Skin disorders with arthritis

A Case of SAPHO Syndrome Complicated by Uveitis with Good Response to Both TNF Inhibitor and JAKinib

Introduction

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome is a rare autoinflammatory condition describing the constellation of inflammatory skin, bone, and joint manifestations which result in diagnostic difficulty and therapeutic challenge.

Case

Here, we present a case of a young male diagnosed with SAPHO syndrome with osteoarticular and cutaneous involvement from an early age in his life. He suffered diagnostic challenges for a long time and was hence inadequately treated. He had minimal response to conventional DMARDs but showed excellent response to TNF inhibitor (adalimumab). Later, he defaulted treatment and presented with acute anterior uveitis which was also dramatically improved with adalimumab and tofacitinib although financial constraint was always an issue for the patient.

Conclusion

The uniqueness of this case was that the patient had a multiorgan involvement including osteoarticular system, skin, and eye. Both TNFi (adalimumab) and JAKinib (tofacitinib) had a good response to all organs with a net improvement in the quality of life of this patient.

Mohammed AG, Adam Essa ME, Abdalla Babker AE, Mohamed Abdelsatir A, Mohammed Elagib E. Neutrophilic dermatoses in a seronegative rheumatoid arthritis patient: A case report

Rheumatoid arthritis (RA) is a chronic inflammatory disease, characterized by symmetric and destructive polyarthritis with a broad-spectrum clinical manifestation of various organs. RND is an unusual distinctive manifestation of RA and typically develops in severe RA. This report aims to present an unusual and a rare neutrophilic skin condition, in a seronegative RA Sudanese patient. A 51-year-old woman was diagnosed with RA three years ago and a history of bilateral polyarthritis, presented with a skin rash involving her extremities and abdomen. Clinical examination of her skin revealed the presence of maculopapular lesions affecting the extensor surfaces of the lower extremities and the lower part of the abdomen with hyperpigmentation. Hand X-ray demonstrated periarticular osteopenia, and laboratory and immunological studies that include C-reactive protein, erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), anticitrullinated peptide antibodies (ACPAs), and antinuclear factor in addition to skin biopsy were all suggested a diagnosis of neutrophilic dermatosis. The patient received steroids for the skin lesion still no significant improvement was seen, and then, cyclosporin 100 mg was administrated twice/ day with close monitoring, and two weeks later marked improvement was shown.

Assessment of enthesopathy in patients with acne vulgaris: A case-controlled trial

AIM

This case-controlled study aimed at evaluating whether enthesitis is possibly associated with acne vulgaris.

METHODS

This study was carried out on 90 patients with acne vulgaris and 30 normal individuals who were subjected to full history talking, acne scoring system, general, dermatological, musculoskeletal examination, and musculoskeletal ultrasonography with Doppler flow.

RESULTS

A significant relation (P < 0.05) was discovered between left femoral condyle tenderness, which increased left femoral condyle hypoechogenicity on ultrasound. Moreover, a highly significant relation (P < 0.001) was established between tenderness on clinical examination and hypoechogenicity on ultrasound at three sites (right humerus epicondyle, right femoral condyle, and left humerus epicondyle). An association between tenderness and ultrasound increased thickness was significantly reported in the left femoral condyle (P < 0.05). Hypoechogenicity on ultrasound examination was more statistically evident with increased acne severity at the left Achilles tendon (LA), while enthesis calcifications (enthesophytes) were significantly associated with increased acne severity in the left humerus epicondyle (LA) and the right Achilles tendon (RA) (P < 0.05).

CONCLUSION

There is a solid possibility acne is a systemic disease triggering other co-morbidities beyond skin which needs to be fully elucidated by further research evidence.

A proteomic profile of synoviocyte lesions microdissected from formalin-fixed paraffin-embedded synovial tissues of rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic inflammation of the synovial joints. Early intervention followed by early diagnosis can result in disease remission; however, both early stage diagnosis and provision of effective treatment have been impeded by the heterogeneity of RA, which details of pathological mechanism are unclear. Regardless of numerous investigations of RA by means of genomic and proteomic approaches, proteins interplaying in RA synovial tissues that contain various types of synoviocytes, are not yet sufficiently understood. Hence we have conducted an HPLC/mass spectrometry-based exploratory proteomic analysis focusing on synoviocyte lesions laser-microdissected (LMD) from formalin-fixed paraffin-embedded (FFPE) synovial tissues (RA, n = 15; OA, n = 5), where those of Osteoarthritis (OA) were used as the control.

Results

A total of 508 proteins were identified from the RA and OA groups. With the semi-quantitative comparisons, the spectral index (SpI), log2 protein ratio (R_SC) based on spectral counting, and statistical G-test, 98 proteins were found to be significant (pair-wise p < 0.05) to the RA synovial tissues. These include stromelysin-1 (MMP3), proteins S100-A8 and S100-A9, plastin-2, galectin-3, calreticulin, cathepsin Z, HLA-A, HLA-DRB1, ferritin, neutrophil defensin 1, CD14, MMP9 etc.

Conclusions

Our results confirmed the involvement of known RA biomarkers such as stromelysin-1 (MMP3) and proteins S100-A8 and S100-A9, and also that of leukocyte antigens such as HLA-DRB1. Network analyses of protein–protein interaction for those proteins significant to RA revealed a dominant participation of ribosome pathway (p = 5.91 × 10⁻⁴⁵), and, interestingly, the associations of the p53 signaling (p = 2.34 × 10⁻⁵). An involvement of proteins including CD14, S100-A8/S100-A9 seems to suggest an activation of the NF-kB/MAPK signaling pathway. Our strategy of laser-microdissected FFPE-tissue proteomic analysis in Rheumatoid Arthritis thus demonstrated its technical feasibility in profiling proteins expressed in synovial tissues, which may play important roles in the RA pathogenesis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12014-015-9091-8) contains supplementary material, which is available to authorized users.

A case of multicentric reticulohistiocytosis

Multicentric reticulohistiocytosis (MRH) is a rare non-Langerhans histiocytosis of unknown etiology with a predilection for joint and skin. The characteristic clinical features are papulonodular skin eruptions and inflammatory polyarthritis, sometimes progressive to arthritis mutilans, a severe destructive arthropathy. Although these manifestations can present at the same time, it is more common that one feature precedes the others. Notably, these features are similar to those found in some rheumatic diseases, such as rheumatoid arthritis or dermatomyositis, and this can lead to a misdiagnosis, especially during periods where only one feature is present. Herein, we report a female patient with polyarthralgia and subsequent skin eruptions, who was eventually diagnosed with MRH. Her symptoms seemed to resemble those of some rheumatic diseases, but several features such as affected joints and the characteristic shape of the skin lesions did not correspond to that. The histological result of infiltration of histiocytes and multinucleated giant cells in the skin ultimately facilitated the correct diagnosis. In this paper, we review MRH briefly and highlight several differential points which enable us to increase the likelihood of correctly diagnosing MRH.

From desk to bed: computational simulations provide indication for rheumatoid arthritis clinical trials

Background

Rheumatoid arthritis (RA) is among the most common human systemic autoimmune diseases, affecting approximately 1% of the population worldwide. To date, there is no cure for the disease and current treatments show undesirable side effects. As the disease affects a growing number of individuals, and during their working age, the gathering of all information able to improve therapies -by understanding their and the disease mechanisms of action- represents an important area of research, benefiting not only patients but also societies. In this direction, network analysis methods have been used in previous work to further our understanding of this complex disease, leading to the identification of CRKL as a potential drug target for treatment of RA. Here, we use computational methods to expand on this work, testing the hypothesis in silico.

Results

Analysis of the CRKL network -available at http://www.picb.ac.cn/ClinicalGenomicNTW/software.html- allows for investigation of the potential effect of perturbing genes of interest. Within the group of genes that are significantly affected by simulated perturbation of CRKL, we are lead to further investigate the importance of PXN. Our results allow us to (1) refine the hypothesis on CRKL as a novel drug target (2) indicate potential causes of side effects in on-going trials and (3) importantly, provide recommendations with impact on on-going clinical studies.

Conclusions

Based on a virtual network that collects and connects a large number of the molecules known to be involved in a disease, one can simulate the effects of controlling molecules, allowing for the observation of how this affects the rest of the network. This is important to mimic the effect of a drug, but also to be aware of -and possibly control- its side effects. Using this approach in RA research we have been able to contribute to the field by suggesting molecules to be targeted in new therapies and more importantly, to warrant efficacy, to hypothesise novel recommendations on existing drugs currently under test.

Ankylosing spondylitis associated with Sweet's syndrome: a case report

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.

Long-term treatment of severe SAPHO syndrome with adalimumab: case report and a review of the literature

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome defines an association of inflammatory cutaneous disorders with osteoarticular manifestations and represents a clinical and therapeutic challenge. We report a case of severe SAPHO syndrome with acne conglobata and a diffuse involvement of the anterior chest wall and sacroiliac joints that required treatment with isotretinoin and adalimumab, a new fully human anti-tumor necrosis factor (TNF)-α monoclonal antibody. Combination treatment determined a complete clinical remission of cutaneous and osteoarticular manifestations after 48 weeks. Despite maintenance of clinical remission, follow-up imaging studies after 24 months of adalimumab monotherapy revealed osteoarticular disease progression, with features of inflammatory osteitis. TNFα antagonists have been used as third-line therapy for SAPHO syndrome in single case reports or case series, but these lack consistent long-term follow-up. SAPHO syndrome can present an intermittent-favorable course in the majority of cases as well as a chronic-progressive course, the latter requiring aggressive combination treatment with TNFα antagonists and conventional systemic agents.

Síndrome de Sweet: estudo de 23 casos

FUNDAMENTOS: A síndrome de Sweet (SS) é uma doença rara, caracterizada por lesões cutâneas eritematovioláceas dolorosas, febre, leucocitose com neutrofilia e derme com infiltrado inflamatório neutrofílico denso à histologia. Apresenta excelente resposta à corticoterapia. OBJETIVOS: Avaliar os casos de SS em hospital universitário, identificando as características clínicas, laboratoriais e epidemiológicas e compará-las com os dados da literatura. MÉTODOS: Realizou-se estudo epidemiológico, retrospectivo, mediante revisão de prontuários. Identificaram-se 23 pacientes que preencheram os critérios diagnósticos para a doença no período de março de 1995 a julho de 2009. Coletaram-se dados clínicos e epidemiológicos dos pacientes, tais como: localização das lesões, presença de manifestações cutâneas e extracutâneas, condições associadas à SS e alguns dados laboratoriais, como con tagem de leucócitos e velocidade de hemossedimentação (VHS). RESULTADOS: As idades variaram entre 2 e 75 anos. Houve predomínio do sexo feminino. As lesões acometeram, preferencialmente, tronco e membros superiores. Febre foi a manifestação sistêmica mais comum, seguida por artralgias e mialgia, conjuntivite e artrite. Os fatores desencadeantes mais comumente detectados foram infecções de vias aéreas. Neoplasias associadas ocorreram em 30% dos pacientes, principalmente hematológicas. CONCLUSÕES: Os dados clínicos e epidemiológicos encontrados no presente estudo são, em sua maior parte, similares aos já disponíveis na literatura. Devido à alta prevalência de doenças malignas na SS é importante diagnosticá-la, realizar investigação sistêmica adequada e manter seguimento dos pacientes.

A comprehensive molecular interaction map for rheumatoid arthritis

Background

Computational biology contributes to a variety of areas related to life sciences and, due to the growing impact of translational medicine - the scientific approach to medicine in tight relation with basic science -, it is becoming an important player in clinical-related areas. In this study, we use computation methods in order to improve our understanding of the complex interactions that occur between molecules related to Rheumatoid Arthritis (RA).

Methodology

Due to the complexity of the disease and the numerous molecular players involved, we devised a method to construct a systemic network of interactions of the processes ongoing in patients affected by RA. The network is based on high-throughput data, refined semi-automatically with carefully curated literature-based information. This global network has then been topologically analysed, as a whole and tissue-specifically, in order to translate the experimental molecular connections into topological motifs meaningful in the identification of tissue-specific markers and targets in the diagnosis, and possibly in the therapy, of RA.

Significance

We find that some nodes in the network that prove to be topologically important, in particular AKT2, IL6, MAPK1 and TP53, are also known to be associated with drugs used for the treatment of RA. Importantly, based on topological consideration, we are also able to suggest CRKL as a novel potentially relevant molecule for the diagnosis or treatment of RA. This type of finding proves the potential of in silico analyses able to produce highly refined hypotheses, based on vast experimental data, to be tested further and more efficiently. As research on RA is ongoing, the present map is in fieri, despite being -at the moment- a reflection of the state of the art. For this reason we make the network freely available in the standardised and easily exportable .xml CellDesigner format at ‘www.picb.ac.cn/ClinicalGenomicNTW/temp.html’ and ‘www.celldesigner.org’.

Abatacept: a T-cell co-stimulation modulator for the treatment of rheumatoid arthritis

Rheumatoid arthritis (RA) is a debilitating autoimmune disease that has traditionally been treated with disease-modifying anti-rheumatic drugs (DMARDs). In the European Union (EU), patients who fail to respond to traditional DMARDs may receive tumor necrosis factor-alpha (TNF-alpha) antagonists. However, approximately one-third of patients fail TNF-alpha antagonists due to adverse effects or lack of efficacy, and there are limited treatment options available to these patients. As knowledge of the underlying immunopathology of RA evolves, new strategies for inhibiting the inflammatory process have emerged. It is well known that activated T cells play a key role in orchestrating the immunopathological mechanisms of RA. Inhibiting the full activation of T cells is a rational strategy in the treatment of RA and represents a novel method of inhibiting disease activity, distinct from inflammatory cytokine blockade. Here, the safety and efficacy of abatacept, a selective T-cell co-stimulation modulator recently approved in the EU, is reviewed in patients with RA who have shown an inadequate response to TNF-alpha antagonists. In a randomized, placebo-controlled, double-blind, phase III trial of patients with an inadequate response to TNF-alpha antagonism, abatacept was effective in improving the signs and symptoms of RA, as well as patient-centered outcomes, such as fatigue, disability, and other mental and physical aspects of health-related quality of life. These improvements were sustained through 2 years during the open-label, long-term extension period. In this trial, abatacept demonstrated a safety and tolerability profile similar to placebo. Taken together, these data suggest that selective co-stimulation modulation with abatacept may be a viable option for patients who are refractory to both traditional therapies and TNF-alpha antagonists.

Increased enthesopathy among Behçet's syndrome patients with acne and arthritis: an ultrasonography study

OBJECTIVE

Behçet's syndrome is characterized by clusters of disease expression, one of which is the coexistence of acne and arthritis. The aim of this study was to test the hypothesis that enthesopathy is increased in this cluster, having features reminiscent of acne-associated arthritis.

METHODS

The study group comprised 35 patients with Behçet's syndrome who had acne and arthritis (BS-AA), 38 patients with Behçet's syndrome who did not have arthritis (BS-WA), 37 patients with ankylosing spondylitis (AS), 25 patients with rheumatoid arthritis (RA), and 25 healthy control subjects. Five entheseal sites (the superior and inferior poles of the patella, the tibial tuberosity, and the superior and inferior poles of the calcaneus) on both lower extremities were examined by 2 independent observers, using ultrasonography. A previously validated composite score was calculated for each patient. The numbers of entheseal sites giving a positive power Doppler signal in each group were also compared.

RESULTS

Patients with AS had the highest enthesopathy score (mean +/- SD 4.1 +/- 2.4; F [4df] = 8.43, P < 0.001) followed by BS-AA patients (3.0 +/- 1.9; F [3df] = 3.63, P = 0.015). The mean +/- SD enthesopathy scores among the remaining 3 groups were similar (for BS-WA, 1.8 +/- 1.4; for RA, 2.2 +/- 1.6; for healthy controls, 2.0 +/- 1.5 [F (2df) = 0.65, P = 0.53]). Power Doppler scores were highest for the BS-AA group (mean +/- SD 3.0 +/- 1.5; F [4df] = 15.54, P < 0.001) followed by the AS group (2.7 +/- 1.8; F [3df] = 14.38, P < 0.001), the RA group (2.6 +/- 1.8; F [2df] = 13.88, P < 0.001), the BS-WA group (1.2 +/- 1.3; F [1df] = 4.48, P = 0.038), and the control group (0.5 +/- 1.1). There was 87% agreement between the 2 observers (kappa = 0.55, intraclass correlation coefficient 0.71).

CONCLUSION

The increased presence of enthesopathy among BS-AA patients compared with that among BS-WA patients further supports the hypothesis that patients with Behçet's syndrome who also have arthritis and acne form a distinct cluster.

Ankylosing spondylitis and Sweet's syndrome

We report a case of a woman, born in 1943, with definite ankylosing spondylitis (AS) fulfilling the revised New York criteria for AS, although human leukocyte antigen B 27 negative. After 20 years of evolution, she developed a febrile skin disease corresponding to Sweet's syndrome, confirmed by skin biopsy. No other underlying condition was found. The relationship between AS and Sweet's syndrome is discussed; only one other case is reported in the literature. Skin involvement in AS is dominated by psoriasis-type lesions. The occurrence of Sweet's syndrome is seldom reported in this condition.