Current Rheumatology Reviews - Volume 14, Issue 1, 2018

Background: Nailfold capillaroscopy is a safe and useful investigational tool that allows an early detection and a qualitative description of the microvascular abnormalities in patients with Raynaud's phenomenon secondary to scleroderma-spectrum disorders. Nowadays, the role of capillaroscopy in the diagnosis of systemic sclerosis is well known. Capillaroscopy has been included in the new 2013 classification criteria for systemic sclerosis and is considered a key investigation in the very early phases of the disease. Conclusion: Because of its potential value in monitoring disease progression and treatment response, nailfold capillaroscopy may also have a role in the management of overt systemic sclerosis. Results: Its application in scleroderma-spectrum disorders in which a microvascular component is suspected may also provide new insights into their pathophysiology.

Background: Nailfold capillaroscopy is a noninvasive instrumental method for morphological analysis of the nutritive capillaries in the nailfold area. In rheumatology, it is a method of choice among instrumental modalities for differential diagnosis between primary and secondary Raynaud's phenomenon (RP) in systemic rheumatic diseases. RP is a common diagnostic problem in rheumatology. Defining the proper diagnosis is a prerequisite for administration of the appropriate treatment. Thus, nailfold capillaroscopic examination is of crucial importance for the every-day practice of the rheumatologists and is currently gaining increasing attention. The most specific capillaroscopic changes are observed in Systemic Sclerosis (SSc). Due to the high prevalence of the capillaroscopic changes in this clinical entity and their early appearance, they could be used for early and very early diagnosis of the disease. More recently, “scleroderma” type capillaroscopic changes have been defined as diagnostic criterion in the new EULAR/ACR classification criteria for SSc together with the presence of scleroderma-related autoantibodies, RP, telangiectasia and other clinical signs. Capillaroscopic changes in other connective tissue diseases and in different rheumatic-like conditions like those in diabetes mellitus (e.g., diabetic stiff-hand syndrome) and paraneoplastic syndromes associated with microvascular pathology should be interpreted properly in order to obtain precise diagnosis in the shortest possible differential diagnostic process.

Background: Scleroderma is a term used to describe diseases that involve hardening and tightening of the skin and the underlying subcutaneous connective tissue. It could be localized to skin and subcutaneous tissue, or may involve the internal organs too in systemic sclerosis. Objective: There are disorders that can cause hardening and tightening of skin and mimic scleroderma but are rarely associated with Raynaud phenomenon, sclerodactyly, and autoantibodies in the serum, features specific to scleroderma/systemic sclerosis. Conclusion: These are termed as “scleroderma variants” or “scleroderma like disorders”. This review discusses the various “scleroderma variants” e.g. scleromyxedema, scleredema, nephrogenic systemic fibrosis, and eosinophilic fasciitis.

Background: Nailfold capillaroscopy is the only method for morphological assessment of nutritive capillaries. The literature data about capillaroscopic findings in healthy individuals are scarce. Objective: To evaluate and compare the capillaroscopic findings of fingers and toes in healthy subjects. Materials and Methods: 22 healthy individuals were included in the study. Capillaroscopic examination was performed with videocapillaroscope Videocap 3.0 (DS Medica). Exclusion criteria were as follows: history of vasospasm, presence of accompanying diseases, taking any medications, arterial hypertension in first degree relatives, overweight or obesity (body mass index > 25kg/m2) and presence of chronic arterial or venous insufficiency. Results: Poor visibility of nailfold capillaries was found significantly more frequently in the toes (22.7%, 5/22) as compared with fingers (0/22). Slight irregularities in capillary distribution and orientation to their parallel axis were significantly more common in the toes (31.8%, 7/22) as compared with fingers (9%, 2/22), (p<0.05). The mean diameter of the arterial (0.012±0.002mm) and the venous limb (0.017±0.002mm) of the toes did not differ significantly as compared to the respective parameters in the fingers (0.013±0.002mm for the arterial limb, p=0.46 and 0.018±0.002mm for the venous limb, p=0.25). The mean capillary density also did not differ significantly in the fingers and toes. The mean capillary length of the toes (0.165±0.096mm) was shorter as compared with hands (0.220±0.079mm), but the difference was not statistically significant (p=0.37). Presence of tortuous capillaries (>10%) was found significantly more often in the toes (12/22) as compared with fingers (6/22, χ2=6.769, p<0.05). Short capillary loops (length<100μm) were observed significantly more often in the toes (11/22 – toes, 1/22 - fingers, χ2=14.666, p<0.05). Conclusion: Capillaroscopic examination of the toes shows some differences as compared to those of the fingers such as greater number of cases with poor visibility and slight irregularities of distribution, greater number of shorter capillaries and increased tortuosity, which might be related to the thicker epidermis of the toes and increased capillary pressure due to gravity. The values of the major capillaroscopic parameters such as capillary diameters and capillary density in fingers and toes do not differ significantly.

Introduction: Although Raynaud's Phenomenon (RP) is observed in a significant proportion of patients with primary fibromyalgia, the available data on capillaroscopic findings in primary fibromyalgia are scarce. Objective: The purpose of the study was to assess the capillaroscopic pattern in patients with primary fibromyalgia. Patients and Methods: 26 patients with primary fibromyalgia (25 women and 1 man) were included in the study. Mean age was 55±10 years. As control groups were examined 31 patients with primary RP and 35 healthy volunteers. Capillaroscopic examination was performed with a videocapillaroscope Videocap 3.0 (DS Medica), magnification 200x with analysis of the main capillaroscopic parameters as follows: capillary distribution, shape, mean capillary diameters and length, mean capillary density, visibility of the subpapillary plexus; presence of avascular areas, microhaemorrhages and neoangiogenic capillaries. Results: Symptoms of RP were observed in 65% (17/26) of the cases with primary fibromyalgia. At capillaroscopic examination, the most frequent finding in patients with primary fibromyalgia was the presence of capillary dilation in 85% (22/26) of the patients - both in cases with and without RP. However, the mean arterial and venous capillary diameters were significantly higher in the subgroup of fibromyalgia patients with clinical symptoms of RP. Of note, microvascular abnormalities characteristic of connective tissue diseases could not be observed in primary fibromyalgia patients. Analogous changes - presence of dilated capillaries - were found in 96.6% (29/30) of patients with primary RP. Conclusion: In our study, the most frequent capillaroscopic finding in patients with primary fibromyalgia was the presence of dilated capillary loops analogous to primary RP. Capillaroscopic signs suggestive of connective tissue disease could not be found in primary fibromyalgia patients.

Background: Bier spots are asymptomatic white anemic macules with irregular shape located on the upper limbs and less often on the lower limbs and trunkus. They are observed predominantly in youg males and may be idiopathic or associated with other conditions. Objective: We report two cases with Bier spots in which videodermatoscopy and nailfold capillaroscopy were performed. Results: Patient 1 was a 34-year-old otherwise healthy male who presented with white spots on his upper limbs for 10 years. Dermoscopy revealed marked narrowing of skin capillaries within the borders of white macules whereas capillaroscopy pattern was normal. Patient 2 was a 20-year-old female with symptoms of Raynaud's phenomenon who presented with white spots on the volar aspects of her hands for 2 years. The capillaroscopy showed abnormal findings with presence of homogenous enlarged capillaries. Conclusion: Bier spots do not require any treatment. The associated conditions found should be monitored.

Background: Biologic agents have contributed significantly to the management of patients with in rheumatoid arthritis (RA). A significant proportion of patients with RA still require arthroplasty procedures however. It is unclear whether these agents increase the risk of post operative infection after lower limb arthroplasty. Method: A literature search was performed for articles published over the last 10 years in the English language examining the association between anti-tumour necrosis factor inhibitors and the incidence of post operative infection in patients with RA undergoing hip and knee arthroplasty procedures. Results: One large meta-analysis has been published suggesting a 2-fold increase in infection rates following orthopaedic surgery in patients receiving biological agents. When subgroup analysis of arthroplasty cases alone was performed the finding failed to reach significance. However, several further studies have demonstrated both an increased risk for surgical site infection with the use of biological agents and several conflicting articles argue the opposite. Conclusion: There is no current consensus on this topic. The safety of continuation of perioperative anti-TNF-α therapy in patients undergoing lower limb arthroplasty procedures is unclear. There is also little robust guidance from specialist rheumatologic societies. There is need for large scale multicentre randomised controlled trials to address this issue.

Osteoporosis is a chronic pathologic condition, particularly of the elderly, in which a reduction of bone mineral density (BMD) weakens bone, leading to the so-called fragility fractures, most often of spine and femur. The gold standard exam for the quantitative measurement of BMD is the dual X-ray photon absorptiometry (DXA), a radiological method. However, a relevant number of fragility fractures occurs in the range of normal BMD values, meaning that also qualitative aspects of bone play a role, namely bone architecture and bone geometry. Bone structure is investigated by microCT and histomorphometry, which necessitate an invasive approach with a biopsy, usually taken at the iliac crest, not the typical site of fragility fractures. New tools, trabecular bone score (TBS) and hip structural analysis (HSA), obtained during DXA, can supply informations about bone structure of spine and femur, respectively, in a not invasive way. Therapy of osteoporosis is based on two types of drugs leading to an increase of BMD: antiresorptive and anabolic treatments. The antiresorptive drugs inhibit the osteoclasts, whereas teriparatide and, in part, strontium ranelate ameliorate bone structure. The present review deals with the relation between the anabolic drugs for osteoporosis and the cited new tools which investigate bone architecture and geometry, in order to clarify if they represent a real advantage in monitoring efficacy of osteoporosis' treatment. Data from the studies show that increases of TBS and HSA values after anabolic therapy are small and very close to their least significant change at the end of the usual period of treatment. Therefore, it is questionable if TBS and HSA are really helpful in monitoring bone quality and in defining reduction of individual fragility fracture risk during osteoporosis treatment with bone anabolic agents.

Background: Temporomandibular joint osteoarthritis (TMJ-OA) is a degenerative disease that involves changes in subchondral bone and progressive degradation of cartilage. Currently, rebamipide, a gastroprotective drug, is administered to protect gastric mucosa and accelerate ulcer healing. Objectives: Recent studies have shown that rebamipide also attenuates cartilage degeneration by suppressing oxidative damage and inducing homeostasis of the extracellular matrix of articular chondrocytes. Regarding the latter, reduced expression of cathepsin K, NFATc1, c-Src, and integrin β3, and increased expression of nuclear factor-kappa B, have been found to be mediated by the transcription factor, receptor activator of nuclear factor kappa-B ligand (RANKL). Methods: Treatment with rebamipide was also found to activate, mitogen-activated protein kinases such as p38, ERK, and JNK to reduce osteoclast differentiation. Taken together, these results strongly indicate that rebamipide mediates inhibitory effects on cartilage degradation and osteoclastogenesis in TMJ-OA. Results and Conclusion: Here, we highlight recent evidence regarding the potential for rebamipide to affect osteoclast differentiation and TMJ-OA pathogenesis. We also discuss the potential role of rebamipide to serve as a new strategy for the treatment of TMJ-OA.

Background: Sensorineural hearing loss (SNHL) and vestibular dysfunction have been described in various autoimmune disorders and systemic vasculitides. A high prevalence of SNHL is reported to occur in established rheumatologic diseases; however, immunologic and rheumatologic disorders make up a small proportion of patients with sudden sensorineural hearing loss (SSNHL). Objectives: This prospective study was carried out in order to determine the prevalence of rheumatologic and immunologic disorders in patients with SSNHL in Northeast Iran. Methods: Patients with a diagnosis of SSNHL referred to our University Hospital were enrolled in this prospective study conducted over a period of 3 years. Immunology-rheumatology evaluations were performed in all patients, including detailed history, physical exams and laboratory tests such as erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), rheumatoid factor (RF), anti neutrophil cytoplasmic antibody (PR3, c-ANCA), perinuclear anti neutrophil cytoplasmic antibody (p-ANCA), antiphospholipid antibody, anti-cyclic citrullinated peptide (ACCP), and complement proteins C3 and C4. Results: Eighty-three patients with a mean age of 42.04±16.94 years were admitted into the study. The female-to-male ratio was 47% to 53%. ANA was positive in one patient, RF in six, p-ANCA in two, ACCP in one, and antiphospholipid antibody was positive in three patients with low titers. No diagnosis of rheumatologic diseases was detected, except for one patient who was diagnosed with primary Sjn's syndrome. Fewer than 5% all cases had specific positive immunologic tests. Conclusion: The low frequency of immunology-rheumatology positive tests and disorders in our patients with SSNHL indicates that it is not reasonable to routinely perform all related tests for every patient. Instead, clinical evaluations should be used to decide whether or not to conduct these tests.

Background: Aim of this study was to assess the lipid status of the patients of pediatric rheumatologic diseases (pRDS). Methods: This observational study was carried out in the department of pediatrics, Khulna medical college hospital, Bangladesh for a period of one year. Total 23 patients were included in this study. These new cases were diagnosed according to the ILAR, ACR, and EULAR criteria. Early morning blood samples were sent to the laboratory for the assessment of lipid status (TC, TG, HDL, and LDL). These values were collected and statistically recorded. Results: Total new cases of pRDS were 23. Among them JIA was 15, SLE 4, and Vasculitis 4 in number. HSP was in 3 and KD in 1 cases of vasculitis group. Male/ Female ratio is 1.6:1. Mean age of the diseases were 8.54 years. TC, and TG was found in significant level in 4(17.4%), and 12(52.8%) pRDS cases respectively. HDL was observed of risk level in 4(17.3%) patients. LDL was observed normal in all the patients. TG was found of significant level in 7(46.7%) JIA, 3(75%) SLE and 2 (50%) vasculitis patients. Conclusion: TG was the lipid observed in significant level in majority of the new pRDS cases. Elevated TG might be considered as an index of disease activity in all cases of pRDS. Measures could be adopted in all pRDS to control the lipid status from the beginning of illness to reduce the complications from dyslipidemia like atherosclerosis and cardiovascular morbidity and mortality in future.

Objetive: Patients with Rheumatoid Arthritis (RA) and nasal carriers of Staphylococcus aureus have an increased risk of developing infections caused by S. aureus. Our objective was to determine the prevalence of S. aureus nasal colonization in patients with RA and its relationship to RA treatments. Methods: Two hundred and seven patients with RA and 37 healthy controls were prospectively included in a cross-sectional study. A nasal secretion sample was collected by swab from both anterior nostrils and was referred to the hospital's microbiology department for culturing. Results: The mean age of the patients (168 women, 78%) was 61 ± 12 years old. The mean disease duration was 13 ± 10 years. Seventy-six percent of the patients were positive for Rheumatoid Factor (RF), and 71% were positive for Anti-citrullinated Peptides Antibodies (ACPA). Seventy percent had joint erosions. The mean DAS28 was 3.1 ± 2.2. S. aureus nasal colonization was found in 36% of the RA patients and 35% of the controls. Three patients and no controls were resistant to oxacilin/ mupirocin. The patients who were positive for ACPA had a higher prevalence of S. aureus colonization (43% vs. 17%; p < 0.05). The colonization prevalence in the patients treated with glucocorticoids was 32% (n: 133); methotrexate and/or leflunomide, 37% (n: 167); anti-TNF agents, 46% (n: 54), p < 0.05 versus patients not treated with anti-TNF agents; rituximab, 22% (n: 18); tocilizumab, 39% (n: 18). Conclusion: The prevalence of S. aureus nasal colonization in patients with RA does not appear to be greater than that of the general population. Anti-TNF agents might confer a higher prevalence of colonization.

Five medical conditions which characterize metabolic syndrome are abdominal obesity, elevated blood pressure, elevated fasting plasma glucose, high serum triglycerides, and low highdensity lipoproteins cholesterol. When a patient has any three of the five above conditions, he is known to have metabolic syndrome, and these conditions represent a key element in cardiovascular diseases. On the other hand, knee osteoarthritis is a degenerative disease which was shown to be affected by some of the parameters of metabolic syndrome. Edible Argane oil is used in Moroccan folk medicine against several health conditions, such as knee osteoarthritis, though, evidence-based medical data about the above health benefit from Argane oil treatment are lacking. In the present clinical controlled study, we have found that consumption of Argane oil by 38 patients who have knee osteoarthritis and metabolic syndrome can improve several of their metabolic syndrome parameters and decrease their blood lipid atherogenic ratios. The present clinical study, to the best of our knowledge, is the first one to show that Argane oil consumption could be a therapeutic preventive tool against key cardiovascular risk factors of metabolic syndrome in knee osteoarthritis patients.