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Concept: Rheumatoid arthritis


BACKGROUND: Foot deformities and related problems of the forefoot are very common in patients with rheumatoid arthritis. The laxity of the medial cuneometatarsal joint and its synovitis are important factors in the development of forefoot deformity. The impaired joint causes the first metatarsal bone to become unstable in the frontal and sagittal planes. In this retrospective study we evaluated data of patients with rheumatoid arthritis who underwent Lapidus procedure. We evaluated the role of the instability in a group of patients, focusing mainly on the clinical symptoms and X-ray signs of the instability. METHODS: The study group included 125 patients with rheumatoid arthritis. The indications of the Lapidus procedure were a hallux valgus deformity greater than 15 degrees and varus deformity of the first metatarsal bone with the intermetatarsal angle greater than 15 degrees on anterio-posterior weight-bearing X-ray. RESULTS: Data of 143 Lapidus procedures of 125 patients with rheumatoid arthritis, who underwent surgery between 2004 and 2010 was evaluated. Signs and symptoms of the first metatarsal bone instability was found in 92 feet (64.3 %) in our group. The AOFAS score was 48.6 before and 87.6 six months after the foot reconstruction. Nonunion of the medial cuneometatarsal joint arthrodesis on X-rays occurred in seven feet (4.9 %). CONCLUSION: The Lapidus procedure provides the possibility to correct the first metatarsal bone varus position and its instability, as well as providing the possibility to achieve a painless foot for walking. We recommend using the procedure as a preventive surgery in poorly symptomatic patients with rheumatoid arthritis in case of the first metatarsal bone hypermobility.

Concepts: Foot, Bunion, Varus deformity, Rheumatoid arthritis, Arthritis, Skeletal disorders, Valgus deformity, Tarsus


Considering importance of ganglioside antibodies as biomarkers in various immune-mediated neuropathies and neurological disorders, we developed a high throughput multiplexing tool for the assessment of gangliosides-specific antibodies based on Biolpex/Luminex platform. In this report, we demonstrate that the ganglioside high throughput multiplexing tool is robust, highly specific and demonstrating ∼100-fold higher concentration sensitivity for IgG detection than ELISA. In addition to the ganglioside-coated array, the high throughput multiplexing tool contains beads coated with influenza hemagglutinins derived from H1N1 A/Brisbane/59/07 and H1N1 A/California/07/09 strains. Influenza beads provided an added advantage of simultaneous detection of ganglioside- and influenza-specific antibodies, a capacity important for the assay of both infectious antigen-specific and autoimmune antibodies following vaccination or disease. Taken together, these results support the potential adoption of the ganglioside high throughput multiplexing tool for measuring ganglioside antibodies in various neuropathic and neurological disorders.

Concepts: Immune system, Medicine, Infectious disease, Infection, Immunology, Rheumatoid arthritis, ELISA, Pain


Anti-drug antibodies (ADAs) against biologic agents may be clinically significant and potentially alter a biologic drug’s treatment efficacy. This systematic review aims to 1) determine the prevalence of ADAs against infliximab, etanercept, adalimumab, and ustekinumab in psoriasis patients; 2) ascertain whether ADAs are associated with changes in drug efficacy; and 3) explore the use of concomitant methotrexate to prevent ADA formation. Through a systematic search using MEDLINE and EMBASE from January 29, 1950 to March 29, 2013, we identified 25 studies that met the inclusion criteria. Of 7,969 psoriasis patients, 950 patients tested positive for ADAs. Antibodies against infliximab, etanercept, adalimumab, and ustekinumab were reported in 5.4%-43.6%, 0.0%-18.3%, 6.6%-44.8%, and 3.8%-5.5% of patients, respectively. Anti-infliximab antibodies were associated with lower serum infliximab concentrations in three studies and decreased treatment response in five studies. ADAs against etanercept were non-neutralizing and not associated with any apparent effects on clinical response. Anti-adalimumab antibodies were associated with lower serum adalimumab concentrations in three of five studies and reduced clinical efficacy in four studies. Two of six studies reported that anti-ustekinumab antibodies were associated with lower PASI responses, and three ustekinumab studies noted that most of these antibodies were neutralizing. Although the use of concomitant methotrexate with biologic agents to prevent ADA formation in other immune-mediated diseases is promising, their use in psoriasis is sparse. ADA development remains a challenge with biologic therapies and therefore should be considered in psoriasis patients who experience diminished treatment response. This article is protected by copyright. All rights reserved.

Concepts: Monoclonal antibodies, Rheumatoid arthritis, Infliximab, Ankylosing spondylitis, Psoriatic arthritis, Psoriasis, Etanercept, Adalimumab


BACKGROUND: Metabolic syndrome, a cluster of classical cardiovascular risk factors, including hypertension, obesity, glucose intolerance, and dyslipidemia is highly prevalent in patients with rheumatoid arthritis (RA). The aim of the study was to assess the frequency of metabolic syndrome (MS) in RA patients, and to evaluate the relationships between metabolic syndrome and RA. METHODS: The study was conducted on 120 RA patients according to the 1987 revised American College of Rheumatology classification criteria, and 100 age and sex matched apparently healthy controls. The frequency of metabolic syndrome was assessed using six Metabolic Syndrome definitions (Joint Consensus 2009, National Cholesterol Education Programme 2004 and 2001, International Diabetes Federation, World Health Organisation and European Group for Study of Insulin Resistance). Logistic regression was used to identify independent predictors of metabolic Syndrome. RESULTS: the frequency of metabolic syndrome varied from 18 to 48.6% in RA according to the definition used and was significantly higher than controls (for all definitions p<0.05). In multivariate analysis, higher ESR was independently associated with the presence of Met S (OR =1.36; CI: 1.18--2.12; p = 0.03). Glucocorticoid use, but not other disease modifying anti-rheumatic drugs (DMARDs), values remained significant independent predictors of the presence of metabolic syndrome in RA patients (OR = 1.45; CI: 1.12--2.14; p = 0.04). CONCLUSIONS: In summary, the frequency of metabolic syndrome in RA varies according to the definition used and was significantly higher compared to controls (for all definitions p<0.05). Higher systemic inflammatory marker, and glucocorticoids use were independent predictors associated with the presence of metabolic syndrome in patients with RA. These findings suggest that physicians should screen for metabolic syndrome in patients with RA to control its components and therefore reduce the risk of cardiovascular disease in these patients.

Concepts: Nutrition, Atherosclerosis, Insulin, Diabetes mellitus, Obesity, Rheumatoid arthritis, Rheumatology, Metabolic syndrome


INTRODUCTION: Sweet’s syndrome is an acute neutrophilic dermatosis characterized by a diffuse dermal infiltrate of mature neutrophils. In most cases, it occurs as an isolated phenomenon (idiopathic Sweet’s syndrome) but it can be drug induced or associated with a variety of underlying diseases such as infections, neoplasms, and chronic inflammatory diseases. The association between Sweet’s syndrome and ankylosing spondylitis is rare. Only a few cases have been reported in the literature. We report a new case in which we describe an outbreak of acute neutrophilic dermatosis revealing ankylosing spondylitis. CASE PRESENTATION: A 33-year-old Moroccan man presented with large-joint polyarthralgia, inflammatory pain in his buttocks and lower lumbar spine, fever and skin lesions. On examination, the patient had a low-grade fever, six tender but not swollen joints, limitation of motion of the lumbar spine, and painful erythematous maculopapules over his face, neck, and hands. Laboratory tests showed hyperleukocytosis, and elevated erythrocyte sedimentation rate and C-reactive protein. The immunological tests and infectious disease markers were negative. Investigations for an underlying neoplastic disease remained negative. Magnetic resonance imaging showed a bilateral sacroiliitis. Skin biopsy findings were consistent with Sweet’s syndrome. The diagnosis of Sweet’s syndrome associated with ankylosing spondylitis was established. Nonsteroid anti-inflammatory drugs were started and the patient showed rapid clinical and biological improvement. CONCLUSION: Three observations of the association between Sweet’s syndrome and spondylarthropathy have been reported in the literature. The cause of this association remains unclear. Some hypotheses have been developed, but further studies are needed to confirm or refute them.

Concepts: Inflammation, Cancer, Infectious disease, Infection, Lumbar vertebrae, Rheumatoid arthritis, Non-steroidal anti-inflammatory drug, C-reactive protein


Hand pain is a relatively common complaint, and careful anamnesis and clinical examination may reveal its aetiology. Multiple joint involvement suggests either osteoarthritis or inflammatory arthritis. In the returning traveller, a more exotic explanation might be the case. A 31 year old woman was referred to our outpatient clinic for evaluation due to peripheral joint arthralgia. The symptoms started six months earlier, on the same day she returned from a three-week holiday in India. There were no signs of inflammatory arthritis or osteoarthritis. Blood tests were normal. Chikungunya virus serology was positive. The patient received symptomatic treatment with nonsteroid anti-inflammatory drugs and improved over a period of months. We describe the first case of Chikungunya fever diagnosed in our hospital.

Concepts: Inflammation, Hospital, Rheumatoid arthritis, Greek loanwords, Osteoarthritis, Non-steroidal anti-inflammatory drug, Arthralgia, Chikungunya


Among 101 feet that presented with symptoms and signs similar to Morton’s neuroma, intermetatarsal rheumatoid nodules were found in five feet (three patients). Two patients had bilateral involvement. Histology of the excised tissue showed the presence of a rheumatoid nodule and Morton’s neuroma in four feet and a rheumatoid nodule with unremarkable nerve bundles in one. A rheumatoid nodule can coexist with Morton’s neuroma, as seen in our patients, and the presentation is often similar to that of a Morton’s neuroma. Our patients were rendered asymptomatic with surgical treatment and went on to have appropriate management of rheumatoid arthritis. Rheumatoid nodule should be considered in the differential diagnosis of Morton’s neuroma in not only rheumatoid arthritis patients but also asymptomatic patients who have never been tested for rheumatoid antibodies.

Concepts: Medical terms, Rheumatoid arthritis, Rheumatology, Histopathology, Greek loanwords, Arthritis, Morton's neuroma, Rheumatoid nodule


BACKGROUND: Variations in the treatment of juvenile idiopathic arthritis (JIA) may impact on quality of care. The objective of this study was to identify and compare treatment approaches for JIA in two health care systems. METHODS: Paediatric rheumatologists in Canada (n=58) and Germany/Austria (n=172) were surveyed by email, using case-based vignettes for oligoarticular and seronegative polyarticular JIA. Data were analysed using descriptive statistics; responses were compared using univariate analysis. RESULTS: Total response rate was 63%. Physicians were comparable by age, level of training and duration of practice, with more Canadians based in academic centres. For initial treatment of oligoarthritis, only approximately half of physicians in both groups used intra-articular steroids. German physicians were more likely to institute DMARD treatment in oligoarthritis refractory to NSAID (p<0.001). Canadian physicians were more likely to switch to a different DMARD rather than a biologic agent in polyarthritis refractory to initial DMARD therapy. For oligoarthritis and polyarthritis, respectively, 86% and 90% of German physicians preferred regular physiotherapy over home exercise, compared to 14% and 15% in Canada. Except for a Canadian preference for naproxen in oligoarthritis, no significant differences were found for NSAID, intra-articular steroid preparations, initial DMARD and initial biologic treatment. CONCLUSIONS: Treatment of oligo- and polyarticular JIA with DMARD is mostly uniform, with availability and funding obviously influencing physician choice. Usage of intra-articular steroids is variable within physician groups. Physiotherapy has a fundamentally different role in the two health care systems.

Concepts: Medicine, Rheumatoid arthritis, Physician, Pediatrics, Arthritis, Juvenile idiopathic arthritis, Canada, Preference


INTRODUCTION. Encephalitis associated to anti-N-methyl D-aspartate (NMDA) receptor antibodies is an autoimmune neurological pathology that has been reported increasingly more frequently in the paediatric population in recent years. We report two cases from our own experience with similar clinical pictures. CASE REPORTS. Case 1: a 5-year-old girl who began with clinical signs and symptoms of convulsions and altered consciousness, associated to movement disorders and regression of previously acquired abilities that developed into autism. Case 2: a 13-year-old girl who presented left-side hemiparesis, abnormal movements, conduct disorder and dysautonomia. In both cases positive anti-NMDA receptor antibodies were obtained in cerebrospinal fluid and they were diagnosed with anti-NMDA receptor encephalitis. In the first case, treatment was established with intravenous perfusion of corticoids and immunoglobulins, and rituximab also had to be associated. In the second case, treatment consisted in corticoids and immunoglobulins. Progress was favourable in both cases, with a slight language disorder as a sequela in the first case and a relapse in the second case, with full resolution. CONCLUSIONS. Anti-NMDA receptor encephalitis is a treatable disorder and early diagnosis and treatment are crucial, since this improves the prognosis and diminishes the chances of relapses.

Concepts: Immune system, Antibody, Medicine, Medical terms, Rheumatoid arthritis, Multiple sclerosis, Neurology, Medical diagnosis


Introduction and objectives: Behçet disease (BD) is a systemic immune-mediated vasculitis of unknown origin characterised by recurrent orogenital ulceration, ocular inflammation and skin lesions. The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with BD.

Concepts: Inflammation, Rheumatoid arthritis, Tinnitus, Otolaryngology