34 [0.04, 0.99]0.02 [0, 0.44]0.018

Disclosure of Interests:

None declared