Current Rheumatology Reviews - Volume 13, Issue 1, 2017

The treatment of metacarpophalangeal destruction by rheumatoid arthritis is an indication for arthroplasty, the swanson spacer is one of the options. The flexible silicone spacer may be implanted with or without titanium guide sleeves ("grommets"). However, the imaginary abrasion protection for the silicone grommets may in turn lead through micro-movements to wear. A 69 years old female patient suffering from rheumatoid arthritis for 30 years is presented. 12 years ago swansen spacers were implanted to metacarpo-phalangeal joints 2 -5 of the right hand. Due to pain, limited movement and swelling at the volar MCP joints she presented at our clinic. Volar synovectomy of the 3rd ray of the right hand was performed, the A2 ring band could be spared. There was massive metallosis induced by wear of the grommets in the third volar tendon sheath, the other flexors were free of metallosis. These results show that in synovitis after swanson spacer implantation using grommets the differential diagnosis of metallosis must be included and complete synovectomy is the treatment of choice.

Sjogren's syndrome is a common autoimmune disease that presents with sicca symptoms and extraglandular features. Sjogren's syndrome is presumably as common as RA; yet it is poorly understood, underdiagnosed and undertreated. From the usual identity as an autoimmune exocrinopathy to its most recent designate as an autoimmune epithelitis – the journey of SS is complex. We herein review some of the most important milestones that have shed light on different aspects of pathogenesis of this enigmatic disease. This includes role of salivary gland epithelial cells, and their interaction with cells of the innate and adaptive immune system. Non-immune factors acting in concert or in parallel with immune factors may also be important. The risk genes identified so far have only weak association, nevertheless advances in genetics have enhanced understanding of disease mechanisms. Role of epigenetic and environmental role factors is also being explored. SS has also some unique features such as congenital heart block and high incidence of lymphoma; disease mechanisms accounting for these manifestations are also reviewed.

Rheumatoid arthritis is the most common form of inflammatory arthritis with a predilection for the hand and wrist. The aggressive nature of the disease can lead to severe joint destruction causing significant disability. Surgical options for pan-carpal arthritis include total wrist arthroplasty and total wrist fusion both with varying outcomes, yet both have a role in the carefully selected patients. Fusion remains a popular procedure with consistent reliable results with few complications. We present a review of current evidence, indications and guidance for both fusion and arthroplasty in rheumatoid arthritis.

Systemic lupus erythematous (SLE) is a multisystem autoimmune disorder characterized by immune dysregulation and formation of autoantibodies. A high index of suspicion is necessary to diagnose SLE. Children have more systemic involvement than adults. Kidney involvement is seen in a significant proportion of children. With advancement of therapy the survival rate of patients with SLE has significantly improved. Even then lupus nephritis is still the most important predictor of morbidity and mortality. Treatment of lupus nephritis is mostly derived from studies in adults as data on children is still lacking. Prednisolone and cyclophosphamide was the mainstay of treatment till now. Recently drugs like mycophenolate mofetil, azathioprine, rituximab are also being used in treatment of lupus nephritis with promising results and without significant adverse effects. In this review we will be discussing lupus nephritis, its diagnosis, pathogenesis, clinical picture and treatment advancements.

In many cases of rheumatoid arthritis (RA) joints of the upper extremities are affected. However, involvement of weight bearing joints of the lower extremities is strongly associated with a decreased activities of daily living ability such as gait disorder. Once the progression of weight bearing joint destruction occurs, lower extremity function will decrease even if RA disease activity is improved by pharmacotherapy. In this article, we investigated joint destruction suppressing effects of pharmacotherapy on the hip and knee joints, as well as risk factors for joint destruction. We also discuss surgical treatment strategies and clinical outcomes for progressive joint destruction.

Background: Ultrasound is one of the most promising candidates for the detection of inflammation and structural damage in hand osteoarthritis. Objective: To evaluate new advances of US as a diagnostic and prognostic tool in hand osteoarthritis assessment. Methods: We conducted a Medline on PubMed search for articles about “ultrasonography” and “hand OA” published between January 2012 and 15th April 2016, limiting our search to articles on human adults in English, excluding those involving systemic inflammatory diseases, visualization of joints other than hands, ultrasound guided injections and surgical procedures. Reviews, case reports, letters, position statements and ex vivo studies were excluded. Concordance between ultrasound and conventional radiography and magnetic resonance imaging was evaluated. Results: Total 46 records were identified, and 16 articles were selected: four showed only ultrasound structural damage (osteophytes, cartilage pathology), six only ultrasound inflammatory variables (synovial thickness, effusion and power Doppler signal), six should considered both ultrasound structural and inflammatory features as well as erosions and two were epidemiological studies. Ultrasound synovitis and power Doppler signal were more frequent in erosive hand osteoarthritis. Followup studies found that ultrasound inflammatory features at baseline are independently associated with radiographic progression; power Doppler signal was the strongest predictor of structural damage. Ultrasound is a reliable tool for cartilage and osteophyte assessment (when performed with static images) and shows a good concordance with magnetic resonance imaging for osteophytes, erosions and synovitis. Conclusions: Ultrasound detected inflammation may predict radiographic progression and may be used in prospective clinical trials of hand osteoarthritis and in everyday clinical practice.

Background: The rheumatologic manifestations of hematologic neoplasms are a collection of diverse syndromes. This review aims to describe the most common syndromes in the context of potential mechanisms of pathogenesis. Methods: We undertook a structured search of the available peer-reviewed literature describing paraneoplastic phenomena associated with hematologic neoplasms and the most current literature on the biology of inflammation and neoplasm. Results: This review describes the common rheumatologic manifestations and discusses their possible underlying pathogenesis. Conclusions: This review describes common clinical features of paraneoplastic phenomena prevalent in hematologic malignancies that may help differentiate them from primary rheumatologic disease and discusses the most current understanding of underlying pathogenesis with a specific focus on the biology of inflammation in neoplastic transformation.

Background: Zn (Zn) is an essential trace element with important roles in protein structure and function. Labile Zn is the fraction available for regulatory functions through it loose binding to albumin. As Zn deprivation reduces labile Zn levels and leads to an immune compromised state, we investigated labile Zn levels in the context of systemic autoimmune disease. Methods: Cross sectional case control study in patients with Systemic Lupus Erythematosus (SLE; n= 45), primary Sjögren’s Syndrome (n= 53) and healthy controls (HC; n= 27). Serum labile Zn levels were measured by an in-house assay using the UV-excitable fluorophore zinquin ethyl ester. Associations between labile Zn levels and SLE manifestations were investigated by nonparametric methods. Results: None of the SLE or pSS patients was found to be Zn deficient. Labile Zn levels were significantly higher in SLE (31.7 mcg/dl) than in pSS patients (22.3 mcg/dl) and HC (19.7 mcg/dl) (p<0.001). Labile Zn levels did not associate with demographics, disease activity scores, or inflammatory cytokine levels, but correlated inversely with lymphocyte counts (Rs -0.37, p<0.01), antidsDNA, anticardiolipin (Rs -0.29, p=0.01), anti-rib P antibody levels (Rs -0.24, p=0.02) and with circulating NK-cell numbers in SLE patients (Rs .27, p= 0.02). Conclusions: There is no evidence of Zn deficiency in patients with pSS or SLE. Labile Zn levels are unexpectedly high in SLE patients, independent of cytokine levels and may play a role in immune modulation through increased NK numbers and autoantibody containment.

Objective: To compare serum 25 OH vitamin D (25 (OH) D) levels between medial femoro-tibial knee osteoarthritis (OA) patients and controls, and to detect structural progression in patients with mild to moderate knee osteoarthritis in relation to baseline 25(OH) D levels in a oneyear longitudinal prospective cohort study. Methods: Thirty eight patients with medial femoro-tibial knee OA according to the ACR criteria and no knee malalignement, and 20 age, sex and BMI-matched pain free controls were included in the vitamin D study. All included OA patients had radiographic Kellgren and Lawrence grades 2 or 3. Baseline serum levels of 25(OH) D, and the “Benefiting from ultraviolet index “(BFUI) score were determined; serum parathormone, total alkaline phosphatase, calcium and phosphorus were measured. In the OA progression study, OA patients were divided into 2 groups according to 25 (OH) D level using a cutoff of 10 ng/ml to identify their status. MRIs were done at baseline and repeated after 12 months with scoring system according to Boston Leeds osteoarthritis knee score (BLOKS). During the study period, the patients were not supplemented with 25(OH)D. Results: The mean values of Vitamin D were statistically lower in the OA patient group than in controls (8.64 ± 6.42 vs. 14.84±0.87 pg/mL, P =0.0295). The BFUI score overall correlated with 25 (OH) D status. Eight patients did not complete the study so only thirty OA patients underwent the 2 MRIs. Of those, 21 had 25(OH) D levels <10 ng/ml, while 9 had levels >10 ng/ml. A significant progression of the medial meniscal grading from baseline to 1 year was seen in the patients with 25(OH)D levels <10 ng/ml as compared to the others (Wilcoxon Z= -3.556 P<0.001). Conclusion: 25 (OH) D levels were significantly decreased in knee OA patients. Significant deterioration of the medial menisci was observed in OA patients with 25 (OH)D levels <10 ng/ml suggesting that Vit D deficiency may play a role in the progression of medial femoro-tibial OA.

Objective: Podoplanin (PDPN) mediates tumor cell migration and invasion, which phenomena might also play a role in severe rheumatoid arthritis (RA). Therefore, the precise cellular distribution of PDPN and it’s relationships with inflammation was studied in RA treated with biologic disease-modifying anti-rheumatic drugs (DMARD) or conventional DMARDs (cDMARD). Methods: PDPN+ cells were immunostained by NZ-1 mAb, and scored (3+; >50%/ area, 2+; 20%- 50%, 1+; 5%-20%, 0: <5%) in synovial tissues from RA treated with biologic DMARDs (BIO, n=20) or cDMARD (n=20) for comparison with osteoarthritis (OA, n=5), followed by cell grading of inflammation and cell-typing. Results: Inflammatory synovitis score was 1.4 in both BIO and cDMARD, compared to only 0.2 in OA. PDPN+ cells were found in the lining layer (BIO 1.6, cDMARD 1.3, OA 0.2) and lymphoid aggregates (BIO 0.6, cDMRD 0.7, OA 0.2), and correlated with RA-inflammation in BIO- and cDMARD-groups in both area (r=0.7/0.9, r=0.6/0.7, respectively p<0.05). PDPN was expressed in CD68+ type A macrophage-like and 5B5+ type B fibroblast-like cells in the lining layer, and in IL- 17+ cells in lymphoid aggregates in RA. Conclusion: PDPN was markedly increased in the immunologically inflamed RA synovitis, which was surgically treated due to BIO- and cDMARD-resistant RA. PDPN may have potential of a new marker of residual arthritis in local joints for inflammation-associated severe RA.