The impact of rheumatic diseases on sexual function

Sexuality is a complex aspect of the human being's life and is more than of only the sexual act. Normal sexual functioning consists of sexual activity with transition through the phases from arousal to relaxation with no problems, and with a feeling of pleasure, fulfillment and satisfaction. Rheumatic diseases may affect all aspects of life including sexual functioning. The reasons for disturbing sexual functioning are multifactorial and comprise disease-related factors as well as therapy. In rheumatoid arthritis and ankylosing spondylitis patients, pain and depression could be the principal factors contributing to sexual dysfunction. On the other hand, in women with Sjögren's syndrome, systemic lupus erythematosus and systemic sclerosis sexual dysfunction is apparently most associated to vaginal discomfort or pain during intercourse. Finally, sexual dysfunction in patients with fibromyalgia could be principally associated with depression, but the characteristic symptoms of fibromyalgia (generalized pain, stiffness, fatigue and poor sleep) may contribute to the occurrence of sexual dysfunction. The treatment of sexual dysfunction will depend on the specific patient's symptoms, however, there are some general recommendations including: exploring different positions, using analgesics drug, heat and muscle relaxants before sexual activity and exploring alternative methods of sexual expression. This is a systemic review about the impact of several rheumatic diseases on sexual functioning. There are no previous overviews about this topic so far.

Neurological adverse events associated with anti-tumor necrosis factor α treatment

Anti-tumor necrosis factor alpha (TNF-alpha) drugs have been successfully used for the treatment of rheumatic autoimmune diseases including rheumatoid arthritis (RA), psoriatic arthritis, psoriasis, ankylosing spondylitis (AS), juvenile chronic arthritis, and Crohn's disease. However, they have been associated with different neurological disorders, including alterations of peripheral nerves, multiple sclerosis (MS), optic neuritis (ON) and acute transverse myelitis (ATM). This article reviews the most current aspect regarding neurological adverse events associated with anti-TNF-alpha drugs with emphasis on the possible explanations for this relation and the pathogenic mechanism of TNF-alpha in neurological disorders.

Impact of rheumatoid arthritis on sexual function

Sexuality is a complex aspect of the human being's life and is more than just the sexual act. Normal sexual functioning consists of sexual activity with transition through the phases from arousal to relaxation with no problems, and with a feeling of pleasure, fulfillment and satisfaction. Rheumatic diseases may affect all aspects of life including sexual functioning. The reasons for disturbing sexual functioning are multifactorial and comprise disease-related factors as well as therapy. Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease characterized by progressive joint destruction resulting from chronic synovial inflammation. It leads to various degrees of disability, and ultimately has a profound impact on the social, economic, psychological, and sexual aspects of the patient's life. This is a systemic review about the impact of RA on sexual functioning.

Calcinosis cutis universalis in a patient with systemic lupus erythematosus

Deposition of calcium salts in the skin and subcutaneous tissue occurs in a variety of rheumatic diseases, being most commonly associated with scleroderma, CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia), dermatomyositis, and overlap syndromes but is a rare complication of systemic lupus erythematosus (SLE). Calcinosis is classified into four subsets: dystrophic, metastatic, idiopathic, or calciphylaxis/iatrogenic. The pathophysiology of calcinosis cutis remains unclear. Our patient developed extensive areas of calcifications in the trunk and extremities (calcinosis universalis) 8 years after SLE diagnosis, which would correspond to a form of dystrophic calcification. No response was observed after treatment with oral diltiazem for 3 months. We review the literature on the pathogenesis and prevalence of calcinosis universalis in SLE.

Macrophage activation syndrome in a patient with systemic onset rheumatoid arthritis: rescue with intravenous immunoglobulin therapy

We report the case of a 7-year-old boy with systemic onset juvenile rheumatoid arthritis (JRA) who developed macrophage activation syndrome during a period of relative remission. He presented with high-grade fever, enlarged lymph nodes, acute hepatitis, severe pancytopenia, and evidence of disseminated intravascular coagulopathy. He became severely ill, with persistent mucosal bleeding, hypovolemia, and vascular instability, and he was admitted to the intensive care unit. No response was observed to treatment with high-dose intravenous corticosteroids and blood product replacements, but the patient fully recovered after the completion of two pulses of intravenous immunoglobulin. This treatment modality may be an alternative to anti-TNF-alpha and cyclosporine A for a prompt response in JRA patients with this potentially fatal condition.

Immunomodulatory effects of statins and autoimmune rheumatic diseases: novel intracellular mechanism involved

Inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, known as statins, are the most commonly prescribed agents for the treatment of hypercholesterolemia. However, the effects of statins may extend beyond their influences on serum cholesterol levels resulting in cholesterol-independent or pleiotropic effects. Clinical, animal and in vitro studies suggest that statins have additional clinical uses because of their anti-inflammatory and immunomodulatory effects, in part due to their capacity to interfere with the mevalonate pathway and inhibit prenylation of Rho family GTPases. This review focuses on the molecular mechanisms of the anti-inflammatory and immunomodulatory effects of statins. In base to all these information, we suggest that statins could have similar inhibitory effects on MAPKs pathways in cells from RA patients, including osteoclasts and fibroblasts.

Tyrosine kinases as targets in rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterized by the accumulation and proliferation of inflammatory cells in the synovial (joint) lining, resulting in the formation of pannus tissue, which invades and destroys adjacent cartilage and bone. In RA macrophages, B cells, mast cells, fibroblast-like synoviocytes (FLSs) and CD4+ T lymphocytes become activated and contribute to synovial inflammation and joint destruction. It has been showed that different tyrosine kinases participate in the activation of those cells having important participation in the physiopathology of RA. Therefore, the tyrosine kinases inhibitors could be the next step in the treatment of patients with RA. This review focuses on recent advances on the role of tyrosine kinases and their inhibitors in the physiopathology of RA.

Acquired amegakaryocytic thrombocytopenic purpura: review of a not very well-defined disorder

Acquired amegakaryocytic thrombocytopenic purpura (AATP) is a hematological disorder characterized by severe thrombocytopenia, probably due to an immunologically induced absence of megakaryocytes with a marked decrease or total absence of megakaryocytes in the bone marrow. AATP may be differentiated from other causes of peripheral destruction of platelets, such as immune thrombocytopenia (ITP). Currently, there are no standard treatments for AATP. However, immunosuppressive therapy including steroids, androgens, anti-thymocyte globulin (ATG), cyclophosphamide, cyclosporine A, immunoglobulins, splenectomy, and allogenic bone marrow transplantation (BMT) have all been utilized with varying degrees of success. However, a positive response in patients with AATP using steroids alone has rarely been reported in the literature.

Effects of statin treatment and withdrawal on angiotensin II-induced phosphorylation of p38 MAPK and ERK1/2 in cultured vascular smooth muscle cells

Abrupt discontinuation of 3-hydroxy-3-methylglutaryl-coenzyme-A-reductase inhibitors (statins) is associated with increased cardiovascular risk. To investigate the molecular mechanisms determining the increased cardiovascular risk after statin withdrawal, we studied the effects of statin treatment and withdrawal on angiotensin II (AII) actions in rat aortic vascular smooth muscle cells (VSMC) in culture. In VSMC, AII stimulated the phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2), and of p38 mitogen-activated protein kinase (p38 MAPK), with an EC50% of 0.86 and 3 nM, respectively. Maximal stimulation was observed after 5-10 min of exposure to AII. Pretreatment with 1-3 microM simvastatin for 24h inhibited AII-mediated stimulation of ERK1/2 and p38 MAPK phosphorylation; without affecting the levels on non-phosphorylated MAPK. Washout of simvastatin produced a rebound increase above control levels of AII-mediated phosphorylation of ERK1/2 and p38 MAPK. As previously reported for other agonists, the rebound increase of AII effects was observed from 1 to 3h after statin withdrawal, and was lost at later times. The basal levels of phosphorylation and the amount of non-phosphorylated kinases were unaffected by statin withdrawal. Similar effects were observed with lovastatin. Our results suggest that statins modulate AII effects in VSMC, and that transient increases in AII effects mediated via the MAPK pathway may play a role in the vascular dysfunction associated with statin withdrawal.

Upregulation of angiotensin II-AT1 receptors during statin withdrawal in vascular smooth muscle cells

Acute discontinuation of statins induces vascular dysfunction and increases cardiovascular events. The mechanisms underlying these events are under investigation. We showed an increase in angiotensin II (AngII) signaling after acute statin withdrawal. We investigated whether AngII-AT1-receptor expression (AT1-R mRNA) and receptor protein (AT1-R) levels mediate increased AngII signaling. In rat aortic vascular smooth muscle cells (VSMC), simvastatin (0.3 to 3 microM for 24 hours) resulted in concentration-dependent inhibition of AngII-stimulated phosphorylation of extracellular-signal regulated kinase 1/2 ERK1/2 (-67 +/- 5% with 3 microM; P < 0.001) and decreased AT1-R mRNA (-34 +/- 8% with 3 microM; P < 0.01) and AT1-R protein (-32 +/- 6% with 3 microM; P < 0.01). Removal of simvastatin led to a rebound increase in mRNA-AT1-R (+39 +/- 2%, P < 0.01), AT1-R protein (+46 +/- 2%; P < 0.01), and AngII-mediated phosphorylation of ERK1/2 (+36 +/- 3%; P < 0.01). The increase in receptor expression was present at 1 hour and lasted for 4 hours, whereas increased AT1-R protein and AngII signaling started at 2 hours and lasted for nearly 2 hours. In summary, increased AngII signaling after statin withdrawal is most likely due to increases in AT1-R number due to increased transcription. The increase in AngII activity may contribute to the vascular dysfunction associated with statin withdrawal.

Axillary vein thrombosis as a manifestation of rapidly progressive neuropathic arthropathy of the shoulder associated with syringomyelia

Neuropathic arthropathy is a destructive joint disease associated frequently with loss of proprioception. Syringomyelia (with or without Arnold-Chiari malformation) is characterized by slow progression over many years; the joints involved most frequently are the shoulders and elbows. Neuropathic arthropathy of the hand is rare, and clinical features are vasomotor problems, digital ulcers, thickening of the fingers, and painless subluxation of the finger joints. We report an unusual case of neuropathic arthropathy of the shoulder and hands, associated with syringomyelia without Arnold-Chiari malformation. Neuropathic arthropathy of the shoulder was rapidly progressive, and axillary vein thrombosis was the first manifestation; however, neuropathic arthropathy of the hands was unrecognized for 7 years, and painless ulceration of the fingers with spontaneous amputation of the terminal phalanx and Raynaud phenomenon were the initial manifestations. To our knowledge, this is the first report of a patient with this constellation of findings.

A case of Sjögren's syndrome with acute transverse myelitis and polyneuropathy in a patient free of sicca symptoms

Acute transverse myelitis (ATM) is an inflammatory process involving a restricted area of the spinal cord. The usually dramatic presentation with rapidly progressive symptoms involving motor, sensory, and autonomic functions makes ATM a medical emergency. ATM has been cited as a rare and unusual complication of Sjögren's syndrome, but early diagnosis and aggressive treatment might improve the prognosis. I report a case of Sjögren's syndrome with ATM and polyneuropathy in a patient free of sicca symptoms and having skin lesions and synovitis as the initial manifestations.

A case of laryngeal paracoccidioidomycosis masquerading as chronic obstructive lung disease

Paracoccidioidomycosis (South American blastomycosis) is a systemic infection caused by a dimorphic fungus (Paracoccidioides brasiliensis). It is common in the rural areas of Latin America. The majority of the reported cases come from Brazil, Colombia and Venezuela. Paracoccidioidomycosis is the most important systemic mycosis of the tropical Americas and can affect any organ, causing symptomatic or asymptomatic lesions. Paracoccidioidomycosis can mimic other diseases, which must be considered in making the differential diagnosis. Patients get infected by inhaling mycelia found in the natural environment or rarely from traumatic inoculation via mucous membranes. The most common lesions frequently occur in the buccal pharynx mucosa. Others lesions occur in the larynx, adrenal glands, liver, bones, gastrointestinal tract, lungs and nervous system.

Durability of treatment with methotrexate in Venezuelan patients with rheumatoid arthritis

A multicenter, national, retrospective, and cross-sectional study of 219 hospital-based Venezuelan patients with rheumatoid arthritis (RA) was aimed to evaluate the probability of continuity of treatment with oral methotrexate (MTX). Treatment survival decreased from 92% at 12 months to 42% at 180 months, as assessed by life table analysis and the Kaplan-Meier method. Forty-seven patients stopped treatment and adverse effects (29.7%) and lack of continuous access to medication (19.1%) were the most common causes for withdrawal. MTX survival was decreased in the group with combined MTX plus leflunomide therapy, as shown by the log-rank test. Venezuelan patients with RA have a probability of continuing treatment with oral MTX comparable to non-Hispanic patient populations. However, concomitant use of leflunomide may increase the risk of interruption of MTX treatment in this RA population.

[Telomerase activity in peripheral blood leukocytes from patients with essential hypertension]

BACKGROUND AND OBJECTIVE

Primary or secondary activation of the immune mechanisms that lead to proliferation and dysfunction of specific cellular groups appears to be involved in the pathogenesis and complications of essential hypertension. In view of the evidence that, on one hand, telomeric length determines the replicative capacity and life span of cells and, on the other hand, idiopathic hypertensive patients have peripheral white cell replicative disorders, we decided to investigate the relationship between the influence of telomerase activity in peripheral leukocytes as an indirect marker of telomeric length and the presence of arterial hypertension.

PATIENTS AND METHOD

Telomerase activity in peripheral white blood cells was measured in healthy individuals, in effectively treated hypertensive patients and in a non-well controlled hypertensive group. White blood cells were separated through a density gradient, then lysed and their DNA amplified by a polimerase chain reaction (PCR). Telomerase activity was determined with an ELISA specific kit.

RESULTS

The white blood cell count was higher in the hypertensive than the control group (p < 0.05). Telomerase activity was positive in all three groups but higher in patients under 45 year-old with bad controlled hypertension as compared with healthy individuals and patients under 45 year-old with well controlled hypertension (p < 0.05); in the latter group, telomerase activity was significantly lower than in the other groups (p < 0.05).

CONCLUSIONS

Our results indicate that there exists a relationship between telomerase activity in peripheral leukocytes, the proliferation of these white blood cells and the presence of essential arterial hypertension.

[Cryptococcal meningitis and systemic lupus erythematosus: a case report and review]

Cryptococcal meningitis is an uncommon but well-known and frequently fatal complication of systemic lupus erythematosus (SLE). The clinical manifestations are unspecific and frequently are confused with lupus activity. A patient with cryptococcal meningitis and SLE, who responded well to amphotericin deoxycholate therapy, is reported. In a review through MEDLINE of the Spanish and English literature, 57 cases of SLE and cryptococcal meningitis were found. Simultaneous presentation of both diseases has been reported in only three cases. This temporal coexistence suggests that specific underlying immune defects associated with SLE directly predisposes to mycotic infections.