The presence of rheumatoid nodules at early rheumatoid arthritis diagnosis is a sign of extra-articular disease and predicts radiographic progression of joint destruction over 5 years

Approach to Pulmonary Nodules in Connective Tissue Disease

The assessment of pulmonary nodules is a common and often challenging clinical scenario. This evaluation becomes even more complex in patients with connective tissue diseases (CTDs), as a range of disease-related factors must also be taken into account. These diseases are characterized by immune-mediated chronic inflammation, leading to tissue damage, collagen deposition, and subsequent organ dysfunction. A thorough examination of nodule features in these patients is required, incorporating anatomic and functional information, along with patient demographics, clinical factors, and disease-specific knowledge. This integrated approach is vital for effective risk stratification and precise diagnosis. This review article addresses specific CTD-related factors that should be taken into account when evaluating pulmonary nodules in this patient group.

Rheumatoid nodules: a narrative review of histopathological progression and diagnostic consideration

Rheumatoid nodules (RNs) are the most common extra-articular manifestation of rheumatoid arthritis and are also seen in patients with other autoimmune and inflammatory diseases. The development of RNs includes histopathological stages of acute unspecified inflammation, granulomatous inflammation with no or minimal necrosis, necrobiotic granulomas typically with central fibrinoid necrosis surrounded by palisading epithelioid macrophages and other cells, and likely an advanced stage of "ghost" lesions containing cystic or calcifying/calcified areas. In this article, we review RN pathogenesis, histopathological features in different stages, diagnostically related clinical manifestations, as well as diagnosis and differential diagnosis of RNs with an in-depth discussion about challenges in distinguishing RNs from their mimics. While the pathogenesis of RN formation remains elusive, it is hypothesized that some RNs with dystrophic calcification may be in transition and may be in coexistence or collision with another lesion in patients with RA or other soft tissue diseases and comorbidities. The diagnosis of typical or mature RNs in usual locations can be readily made by clinical findings often with classic RN histopathology, but in many cases, particularly with atypical or immature RNs and/or unusual locations, the clinical and histopathological diagnosis can be challenging requiring extensive examination of the lesional tissue with histological and immunohistochemical markers to identify unusual RNs in the clinical context or other lesions that may be coexisting with classic RNs. Proper diagnosis of RNs is critical for appropriate treatment of patients with RA or other autoimmune and inflammatory diseases.

[18F]FDG PET/CT in rheumatoid arthritis

[¹⁸F]fluorodeoxyglucose (FDG) PET/CT can be used to image the inflammation in rheumatoid arthritis. Specifically, the synovial metabolic activity can be evaluated visually and measured using standard uptake values. Fluorine-18-labeled Sodium fluoride (NaF) PET/CT can be used to determine synovial osteoblastic activity. Response assessment using FDG PET/CT is routine in many cancers and this is now an emerging technique for rheumatoid arthritis. Vasculitis in rheumatoid arthritis (RA) can be also studied with FDG PET/CT and aortic calcification with NaF PET/CT. These techniques could be useful in determining RA disease severity. FDG PET/CT is a useful technique to exclude underlying malignancy when RA does not follow the expected course. A number of novel tracers are being studied with regard to their applicability in rheumatoid arthritis and some of these could even be used in a theranostic manner in the future.

Imaging Features of Soft Tissue Tumor Mimickers: A Pictorial Essay

Soft tissue lesions are commonly encountered and imaging is an important diagnostic step in the diagnosis and management of these lesions. While some of these lesions are true neoplasms, others are not. These soft tissue tumor mimickers can be due to a variety of conditions including traumatic, iatrogenic, inflammatory/reactive, infection, vascular, and variant anatomy. It is important for the radiologist and clinician to be aware of these common soft tissue tumor mimickers and their characteristic imaging features to avoid unnecessary workup and provide the best treatment outcome.

Interleukin 27 Signaling in Rheumatoid Arthritis Patients: Good or Evil?

The occurrence and development of rheumatoid arthritis (RA) is regulated by numerous cytokines. Interleukin 27 (IL-27) is a soluble cytokine that exerts biological effects by regulating the Janus tyrosine kinase (JAK)/signal transducer and activator of the transcription (STAT) signaling pathway via the IL-27 receptor. IL-27 is known for its pleiotropic roles in modulating inflammatory responses. Previous studies found that IL-27 levels are elevated in RA blood, synovial fluid, and rheumatoid nodules. Cellular and animal experiments indicated that IL-27 exerts multiple regulatory functions in RA patients via different mechanisms. IL-27 inhibits ectopic-like structure (ELS) formation and CD4⁺ T helper type 2 (Th2) cell, CD4⁺ T helper type 17 (Th17) cell, and osteoclast differentiation in RA, contributing to alleviating RA. However, IL-27 promotes Th1 cell differentiation, which may exacerbate RA synovitis. Moreover, IL-27 also acts on RA synovial fibroblasts (RA-FLSs) and regulatory T cells (Tregs), but some of its functions are unclear. There is currently insufficient evidence to determine whether IL-27 promotes or relieves RA. Targeting IL-27 signaling in RA treatment should be deliberate based on current knowledge.

[Rheumatoid arthritis : These dermatoses lead you to the diagnosis]

BACKGROUND

Rheumatoid arthritis is one of the most common autoimmune disorders. In addition to chronic arthritis, rheumatoid arthritis may present a variety of extra-articular manifestations, most commonly of the skin.

OBJECTIVES

Cutaneous manifestations associated with rheumatoid arthritis can be diverse, both specific and nonspecific. Which dermatoses should lead you to the diagnosis of an underlying rheumatoid arthritis?

METHODS

Evaluation of exemplary overviews, case presentations and relevant textbook articles.

RESULTS

Rheumatoid arthritis presents various specific and nonspecific skin manifestations. Besides visual diagnosis like classic rheumatoid nodules a histopathologic correlation or an interdisciplinary approach is often needed, such as for diagnosis of pyoderma gangrenosum.

CONCLUSIONS

The early detection and correct classification of cutaneous manifestations associated with rheumatoid arthritis can be groundbreaking for a successful therapy and a consequently better prognosis for patients with rheumatoid arthritis. Therefore dermatologists bear responsibility in the patient-centered care.

Cutaneous manifestations are frequent and diverse among patients with rheumatoid arthritis and impact their quality of life: a cross-sectional study in a cohort of patients with recent-onset disease

INTRODUCTION/OBJECTIVES

Cutaneous involvement is often overlooked in rheumatoid arthritis (RA). We described cutaneous findings in outpatients attending a recent-onset cohort and identified factors associated with skin involvement and reduced (R) dermatological quality of life (DQoL).

METHODS

Skin and rheumatological examinations were performed in 122 patients. DQoL was assessed through the Dermatology Life Quality Index (DLQI). Skin findings were classified as RA-specific and RA-nonspecific. Multiple regression analysis identified factors associated to skin involvement and RDQoL (DLQI score > 1).

RESULTS

Patients were middle-aged females (91%), with a 1-year mean disease activity score in 28 joints as 2.0 (interquartile range: 1.5-2.6). There were 94 (77%) patients in whom at least one cutaneous finding was observed: 17 (13.1%) had RA-specific findings (all were rheumatoid nodules) and 91 (96.8%) had at least one RA-nonspecific finding, further classified into skin diseases (35.2%), hair diseases (20.9%), and skin-related signs (76.9%, among whom 94.3% had xerosis). Age (odds ratio [OR]: 1.054, 95% confidence interval [CI]: 1.015-1.094) and skin-health concerns (OR: 5.657, 95% CI: 1.771-18.070) were associated with cutaneous involvement, whereas increased age and DLQI score were associated with a higher number of skin findings/patient. There were 29 patients (24.2%) with RDQoL, which were associated with the Short Form-36 emotional component (OR: 0.955, 95% CI: 0.923-0.988) and the number of skin findings/patient (OR 2.873, 95% CI 1.723-4.791). Pruritus and hair diseases were the individual categories associated with RDQoL.

CONCLUSIONS

Cutaneous manifestations are frequent in RA patients and have the potential to impact the emotional component of health-related quality of life. Key Points • Up to 77% of the RA patients with substantial follow-up, from a recent-onset disease cohort, had cutaneous manifestations; these were primarily RA-nonspecific findings, whereas 13.1% had RA-specific findings. • Skin-health concerns and age were associated with cutaneous involvement; meanwhile, increased age and Dermatology Life Quality Index (DLQI) score were associated with a higher number of cutaneous findings/patient. • Reduced dermatological quality of life (RDQoL) was documented in one in four patients and was associated with the SF-36 emotional component and the number of cutaneous findings/patient.

Endothelial Dysfunction and Extra-Articular Neurological Manifestations in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory autoimmune disease that affects about 1% of the global population, with a female–male ratio of 3:1. RA preferably affects the joints, with consequent joint swelling and deformities followed by ankylosis. However, evidence has accumulated showing that patients suffering from RA can also develop extra-articular manifestations, including cardiovascular disease states, neuropathies, and multiorgan dysfunction. In particular, peripheral nerve disorders showed a consistent impact in the course of the disease (prevalence about 20%) mostly associated to vasculitis of the nerve vessels leading to vascular ischemia, axonal degeneration, and neuronal demyelination. The pathophysiological basis of this RA-associated microvascular disease, which leads to impairment of assonal functionality, is still to be better clarified. However, endothelial dysfunction and alterations of the so-called brain-nerve barrier (BNB) seem to play a fundamental role. This review aims to assess the potential mechanisms underlying the impairment of endothelial cell functionality in the development of RA and to identify the role of dysfunctional endothelium as a causative mechanism of extra-articular manifestation of RA. On the other hand, the potential impact of lifestyle and nutritional interventions targeting the maintenance of endothelial cell integrity in patients with RA will be discussed as a potential option when approaching therapeutic solutions in the course of the disease.

Giant Infrascapular Rheumatoid Nodules Mimicking Elastofibroma Dorsi: A Case Report

Rheumatoid nodules are the most common extra-articular presentations of rheumatoid arthritis. Although rheumatoid nodules can develop anywhere in the body, they develop most commonly in the subcutaneous region, where they are easily exposed to repetitive trauma or pressure. However, an infrascapular presentation has not yet been reported. We report a case of giant bilateral rheumatoid nodules that developed in the infrascapular area, complicating its distinction from elastofibroma dorsi on radiological examination.

Distinctive Clinical Characteristics and Outcome of ILD-Onset Rheumatoid Arthritis and ACPA-Positive ILD: a Longitudinal Cohort of 282 Cases

The aim of this study is to investigate the clinical features and outcome of interstitial lung disease (ILD)-onset rheumatoid arthritis (RA) and anti-citrullinated protein antibody (ACPA)-positive ILD-only patients. Arthritis-onset and ILD-onset RA-ILD and ACPA-positive ILD-only patients consecutively admitted to Peking Union Medical College Hospital from January 2008 to December 2017 were enrolled and followed-up. Their demographic, clinical, and laboratory features as well as outcome were collected and analyzed. Compared with arthritis-onset RA-ILD (n = 166, median arthritis-to-ILD interval: 60 months), the ILD-onset RA-ILD (n = 75, median ILD-to-arthritis interval: 2 months) had less rheumatoid nodules and higher titer of ACPA, and manifested more stable ILD (median estimated progression-free survival: 120 vs. 100 months, p = 0.019). Elder age (≥ 65 years) at ILD diagnosis and UIP pattern were associated with ILD progression by both univariate and Cox hazards modeling analysis (p < 0.05). In ACPA-positive ILD-only patients (n = 41), arthritis developed in 7 (17.1%) female patients after a median interval of 24 months. ACPA-positive ILD who subsequently developed arthritis exhibited higher frequency of rheumatoid factor (RF), higher titer of ACPA, and higher levels of ESR and CRP (p < 0.05). Multivariate regression analysis showed that positive RF (OR 12.55, 95% CI 1.31 to 120.48) was the independent risk factor for arthritis development in ACPA-positive ILD-only patients. ILD-onset RA-ILD had more stable ILD compared with arthritis-onset RA-ILD. ACPA-positive ILD patients with positive RF are at increased risk of developing RA.

The incidence of extra-articular manifestations in southern Chinese patients with inflammatory joint diseases

AIM

Inflammatory joint diseases (IJDs) are chronic arthritis, but frequently present with co-morbidities of other organs and systems, which is known as extra-articular manifestations (EAMs). It is still unclear which clinical characteristics or bio-markers can predict the development of EAMs. The aim of this study was to estimate the proportion of EAMs in southern Chinese patients with IJDs and to explore the risk factors.

METHODS

This was a retrospective cohort study of a total 1135 IJDs patients, including 788 rheumatoid arthritis (RA) patients, 307 ankylosing spondylitis (AS) patients and 40 psoriatic arthritis (PsA) patients. Demographic data, disease characteristics, laboratory blood tests, medical imaging, and the presence of EAMs were recorded.

RESULTS

We found 459 (40.44%) patients presented with EAMs: 30.84% had cardiovascular involvement, 7.67% had pulmonary involvement, 5.29% had osteoporosis/low bone mineral density, 2.29% had ocular, 0.79% had gastrointestinal and 0.26% had renal involvements. Multivariate logistic regression showed older age (odds ratio [OR] 1.06, P < .001) and higher anti-cyclic citrullinated peptide antibody (anti-CCP) levels (OR 1.003, P = .019) were independent risks of EAMs in RA patients. In the AS group, older age (OR 1.07, P < .001) and higher disease activity (OR 3.24-7.42, both P < .05), were independent risks of EAMs. In the PsA group, longer disease duration (OR 1.01, P = .036) and higher disease activity (OR 1.15, P = .004) were univariate associated factors.

CONCLUSION

These results suggested the high prevalence of EAMs, and it is important to regularly screen for EAMs, as they influence treatment decisions and impact on patients' quality of life.

Thoracic Manifestations of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is commonly associated with pulmonary disease that can affect any anatomic compartment of the thorax. The most common intrathoracic manifestations of RA include interstitial lung disease, airway disease, pleural disease, rheumatoid nodules, and drug-induced toxicity. Patients with RA with thoracic involvement often present with nonspecific respiratory symptoms, although many are asymptomatic. Therefore, clinicians should routinely consider pulmonary disease when evaluating any patient with RA, particularly one with known risk factors. The optimal screening, diagnostic, and treatment strategies for RA-associated pulmonary disease remain uncertain and are the focus of ongoing investigation.

Clinicopathologic features of rheumatoid nodules: a retrospective analysis

OBJECTIVES

The clinical and histopathologic features of patients that have been diagnosed with rheumatoid nodules were investigated.

METHODS

This study included patients with rheumatoid nodules, confirmed by histologic assessment, between 2005 and 2018 at the Hanyang University Hospital. Each patient had a total score of 6 or more according to the American College of Rheumatology criteria.

RESULTS

A total of 57 cases were included in this study. The median age of the patients at the time of diagnosis was 57 years (range, 39-70 years). The average duration between the onset of treatment and occurrence of rheumatoid nodule was 11.6 years. Bone erosion was observed in 44 patients (77.2%). Among 57 patients, 56 (98.2%) were treated with disease-modifying anti-rheumatic drugs; most of the patients (87.7%) showed high-positive rheumatoid factor or high-positive anti-citrullinated protein antibodies. The foot, hand, and wrist, in order of decreasing frequencies, were the anatomical sites with the highest occurrence of rheumatoid nodules, whereas, the soft tissue adjacent to the joint, subcutis, dermis, lung parenchyma, and submucosal layer of the supraglottic area, also in an order of highest frequency, were the histological sites with the highest occurrence. Microscopically, central necrobiosis was present in all cases. Stromal fibrosis (96.5%), palisading of histiocytes (82.5%), perivascular lymphocytic infiltration (68.4%), and cleft or cystic degeneration (63.2%) were also observed.

CONCLUSIONS

A clinicopathological review of cases diagnosed with rheumatoid nodules histologically was performed to confirm characteristics that can help clinicians understand the pathophysiology of the condition and make accurate diagnoses of rheumatoid nodules. Key Points • We reviewed the clinical, imaging, and histologic features of rheumatoid nodule. • The average duration between the onset of treatment and occurrence of rheumatoid nodule was 11.6 years. • Among 57 rheumatoid nodule patients, 98.2% were treated with disease-modifying anti-rheumatic drugs.

Antibody-dependent and -independent mechanisms of inflammatory arthritis

Inflammatory arthritis encompasses a set of common diseases characterized by immune-mediated attack on joint tissues. Most but not all affected patients manifest circulating autoantibodies. Decades of study in human and animal arthritis have identified key roles for autoantibodies in immune complexes and through direct modulation of articular biology. However, joint inflammation can arise because of pathogenic T cells and other pathways that are antibody-independent. Here we review the evidence for these parallel tracks, in animal models and in humans, to explore the range of mechanisms engaged in the pathophysiology of arthritis and to highlight opportunities for targeted therapeutic intervention.

Low Prevalence of Nodules in Rheumatoid Arthritis Patients in Kuwait: A Description and a Comparison of Patients from the Kuwait Registry for Rheumatic Diseases

OBJECTIVES

To describe the prevalence of rheumatoid nodules (RN) in patients with rheumatoid arthritis (RA) and to compare their features with those of patients without RN.

SUBJECTS AND METHODS

Adult RA patients (n = 952) in the Kuwait Registry for Rheumatic Diseases from February 2013 to December 2015 were evaluated for RN. Demographic and serological features and disease activity and severity were obtained from the registry.

RESULTS

Of the 952 RA patients, 22 (2.3%) had RN and 930 (97.7%) did not. Age, sex, disease duration, smoking, and family history of an autoimmune rheumatic disease were similar. Obesity was more prevalent in the RN group, i.e. 11 (50%) vs. 326 (35.1%), p = 0.016. There was no difference in rheumatoid factor (RF) or anti-cyclic citrullinated peptide antibody positivity. Patients with RN had more sicca symptoms, i.e. 8 (36.4%) vs. 152 (16.3%), p = 0.025, a higher mean score on the visual analogue scale pain (3 ± 2.9 vs. 2 ± 2.7, p < 0.001), more tender joints (6.4 ± 8.8 vs. 4.2 ± 7.2, p = 0.001), a higher patient global assessment of disease activity (3.3 ± 2.7 vs. 2.3 ± 2.7, p < 0.001), and more deformities, i.e. 3 (13.6%) vs. 74 (8%), p = 0.034. The mean health assessment questionnaire score in RN patients was 1.1 versus 0.9 in patients without RN (p = 0.08). Patients with RN had a low disease activity (means: disease activity score [DAS-28], 3.02; clinical disease activity index, 7.7; and simple disease activity index, 10.4), similar to the other group. While the rates of methotrexate treatment were comparable, biologic therapy was administered more in patients with RN (i.e. 15 [68.2%] vs. 478 [51.4%], p < 0.001).

CONCLUSION

In Kuwait, the prevalence of RN is low among RA patients. Patients with and without RN are similar in terms of demographics and serologic features, except for more obesity. However, patients with RN have more sicca symptoms, joint deformities, and painful and tender joints. Disease activity scores are low with more frequent biologic therapy.

Factors Associated with Erosive Arthritis in Rheumatoid Arthritis and Other Connective Tissue Diseases: A Retrospective Study From a Southern Chinese Population

OBJECTIVE

To investigate the clinical predictors of erosive arthritis (EA) in patients with rheumatoid arthritis (RA) and other connective tissue diseases.

METHODS

Four hundred and one consecutive patients with newly diagnosed RA between January 2010 and January 2013 were enrolled in the study. During the study period, 729 consecutive patients with non-RA connective tissue diseases were also included, and a cross-sectional study was performed. Medical records were reviewed. Only those patients with data for 2 years were considered in the analysis (338).

RESULTS

Erosive arthritis was noted in 60.4% (204 /338) of patients with RA and occurred early in RA. The multivariate logistic regression analysis indicated that rheumatoid nodules, anemia, and positive anticyclic citrullinated peptide antibody (ACPA) were strongly associated factors for the occurrence of EA in RA patients. Erosive arthritis was also noted in 1.5% of patients with SLE, 5.8% of patients with primary Sjögren syndrome, and 9.1% (3/33) of patients with systemic sclerosis. When compared with patients without EA, high level and prominently higher positive rate of ACPA was found in these patients with EA. On receiver operating characteristic curve analysis, ACPA exhibited a maximum sensitivity with a cutoff value of 1.6 U/mL and 0.6 U/mL for RA and SLE patients, respectively.

CONCLUSION

Erosive arthritis had a high prevalence in Chinese RA patients and occurred early. Anemia, rheumatoid nodules, and ACPA were associated with EA in RA. Erosive arthritis also could be detected in SLE, primary Sjögren syndrome, and systemic sclerosis. Anticyclic citrullinated peptide antibodies were also associated with EA in these diseases. Intensive monitoring for erosions was recommended for RA patients with a cutoff of ACPA greater than 1.6 U/mL and greater than 0.6 U/mL for SLE patients.

Multiple myeloma masquerading as severe seropositive rheumatoid arthritis with subcutaneous nodules and mononeuritis multiplex

Multiple myeloma can rarely mimic seronegative rheumatoid arthritis (RA). We report a 55-year-old woman who presented with longstanding deforming polyarthritis with extensive subcutaneous nodules, tenosynovitis, anti-cyclic citrullinated peptide positivity and mononeuritis multiplex. Even though the clinical picture was consistent with seropositive RA, the absence of bone erosion or joint space narrowing on hand and knee radiographs led us to question the diagnosis of RA. Further investigation revealed a diagnosis of multiple myeloma with cutaneous amyloid deposits, based on serum immunofixation, bone marrow aspiration and biopsy of a subcutaneous nodule. The only clue to suspect myeloma from the basic investigations and clinical examination was mild hypercalcemia. This case serves to reiterate the need to maintain a heightened suspicion for other diagnoses even when RA appears most likely.

Skin Signs of Rheumatoid Arthritis and its Therapy-Induced Cutaneous Side Effects

Rheumatoid arthritis (RA) is a systemic inflammatory disorder that primarily affects the joints, but may exhibit extra-articular, including cutaneous, manifestations such as rheumatoid nodules, rheumatoid vasculitis, granulomatous skin disorders, and neutrophilic dermatoses. A large burden of cutaneous disease may be an indication of RA disease activity and the need for more aggressive treatment. Many of the therapeutic agents used to treat RA can also result in cutaneous adverse effects, which pose their own diagnostic and therapeutic challenges. Anti-TNFα agents, in particular, have a wide variety of adverse effects including psoraisiform eruptions, granulomatous conditions, and cutaneous connective tissue disorders. Herein we provide an update on the clinical presentations and management of RA-associated cutaneous findings as well as drug-induced cutaneous effects, with particular attention to the adverse effects of biologic disease-modifying agents.

Determination of specificity and sensitivity of anti-RA 33 in diagnosis of early rheumatoid arthritis

Background:

Rheumatoid arthritis is a chronic inflammatory disease with uncertain etiology. It is characterized by symmetric polyarthritis in peripheral joints. Its diagnosis is based on clinical findings and serologic tests. However, its diagnosis is rarely conclusive in early course of the disease. So, its early diagnosis could be difficult. The present study was designed to evaluate the role of anti -RA33; an auto-antibody against RA33 in early diagnosis of the disease.

Materials and Methods:

forty three patients with RA who had been visited in a rheumatology clinic were randomly selected. Their disease has been diagnosed by a rheumatologist. They served as the case group. 55 persons were also chosen from healthy individuals who had attended in other clinic. They served as control. Their age and sex were matched with the case group. Anti-RA33 and RF titers were measured in their blood sample using standard methods.

Findings:

RF and anti-RA33 titers had significant correlation in the case group (p=0.015). Anti -RA33 test had 98% sensitivity, 20% specificity, 50% positive predictive value, and 90% negative predictive value.

Conclusion:

Anti -RA33 could have diagnostic and prognostic importance in diagnosis and evaluation of patients with RA, and its differentiation from other small joint disorders, particularly when the other serologic tests are negative.

[Extra-articular manifestations of rheumatoid arthritis]

Rheumatoid arthritis (RA) represents an autoimmune disease affecting mostly joints, in particular small finger and toe joints. In addition RA can show extra-articular manifestations in many organs. Information on the frequency of extra-articular manifestations (EAMs) in RA varies greatly in different publications from 17.8% to 40.9% and EAMs tend to become higher with increasing duration and severity of the disease. The exact etiology and pathogenesis are still unclear but vasculitic alterations together with deposition of immune complexes can often be found histopathologically in affected organs. It must also be taken into consideration that EAMs can also be a result of the pharmaceutical therapy. The organ findings can vary greatly which is also reflected in the multitude of clinical symptoms. Possible target organs are the blood vessels, kidneys, central nervous system, cardiovascular system, the lungs, eyes, skin, nails as well as blood and the hemopoetic system. The prognosis for RA becomes progressively worse in the presence of EAMs. Regular and continuous control investigations are necessary in order to be able to diagnose EAMs early and to begin therapy. Therapy includes the administration of non-steroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs) and especially in advanced stages cyclophosphamide or biologicals. Therapy is still very empirical due to the lack of appropriate studies.

Extraarticular manifestations of rheumatoid arthritis in a multiethnic cohort of predominantly Hispanic and Asian patients

We conducted a study to determine the prevalence of extraarticular manifestations (ExRA) in a cohort of predominantly Hispanic and Asian patients with rheumatoid arthritis (RA), to identify factors associated with the development of ExRA, and to compare the prevalence of ExRA between Hispanic and Asian patients. Patients with RA followed in the outpatient rheumatology clinics of a public hospital were included if they were aged ≥18 years and met the 1987 American College of Rheumatology criteria for the diagnosis of RA. We performed a cross-sectional analysis in which patients with ExRA were identified based on predefined criteria. We compared sociodemographic and clinical characteristics in patients with and without ExRA. Multivariate logistic regression was used to examine the association between sociodemographic variables, clinical characteristics, and the presence of ExRA. The prevalence of ExRA was 21.5%, and the most common manifestations were subcutaneous nodules (17.2%) and interstitial lung disease (3.6%). Hispanic patients were significantly more likely to develop ExRA than Asian patients (odds ratio, 2.53; 95% confidence interval, 1.26-5.09). The development of ExRA was also associated with disease duration, male sex, and seropositivity for serum rheumatoid factor.

Blood monocyte chemotactic protein-1 (MCP-1) and adapted disease activity Score28-MCP-1: favorable indicators for rheumatoid arthritis activity

OBJECTIVE

We assessed blood pentraxin 3 (PTX3) and macrophage chemotactic factor-1 (MCP-1) levels as indicators of disease activity in rheumatoid arthritis (RA) patients, because data on disease activity score 28 (DAS28)-erythrocyte sedimentation rate (ESR) and DAS28-C-reactive protein (CRP) are still imperfect.

METHODS

In 111 patients with RA, we examined longitudinal and cross-sectional correlations of blood PTX3, MCP-1, CRP, and ESR levels with measures of clinical arthritic activity, namely, swollen joint count (SJC), tender joint count (TJC), visual analog scale for general health (GH), DAS28, and adapted DAS28-MCP-1.

RESULTS

Blood MCP-1, but not PTX3, was significantly correlated with SJC, TJC, DAS28, and DAS28-CRP. DAS28-MCP-1 was strongly correlated with DAS28 (r  = 0.984, P<0.001) and DAS28-CRP (r  = 0.971, P<0.001), and modestly correlated with CRP (r  = 0.350, P<0.001), and ESR (r  = 0.386, P<0.001). Similarly, the duration of arthritic symptoms, but not sex, was significantly correlated with variables of arthritic activity. In particular, DAS28-MCP-1 significantly correlated with DAS28 during a 6-month period (r  = 0.944, P<0.001; r  = 0.951, P<0.001; r  = 0.862, P<0.001; and r  = 0.865, P<0.001 for month 0, 1, 3, and 6, respectively).

CONCLUSION

Blood MCP-1 and adapted DAS28-MCP-1, but not blood PTX3, may be useful in monitoring RA activity.

Extra-articular manifestations of rheumatoid arthritis: An update

Rheumatoid arthritis (RA) is an immune-mediated disease involving chronic low-grade inflammation that may progressively lead to joint destruction, deformity, disability and even death. Despite its predominant osteoarticular and periarticular manifestations, RA is a systemic disease often associated with cutaneous and organ-specific extra-articular manifestations (EAM). Despite the fact that EAM have been studied in numerous RA cohorts, there is no uniformity in their definition or classification. This paper reviews current knowledge about EAM in terms of frequency, clinical aspects and current therapeutic approaches. In an initial attempt at a classification, we separated EAM from RA co-morbidities and from general, constitutional manifestations of systemic inflammation. Moreover, we distinguished EAM into cutaneous and visceral forms, both severe and not severe. In aggregated data from 12 large RA cohorts, patients with EAM, especially the severe forms, were found to have greater co-morbidity and mortality than patients without EAM. Understanding the complexity of EAM and their management remains a challenge for clinicians, especially since the effectiveness of drug therapy on EAM has not been systematically evaluated in randomized clinical trials.