Presence of organ‑specific antibodies in patients with systemic sclerosis

INTRODUCTION According to the literature, organ‑specific antibodies may be present in the course of systemic sclerosis (SSc). OBJECTIVES The aim of this study was to assess the prevalence of antithyroid antibodies (antithyroid peroxidase antibodies [anti‑TPO] and antithyroglobulin antibodies) and of antimitochondrial antibodies (AMAs), as well as to evaluate their clinical significance in patients with SSc. PATIENTS AND METHODS The study involved 86 consecutive in‑hospital patients with SSc (32 patients with diffuse cutaneous SSc [dcSSc] and 54 with limited cutaneous SSc [lcSSc]). Patients were observed for autoimmune thyroid diseases (ATDs) and primary biliary cirrhosis (PBC). Serum samples were obtained from each patient. RESULTS Positive antithyroid antibody titers were observed in 27 patients (31%) and positive AMA titers-in 11 patients (13%). ATD was diagnosed in 26 patients (30%) and PBC-in 10 patients (12%) with SSc. No significant differences in the prevalence of antithyroid antibodies were found between patients with dcSSc and those with lcSSc, but the prevalence of AMAs was significantly higher in patients with lcSSc compared with those with dcSSc. The prevalence of anti‑Ro‑52 antibodies was significantly higher in the SSc group with positive anti‑TPO antibody titers compared with the SSc group with negative anti‑TPO antibody titers. The prevalence of anticentromere antibodies (ACAs) was significantly higher in the SSc group with positive AMA titers compared with the SSc group with negative AMA titers. CONCLUSIONS The prevalence of organ‑specific antibodies in SSc patients is relatively high. The prevalence of AMAs is higher in patients with lcSSc than in those with dcSSc and is strongly associated with the presence of ACAs. Patients with SSc should be evaluated for coexisting ATDs and PBC.

Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center

BACKGROUND

Traumatic brain injury (TBI) is a frequent cause of mortality and acquired neurological impairment in children.

HYPOTHESIS

We hypothese that due to adequate treatment of EDH in children and adolescence excellent clinical and functional outcome can be reached.

PURPOSE

To evaluate retrospectively our treatment process of EDH and to elucidate the relationship between trauma mechanism, injury pattern, radiological presentation, subsequent therapy and functional outcome.

PATIENTS AND METHODS

Hundred and twenty infants and children with traumatic brain injuries (TBI) were treated between 1992 and 2009 at a single level-one trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. To classify the outcomes the Glasgow Outcome Scale (GOS) scores at hospital discharge and at follow-up visits were used. EDH was classified according to the Rotterdam score.

RESULTS

Finally, 41 cases were diagnosed with an EDH and therefore included in our study. Twenty-one cases were treated surgically; however of these in 11 patients delayed surgery was necessary. Twenty patients were treated conservatively. Two patients (5%) died within 24hours, 39 patients (95%) survived. One of the operatively treated patients (2%) presented in a vegetative state, another one had severe disability, and however, 32 patients (78%) showed good recovery at latest follow-up.

DISCUSSION

Age, severity of TBI, and neurological status were the main factors influencing outcome after TBI due to acute EDH. We found that immediate as well as delayed surgical evacuation of EDH resulted in excellent outcomes in most cases. Conservative treatment was started in 76% of our cases - however needing in 35% delayed surgical intervention. Overall in all groups excellent final clinical and neurological outcomes could be reached.

Assessment of education requirements for patients with rheumatoid arthritis, based on the Polish version of the Educational Needs Assessment Tool (Pol-ENAT), in the light of some health problems - A cross-sectional study

INTRODUCTION

Patients with chronic rheumatoid arthritis (RA) need advice in order to face the problems of everyday life, as well as suffering associated with the disease. Health professionals should attempt to raise the level of resourcefulness and independence of the patient.

OBJECTIVE

To assess the relationship between the deficit of knowledge about RA and the degree of pain, fatigue, morning stiffness, assessment of disease activity as well as functional efficiency.

MATERIALS AND METHOD

The study was conducted on 277 patients with RA in 7 rheumatologic centres in Poland. The method applied was the questionnaire Pol-ENAT (0-156); HAQ DI (0-3); analog scales (0-100).

RESULTS

Mean (SD) age was 53.28 (13.01) and disease duration 13.70 (10.63) years. The mean (SD) value was 54.93 (23.17) for pain, 52.97 (21.98) for fatigue, 48.28 (24.76) for morning stiffness (0-100 mm). HAQ DI was 1.40 (0.66), with an upward trend with duration of disease (p<0.001). There was a positive correlation between the demand for knowledge about the movement (r=0.194; p=0.001), self-care (r=0.134; p=0.026), assistance/support(r =0.163; p=0.006) and morning stiffness experienced. There was a negative correlation between the need for knowledge concerning managing pain, feelings and the arthritis process and daily ability assessed with HAQ DI.

CONCLUSIONS

The study shows that health education should be targeted at young patients with early RA. In the case of the severity of morning joints stiffness, there is a need to increase knowledge about the methods of mobility aids, self-care and the possibility of obtaining support.

[Autoimmune polyglandular syndromes - literature review and analysis of clinical course in chosen cases]

Autoimmune polyglandular syndromes (APS) are the conditions characterized by coexistence of at least two organ-specific endocrine autoimmune disorders. The syndromes often coexist with connective tissue diseases with the presence non-organ specific antibodies. The aim of the study was to present two clinical cases of polymyositis and dermatomyositis in the course of APS type 3d. Case 1, a 24-year-old woman, with diabetes mellitus type 1 was diagnosed at the age of 17 years and polymyositis recognized at the age of 24 years based on clinical manifestations and additional tests (proximal muscle weakness, typical electromyographic changes, typical histopathological changes in skin and muscles biopsy, elevated muscle enzymes) accompanied by interstitial lung disorder. Moreover, Hashimoto`s autoimmune thyroiditis was diagnosed. Case 2, a 47-year-old man, with a several-year history of diabetes mellitus type 1, diagnosed with dermatomyositis and autoimmune thyroiditis. The immunosuppressive therapy was instituted in both cases, which reduced the symptoms of connective tissue disease. To sum up, about 25-30% of patients are affected by extraglandular autoimmune diseases, including connective tissue diseases, in the course of APS. An interdisciplinary approach is required in this group of conditions due to a multitude of disorders as well as diagnostic and therapeutic difficulties.

[Clinical and ultrasound assessment of the disease activity in patients with rheumatoid arthritis]

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease, leading to irreversible joint destruction and deformities. The adequate assessment of the disease activity enables the correct choice of therapy and evaluation of the treatment efficacy. The aim of the study was to compare different methods of assessment of the disease activity, using clinical data and ultrasonography (US) of joints, in patients with RA, in daily clinical practice.

MATERIAL AND METHODS

The study group consisted of 68 patients with RA. The clinical assessment of the disease activity was performed using the Disease Activity Score based on evaluation of 28 joints (DAS28). Ultrasonography (US) examination of joints was performed in 24 small joints, evaluating hypertrophy and vascularity of the synovium. Ability to perform daily activities was measured using the modified Health Assessment Questionnaire (M-HAQ) Results: There were statistically significant correlations between the grade of synovial vascularity of joints and parameters of clinical activity [tender joints count (TJC), swollen joints count (SJC), DAS28] and laboratory acute phase parameters (ESR, CRP). The grade of synovial hypertrophy was significantly associated with SJC and DAS28, and not with laboratory parameters. M-HAQ value was significantly associated only with TJC.

CONCLUSIONS

In RA patients an assessment of the disease activity should be performed taking into consideration several parameters, clinical activity, laboratory parameters, US and quality of life assessment. US examination enables verification of synovial inflammatory activity, which is not always possible in clinical examination.

[Autoimmune diseases with the presence of anti-ku antibodies - analysis of three cases]

a-Ku are rare antibodies, which are reported in course of connective tissue diseases. Their prevalence ranges from 0 to 10% , 2%, on average. The main symptoms associated with the presence of a-Ku antibodies include: myositis, arthritis, Raynaud`s phenomenon and skin lesions. The above features are often defined as autoimmune clinical syndrome associated with a-Ku antibodies. In recent years, three cases with the presence of a-Ku antibodies were observed at the Department of Rheumatology and Connective Tissue Diseases. Case 1, a 77-year-old man, with the diagnosis of mixed connective tissue disease according to Raynaud`s phenomenon, myositis, arthritis and presence of a-ribonucleoprotein antibodies. Moreover, secondary Sjögren syndrome (SS) and myasthenia gravis were diagnosed. Case 2, a 56-year-old woman with longstanding history of Raynaud`s phenomenon, sclerodactyly, myositis and arthritis. Based on clinical manifestations and additional tests, systemic sclerosis and myositis were diagnosed. Case 3, a 46-year-old woman with SS diagnosis, long-standing history of Raynaud`s phenomenon, arthralgia and polyneuropathy. Moreover, HCV infection with the presence of cryoglobulin was confirmed. The presence of a-Ku antibodies in high titers was found in all cases. The clinical conditions improved after steroid and immunosuppressive therapy. In conclusion, clinical syndromes with the presence of a-Ku antibodies are associated with a wide range of non-specific symptoms, regarding muscle, joint and skin involvement, in particular. The conditions are more often diagnosed in the elderly; in the majority of cases, they are characterized by mild courses, good response to steroid therapy and good prognosis.

[Diagnosis and therapy of steroid-induced hyperglycemia based on literature reports]

The increase of the incidence of autoimmune diseases leads to a growing number of patients treated with immunosuppressants. One of the main group of drugs used in immunosuppression are glucocorticoids, which are connected with a significant risk of glucose tolerance disorders. It seems that a decisive role in the hyperglycemic activity plays a reduction of peripheral glucose uptake at the level of skeletal muscle, but in case of higher doses of glucocorticosteroids, stimulation of hepatic glucose production can be dominant. The diagnosis of glucocorticoid-induced diabetes is not different from the generally accepted criteria. There are not commonly accepted diagnostic and therapeutic rules in this area. The majority of hyperglycaemia cases in patients treated with high doses of glucocorticosteroids occur within the first 48 hours after start of glucocorticoids therapy. The closely monitoring of glucose profile should be performed in this time period. In the case of prolonged glucocorticoids treatment, regularly assessment of postprandial glucose and periodically performed oral glucose tolerance test is recommended. The diagnostic significance of glycated hemoglobin in this area has been not yet determined. The therapeutic targets are adequate as for type 2 diabetes. Pharmacological treatment should be implemented when glucose values reach up above 12mmol/l (216mg/dl) twice a day. The therapeutic hopes are connected with the use of new classes of drugs, in particular with incretin-drugs, especially with glucagon-like peptide (GLP) -1 receptor agonists. When the therapy goals are not able to achieve, the insulin treatment should be implemented.

[Immune-Mediated Inflammatory Diseases and accompanying comorbidities]

Immune-Mediated Inflammatory Diseases (IMIDs) are a group of unrelated conditions that share common inflammatory pathways with immune dysregulation and imbalance in inflammatory cytokines. The aetiology of these conditions is unknown. IMIDs encompassing disorders as diverse as asthma, type 1 and 2 diabetes mellitus, inflammatory bowel diseases (IBD) Crohn disease and ulcerative colitis, rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriasis (Ps), psoriatic arthritis (PsA), uveitis, juvenile idiopathic arthritis (JIA). IMIDs are associated with relative over-expression of cytokines such as TNF α. TNF α blockers are licensed for clinical use in IMIDs conditions such as RA, Ps, PsA, uveitis, IBD, AS, JIA. In patients with spondyloarthritis extra-articular manifestations are frequently observed e g psoriasis, uveitis, and IBD. Such conditions should be managed in collaboration with rheumatologists, gastroenterologists and dermatologists by drugs effective in all conditions. TNF α blockers could be a such alternative. Screening and treatment of accompanying comorbidities is very important in patients with IMIDs.

The occurrence of antibodies against Legionella pneumophila in patients with autoimmune rheumatic diseases

INTRODUCTION

Patients with autoimmune rheumatic diseases are more susceptible to infection, owing to the underlying disease itself or to its treatment. Most commonly, infections affect the respiratory and urinary tracts. One of the etiological factors of infections in these patients is the bacteria of the genus Legionella.

OBJECTIVES

The aim of the study was to assess the prevalence of anti-Legionella pneumophila (L. pneumophila) antibodies in patients with autoimmune rheumatic diseases and to analyze individual and environmental risk factors for the development of Legionella infection in patients with positive antibody results.

PATIENTS AND METHODS

The study group consisted of 165 patients with autoimmune rheumatic diseases and 100 healthy subjects. Serum samples were tested for the presence of specific antibodies in the immunoglobulin (Ig) M and IgG classes against L. pneumophila serogroups 1 to 7 (SG 1-7) and the IgG class for serogroup 1 (SG 1).

RESULTS

Antibodies against L. pneumophila were found in 7 patients (4%): 5 cases with antibody positivity only in the IgG class and 2 cases with antibody positivity in both classes. In patients with positive IgG antibodies for SG 1-7, specific antibodies for L. pneumophila SG 1 were not detected. In the control group, positive results were obtained in 9 cases (9%): IgM positivity in 6 (6%) and IgG positivity in 3 (3%).

CONCLUSIONS

The frequency of antibodies to L. pneumophila in our patients is comparable to that in healthy individuals. L. pneumophila should be recognized as a potential pathogen in patients with autoimmune rheumatic diseases. Primary disease condition, immunosuppressive therapy, and other risk factors should not be ignored in these patients.

Clinical picture of late-onset systemic lupus erythematosus in a group of Polish patients

INTRODUCTION

The prevalence of late-onset systemic lupus erythematosus (SLE) diagnosed in patients over the age of 50 years is estimated at 10% to 20%. SLE in elderly patients has specific features with misleading signs and symptoms, but its clinical course seems milder compared with that in younger patients.

OBJECTIVES

The aim of the study was to assess clinical manifestations of late-onset SLE in a group of patients treated in Poland.

PATIENTS AND METHODS

From a group of 230 consecutive patients with SLE, individuals with late-onset disease were selected. We retrospectively analyzed the incidence of clinical features of SLE, concomitant diseases, and treatment. The incidence of clinical features in late-onset patients was compared with that in a group of 108 patients with early-onset SLE.

RESULTS

Late-onset SLE was confirmed in 20 patients (8.7%) including 16 women (80%) and 4 men (20%). A delay in diagnosis was 31.7 months (0-144). The most common SLE features were arthritis (50%), rash (40%), nephropathy (40%), photosensitivity (30%), mouth ulcerations (30%), interstitial lung disease (30%), fever (25%), leukopenia (65%), and thrombocytopenia (35%). Kidney involvement was present in all men and in 25% of women. Thrombotic complications were noted in 38.8% of the patients. Concomitant diseases were common in our study group.

CONCLUSIONS

The clinical picture of late-onset SLE differs from that of early-onset SLE. Arthritis, leukopenia, and thrombotic complications are frequent, while skin manifestations, photosensitivity, nephropathy, vasculitis, and central nervous system involvement are less common in late-onset SLE. The diagnosis of late-onset SLE is often delayed, and treatment is determined by the presence of concomitant diseases.

[Biological treatment in severe Still's disease--a case report]

Still's disease and systemic juvenile idiopathic arthritis (JIA) are multisystem inflammatory diseases of unknown etiology, different disease course and prognosis. Still's disease is characterized by hectic fever, arthritis, skin rash, organomegaly, elevated serum ferritin and inflammatory factors. Early diagnosis and intensive treatment can prevent disease progression and reduce complications such as amyloidosis, physical disability. The first choice of treatment are high doses of corticosteroids and synthetic disease-modifying drugs (DMARDs), including methotrexate (MTX), cyclosporine (CsA). Biologic agents are second line therapy when DMARDs aren't effective, e.g. monoclonal antibodies blocking the action of TNF-alpha (anti-TNF-α), interleukin-1 (ANK--anakinra) and interleukin-6 (TCZ--tocilizumab). We describe in details treatment strategies applied in a young woman with severe Still's disease treated with combination therapy of DMARDs and anti-TNF-α, including etanercept (ETA) or certolizumab (CER). TCZ was applied for the treatment of Still's disease following treatment failure with anti-TNF-α. We've achieved a complete remission of the Still's disease during treatment TCZ.

[Insulin resistance and metabolic syndrome - a different image of disorders in rheumatoid arthritis and ankylosing spondylitis]

INTRODUCTION

Chronic inflammation is associated with impaired glucose tolerance and insulin resistance (IR) phenomenon. Proinflammatory cytokines such as interleukin-6 and tumor necrosis factorTNF-α play a significant role in the pathogenesis of rheumatoid arthritis (RA) and ankylosing spondylitis (AS). However, the relationships between prevalence of IR and metabolic syndrome (MetS) in patients (pts) with a different rheumatic diseases have not been yet well characterized.

MATERIAL AND METHODS

The study was conducted in 102 pts aged 18-65 years, including 60 pts with RA (45 women, 15 men) and 42 pts with AS (4 women, 38 men). In all of pts serum fasting hemoglobin (Hb), fibrinogen, uric acid, vitamin D3, lipids, ESR, CRP, IL-6, hs-CRP, SAA, IL-6 sR, RF-IgM titer, a-CCP, and glucose, insulin after 0, 30, 60, 120 min during the oral glucose tolerance test with the calculation of indicators of IR (HOMA-IR, insulin/glucose) and insulin sensitivity (QUICKI, Matsuda) were performed. Moreover, BMI, WHR, disease activity indices (DAS28 in RA, BASDAI in AS) and the criteria for diagnosis of MetS were evaluated. The results were statistically analyzed.

RESULTS

IR and MetS occur more frequently in patients with RA. Forthese disorders a strongly correlation with BMI and WHR, whereas not with disease activity indices has been shown. RA patients with MetS had a higher titers of RF-IgM and hemoglobin concentration.

CONCLUSIONS

Patients with RA have an increased risk of MetS with IR compared to patients with AS. In addition, higher RF-IgM titer increases the risk of developing MetS in RA.