Haemoglobinopathies and the rheumatologist

Hemoglobin alpha is a redox-sensitive mitochondrial-related protein in T-lymphocytes

Hemoglobin subunits, which form the well-characterized, tetrameric, oxygen-carrying protein, have recently been described to be expressed in various non-canonical cell types. However, the exact function of hemoglobin subunits within these cells remains to be fully elucidated. Herein, we report for the first time, the expression of hemoglobin alpha-a1 (Hba-a1) in T-lymphocytes and describe its role as a mitochondrial-associated antioxidant. Within naïve T-lymphocytes, Hba-a1 mRNA and HBA protein are present and highly induced by redox perturbations, particularly those arising from the mitochondria. Additionally, preliminary data using a T-lymphocyte specific Hba-a1 knock-out mouse model indicated that the loss of Hba-a1 led to an exacerbated production of mitochondrial reactive oxygen species and inflammatory cytokines after a stress challenge, further supporting the role of HBA acting to buffer the mitochondrial redox environment. Interestingly, we observed Hba-a1 expression to be significantly upregulated or downregulated depending on T-lymphocyte polarization and metabolic state, which appeared to be controlled by both transcriptional regulation and chromatin remodeling. Altogether, these data suggest Hba-a1 may function as a crucial mitochondrial-associated antioxidant and appears to possess critical and complex functions related to T-lymphocyte activation and differentiation.

[Inflammatory rheumatic diseases in migrants]

The immigration of people from other countries or even from other continents represents new challenges even for rheumatologists. Although all inflammatory rheumatic diseases that occur in this country also exist in the countries of origin of immigrants, the frequencies are different. Diseases such as familial Mediterranean fever (FMF) or Behçet syndrome (BS) are rare in western Europe but are often more frequent than rheumatoid arthritis (RA) and spondylarthritis (SPA) in North Africa and Mediterranean countries. Furthermore, FMF is associated with the occurrence of spondyloarthritis, which is then frequently negative for the human leucocyte antigen B27 (HLA-B27). There is also an association with BS. Rheumatic fever also still occurs relatively frequently especially in African countries, whereas it is almost eradicated in Europe. Possible differential diagnoses such as rheumatic symptoms in genetically determined anemia or infections such as human immunodeficiency virus (HIV) infections, hepatitis, tuberculosis and parasitosis need to be considered as they are all much more frequent in the countries of origin of immigrants than in northwestern Europe. Last but not least, the treatment situation with modern diagnostic and treatment modalities is different in the countries of origin of the migrants, either because these possibilities are unavailable due to limited resources or because the situation has dramatically deteriorated due to acute events, such as the recent war in Ukraine.

Risk of gout attack not increased in patients with thalassemia: a population-based cohort study

The incidence of gout arthritis in patients with thalassemia and the association between them was indefinite. We aimed to give epidemiological evidence regarding the association between thalassemia and gout arthritis. This retrospective cohort study extracted data relating to the risk of gout arthritis from patients diagnosed with thalassemia between 2000 and 2013. We selected the control group at a ratio of 1:4 by propensity score matching (PSM). Univariable and multivariable Cox proportional hazard regression models were performed to analyze the association between thalassemia and gout arthritis and to evaluate the hazard ratio (HR) of gout arthritis after exposure with thalassemia. The sensitivity analysis was performed to avoid the mislabeled thalassemia disease, the transfusion-dependent thalassemia was classified to compare the risk of gout arthritis. The secondary outcome for the risk of gout arthritis with antigout drugs treatment was also evaluated between study groups. In the age and sex matched cohort, the majority of thalassemia patients were women (62.03%) and aged younger than 30 years old (44.79%). There were 138 (4.2%) and 500 (3.8%) incident cases of gout arthritis in the thalassemia and non-thalassemia group. After PSM, the incidence rate, per 100 person-years, of gout arthritis was 0.48 (95% CI 0.42 to 0.56) and 0.60 (95% CI 0.51 to 0.72) in non-thalassemia individuals and patients with thalassemia, respectively. In the Cox proportional hazard regression, patients with thalassemia had no significant increase in the risk of gout arthritis (adjusted HR, 1.00; 95%CI: 0.80 to 1.25) after adjusting demographic variables and comorbidities. The Kaplan-Meier curve showed that the cumulative incidence of gout arthritis was not a significant difference in the thalassemia group than in the comparison group (p > 0.05). The sensitivity analysis showed the consistent results about the risk of gout arthritis in patients with thalassemia. Our study indicated that there was no significant increase in the risk of gout arthritis in subjects with thalassemia.Future research needs to clarify the biological mechanisms behind this connection.

Risk of vaso-occlusive episodes in patients with sickle cell disease exposed to systemic corticosteroids: a comprehensive review

INTRODUCTION

Sickle cell disease (SCD) is the most frequent inherited disorder in the world. It is caused by a single amino acid mutation on the beta-globin chain, which lead to red blood cell deformation, haemolysis, and chronic inflammation. Clinical consequences are vaso-occlusives crisis, acute chest syndrome, thrombosis, infection, and chronic endothelial injury.

AREAS COVERED

Corticosteroids are an old therapeutic class, that are inexpensive and widely available, which can be administered in different forms. Their adverse effects are numerous and well-known. This class could appear to be useful in SCD treatment due to its anti-inflammatory effect. Moreover, corticosteroids remain an essential therapeutic class for many indications, besides SCD. Although specific adverse effects of corticosteroids have been suspected in SCD patients for decades, recent papers has reported strong evidence of specific and severe adverse effects in this population. Based on a literature review, we will discuss pathophysiological considerations, consequences, and practical use of corticosteroids in SCD.

EXPERT OPINION

High corticosteroid doses, for any indication , induce vaso-occlusive crises, acute chest syndrome, and re-hospitalization in patients with SCD. There is no evidence of any benefits of corticosteroid use in the SCD acute events. Prevention by hydroxyurea and/or red blood cell transfusion or exchange should be discussed when corticosteroid use is indispensable.

Sickle cell disease chronic joint pain: Clinical assessment based on maladaptive central nervous system plasticity

Chronic joint pain (CJP) is among the significant musculoskeletal comorbidities in sickle cell disease (SCD) individuals. However, many healthcare professionals have difficulties in understanding and evaluating it. In addition, most musculoskeletal evaluation procedures do not consider central nervous system (CNS) plasticity associated with CJP, which is frequently maladaptive. This review study highlights the potential mechanisms of CNS maladaptive plasticity related to CJP in SCD and proposes reliable instruments and methods for musculoskeletal assessment adapted to those patients. A review was carried out in the PubMed and SciELO databases, searching for information that could help in the understanding of the mechanisms of CNS maladaptive plasticity related to pain in SCD and that presented assessment instruments/methods that could be used in the clinical setting by healthcare professionals who manage chronic pain in SCD individuals. Some maladaptive CNS plasticity mechanisms seem important in CJP, including the impairment of pain endogenous control systems, central sensitization, motor cortex reorganization, motor control modification, and arthrogenic muscle inhibition. Understanding the link between maladaptive CNS plasticity and CJP mechanisms and its assessment through accurate instruments and methods may help healthcare professionals to increase the quality of treatment offered to SCD patients.

Multifocal Osteonecrosis in a 3-Year-old Child With Sickle Beta Plus Thalassemia

Sickle beta+thalassemia is considered to be a mild form of sickle cell disease. However, some patients with mild disease can present with osteonecrosis. Here, we present a rare 3-year-old male who presented with acute pain, a baseline hemoglobin of 13 g/dL, who acutely developed multifocal osteonecrosis, and improved with partial exchange transfusion and hydroxyurea therapy.

Musculoskeletal imaging manifestations of beta-thalassemia

Beta-thalassemia is a heterogeneous group of anemic disorders caused by the absence or defective production of beta-globin chains. Their clinical manifestations vary from asymptomatic to severe symptoms leading to a transfusion-dependent anemic state. The genes that cause thalassemia are prevalent in Asian and African populations, particularly concentrated in the Middle East, Mediterranean region, parts of India, and South East Asia. Over time, the disease causes various musculoskeletal abnormalities with complex pathophysiology secondary to chronic anemia. The compensatory mechanisms result in diffuse marrow hyperplasia, yellow to red marrow reconversion, osteopenia, and pathologic fractures. Inability to remove excess iron and inevitable iron overload as a result of multiple blood transfusions in patients with thalassemia major and intermedia is another face of the disease. Musculoskeletal manifestations include osteopenia, coarse trabeculae, bone expansion, synovitis, joint effusion, and metaphyseal dysplasia. These complications have long-lasting effects on the skeletal growth pattern resulting in bone deformity, short stature, premature closure of physes, and predisposition to infection. Additionally, there are radiologic features of iron-chelator therapy, which are unique and unrelated to the disease process itself. Familiarity of radiologists with the imaging features of beta-thalassemia is crucial in both diagnosis and timely management of the disease and its complications.

Chronic osteo-articular changes in patients with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) is an autosomal recessive genetic disease in which a mutation occurs in the β-globin chain gene, resulting in abnormal hemoglobin levels. In an environment with reduced oxygen concentration, red blood cells change their conformation, resulting in chronic hemolysis and consequent anemia and vaso-occlusive crises with injuries to several organs, with a significant impairment of the osteoarticular system. This study aimed to verify the chronic osteoarticular alterations and their association with clinical and laboratory characteristics of patients with SCD with a more severe phenotype (SS and Sβ⁰), on a steady-state fasis.

METHODS

Fifty-five patients were referred to a medical consultation with a specialized assessment of the locomotor system, followed by laboratory tests and radiographic examinations.

RESULTS

In total, 74.5% patients had hemoglobinopathy SS; 67.3% were female; and 78.2% were non-whites. The mean patient age was 30.5 years. Most patients (61.8%) reported up to three crises per year, with a predominance of high-intensity pain (65.5%). Radiographic alterations were present in 80% patients. A total of 140 lesions were identified, most which were located in the spine, femur, and shoulders. Most lesions were osteonecrosis and osteoarthritis and were statistically associated with the non-use of hydroxyurea.

CONCLUSIONS

There was a high prevalence of chronic osteoarticular alterations, which was statistically associated only with the non-regular use of hydroxyurea.

Optimizing the management of chronic pain in sickle cell disease

Chronic pain in sickle cell disease (SCD) refers to pain present on most days lasting over six months. It can start during childhood and the prevalence increases with age. By adulthood, over 55% of patients experience pain on over 50% of days; 29% reporting pain on 95% of days. The true prevalence of chronic pain in SCD is likely underappreciated as it is mostly managed at home. Patients with chronic pain and SCD frequently seek acute care for exacerbation of underlying chronic pain difficult to distinguish from their usual acute vaso-occlusive crises. When treating chronic pain in SCD, the challenge is distinguishing between non-SCD related etiologies versus chronic pain resulting from SCD pathophysiological processes. This distinction is important to delineate as it will drive appropriate management strategies. Chronic pain in SCD has profound consequences for the patient; is often associated with comorbid psychiatric illnesses (depression and anxiety), not dissimilar from other chronic pain syndromes. They may also experience challenges with sleep hygiene, various somatic symptoms, and chronic fatigue that impair quality of life. How best to treat chronic pain in SCD is not definitively established. Both acute and chronic pain in SCD is typically treated with opioids. Emerging data suggests that chronic opioid therapy (COT) is a suboptimal treatment strategy for chronic pain. This review will discuss the complexity of managing chronic pain in SCD; pain that may be dependent or independent of the underlying SCD diagnosis. We will also describe alternative treatment approaches to high-dose COT.

Rheumatic Manifestations of Haemoglobinopathies

PURPOSE OF THE REVIEW

To provide a clinically useful literature review on the rheumatic manifestations of haemoglobinopathies, critically analysing the literature from the past 5 years.

RECENT FINDINGS

There are limited new data to guide the management of rheumatic manifestations of haemoglobinopathies. Data further confirm the wide spectrum of potential rheumatic/MSK involvement in haemoglobinopathies, which poses both a diagnostic and therapeutic challenge. Inflammatory arthritis may be more common than previously believed. Steroid therapy by any route of administration can provocate a potential life-threatening vaso-occlusive crisis. Vitamin D deficiency is common. There are limited data to guide the drug treatment of reduced bone density in haemoglobinopathies. There have been a number of studies examining pain in sickle cell anaemia. Plasma levels of Klotho may represent a novel biomarker in patients with β-Thalassemia. There are little new data on the rheumatic manifestations in haemoglobinopathies and future high-quality research is needed.

Rheumatological complications of beta-thalassaemia: an overview

Beta-thalassaemia, an autosomal recessive haemoglobinopathy, ranks among the most frequent monogenetic diseases globally. The severe form of the disease, beta-thalassaemia major, is accompanied by progressive involvement of multiple organ systems as a result of the disease pathophysiology as well as iron overload from blood transfusions on a regular basis. Some of the manifestations might also be caused by medications used to manage iron overload. The purpose of this review is to highlight the rheumatological complications of beta-thalassaemia, which include musculoskeletal manifestations, such as arthritis and arthropathies, joint effusions, osteoporosis, bone fractures and myalgias, in addition to CTDs, such as pseudoxanthoma elasticum. Rheumatologists are strongly encouraged to take part in a multidisciplinary approach to the management of this debilitating disease.

Coexisting Juvenile Dermatomyositis and Sickle Cell Disease: Maintaining a High Degree of Suspicion

Juvenile dermatomyositis is an idiopathic inflammatory myopathy of childhood not previously described in a patient with sickle cell disease. We present a case of an 11-year-old girl with sickle cell disease who was diagnosed subsequently with juvenile dermatomyositis, and highlight the diagnostic and therapeutic challenges of these concurrent chronic diseases.

Myonecrosis in Sickle Cell Anemia: Case Study

Patient: Male, 27

Final Diagnosis: Myonecrosis of sickle cell anaemia

Symptoms: Pain • redness to feet • swelling foot

Medication: —

Clinical Procedure: MRI

Specialty: Podiatry