1
|
Gangadharan H, Peter R, VS V, Punnoose V, George J. Hemichorea as the First and Sole Manifestation in Lupus: Case-Based Review. Mediterr J Rheumatol 2024; 35:156-163. [PMID: 38736954 PMCID: PMC11082775 DOI: 10.31138/mjr.180323.haf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/18/2023] [Accepted: 09/10/2023] [Indexed: 05/14/2024] Open
Affiliation(s)
- Harikrishnan Gangadharan
- Unit of Rheumatology, Department of Internal Medicine, Government Medical College Kottayam, Kerala, India
| | - Rahul Peter
- Department of Internal Medicine, Government Medical College Kottayam, Kerala, India
| | - Vineetha VS
- Department of Neurology, Government Medical College Thiruvananthapuram, Kerala, India
| | - Varghese Punnoose
- Department of Psychiatry, Government Medical College Kottayam, Kerala, India
| | - Josemon George
- Department of Internal Medicine, Government Medical College Kottayam, Kerala, India
| |
Collapse
|
2
|
Gangadharan H, Balan S, Narayanan DL, Badiger VA, Sreelatha PR, Jayaprakash KP. Cleavage Resistant RIP Kinase1 Induced Autoinflammatory Syndrome (CRIA) - A Novel Autoinflammatory Syndrome. Indian J Pediatr 2024; 91:89. [PMID: 37615826 DOI: 10.1007/s12098-023-04831-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/08/2023] [Indexed: 08/25/2023]
Affiliation(s)
| | - Suma Balan
- Department of Pediatric Rheumatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Dhanya Lakshmi Narayanan
- Department of Medical Genetics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
- DBT Wellcome Trust India Alliance Early Career Clinical and Public Health, Hyderabad, India
| | - Vaishnavi Ashok Badiger
- Department of Medical Genetics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - P R Sreelatha
- Department of Pediatrics, Government Medical College, Kottayam, Kerala, India
| | - K P Jayaprakash
- Department of Pediatrics, Government Medical College, Kottayam, Kerala, India
| |
Collapse
|
3
|
Gangadharan H, Paul VJ, Ravi R, Arasan SS, Venugopal S, Sundaram S, Kandiyil SK, Yadav RM, Madkaikar M, George J. Gastrointestinal involvement of common variable immunodeficiency: A diagnostic challenge to the physician. J R Coll Physicians Edinb 2022; 52:34-38. [DOI: 10.1177/14782715221088963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 35-year-old male presented with fatigue for 1 month and was found to have megaloblastic anaemia. Further evaluation showed low globulin levels and pan hypogammaglobulinemia. Past history was significant for chronic small bowel diarrhoea and bilateral genu valgum deformity from childhood. Hence, a malabsorption syndrome with a probable antibody deficiency was suspected. An upper gastrointestinal (GI) endoscopy was done, which revealed chronic atrophic gastritis with Helicobacter pylori infection, dysplasia and subtotal villous atrophy with a paucity of plasma cells, which was suggestive of common variable immunodeficiency (CVID)-related enteropathy. CVID can present with predominantly autoimmune GI manifestations without any history of recurrent infections. The risk of gastric dysplasia and malignancy is high in CVID and needs close monitoring.
Collapse
Affiliation(s)
| | - Vipin Joseph Paul
- Department of General Medicine, Government Medical College Kottayam, Kottayam, India
| | - Roopa Ravi
- Department of General Medicine, Government Medical College Kottayam, Kottayam, India
| | | | | | - Sankar Sundaram
- Department of Pathology, Government Medical College Kottayam, Kottayam, India
| | - Sunil Kumar Kandiyil
- Department of Gastroenterology, Government Medical College Kottayam, Kottayam, India
| | - Reetika Malik Yadav
- Department of Pediatric Immunology and Leucocyte Biology, ICMR-National Institute of Immunohematology, Mumabi, India
| | - Manisha Madkaikar
- Department of Pediatric Immunology and Leucocyte Biology, ICMR-National Institute of Immunohematology, Mumabi, India
| | - Josemon George
- Department of General Medicine, Government Medical College Kottayam, Kottayam, India
| |
Collapse
|
4
|
Kumar A, Gangadharan H, Manju R, Prakash A, Arasan SS, Kumar S. A rare complication of Yellow Phosphorous poisoning. Trop Doct 2022; 52:346-348. [DOI: 10.1177/00494755221076945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Yellow phosphorous is one of the most common toxins reported to cause fulminant hepatic failure. Yellow phosphorous is a component of rodenticides and fireworks, and is freely available over the counter. The mortality rate as high as 27% from fulminant hepatic failure has been reported following ingestion of yellow phosphorous. 1 Multisystem toxicity affecting gastrointestinal, cardiac, renal and central nervous systems occurs. 2 There is a paucity of literature on its haematological toxicity. In this case report, we highlight the clinically significant myelosuppression observed in a patient resulting from yellow phosphorous; a small literature review has also been done on this rare complication.
Collapse
Affiliation(s)
- Aswin Kumar
- Department of General Medicine, Government Medical College Kottayam, Kerala, India
| | | | - Remya Manju
- Department of General Medicine, Government Medical College Kottayam, Kerala, India
| | - Akhil Prakash
- Department of General Medicine, Government Medical College Kottayam, Kerala, India
| | - Saravana S Arasan
- Department of General Medicine, Government Medical College Kottayam, Kerala, India
| | - Satish Kumar
- Department of General Medicine, Government Medical College Kottayam, Kerala, India
| |
Collapse
|
5
|
Gangadharan H, Singh A, Majumder S, Aggarwal A. Adenosine Deaminase Gene Polymorphism and Baseline Serum Level of Adenosine Deaminase as a Biomarker of Response to Methotrexate in Rheumatoid Arthritis. J Clin Rheumatol 2021; 27:e609-e611. [PMID: 33044386 DOI: 10.1097/rhu.0000000000001594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Methotrexate (MTX) is the first-line therapy for rheumatoid arthritis (RA), but nearly 30% of RA patients do not respond to it. Methotrexate acts by enhancing the level of adenosine, which gets converted to inosine by the enzyme adenosine deaminase (ADA). We studied whether ADA gene polymorphism and serum levels of total ADA are associated with responsiveness to MTX. METHODS Two hundred seven disease-modifying antirheumatic drug-naive active RA patients (DAS28-ESR [Disease Activity Score-28 for rheumatoid arthritis with erythrocyte sedimentation rate] ≥3.2) satisfying the European League Against Rheumatism (EULAR)/American College of Rheumatology 2010 criteria were enrolled. Genotyping was done in all patients, and in a subset (n = 59), blood was collected at baseline and at 2 months of MTX treatment for serum total ADA estimation by ELISA. Response at 4 months was assessed by EULAR criteria, and patients were classified as responders or nonresponders. The correlation of baseline clinical parameters, ADA gene polymorphism, and serum total ADA levels with EULAR response was sought. RESULTS After 4 months of MTX monotherapy, 172 patients (83.1%) were classified as responders and 35 (16.9%) as nonresponders. Except DAS28-ESR (6.1 [5.43-6.84] in responders vs 5.6 [4.77-6.21] in nonresponders, p = 0.02), other baseline parameters (age, disease duration, ESR, and C-reactive protein level) were similar between responders and nonresponders. Single nucleotide polymorphisms in ADA gene, baseline serum ADA levels (10.52 ± 5.37 ng/mL in responders vs 12.28 ± 5.14 ng/mL in nonresponders), or change in ADA levels after 2 months of MTX therapy did not show any association with MTX response (p = 0.73, p = 0.34, p = 0.55, respectively). Adenosine deaminase genotype did not affect the blood ADA level. CONCLUSIONS No association was seen between ADA single nucleotide polymorphism rs244076 as well as serum ADA level and response to MTX therapy.
Collapse
Affiliation(s)
- Harikrishnan Gangadharan
- From the Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | | | | |
Collapse
|
6
|
Sait H, Gangadharan H, Gupta A, Aggarwal A, Jain M, Phadke SR. Monogenic Lupus with IgA Nephropathy Caused by Spondyloenchondrodysplasia with Immune Dysregulation. Indian J Pediatr 2021; 88:819-823. [PMID: 33712926 DOI: 10.1007/s12098-020-03636-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/18/2020] [Indexed: 10/21/2022]
Abstract
Monogenic disorders causing systemic lupus erythematosus represent a small subset of cases. Type-1 interferonopathies, like spondyloenchondrodysplasia with immune dysregulation constitute an important functional category of monogenic lupus. Apart from autoimmune disorders, neurological and skeletal abnormalities are additional manifestations observed in this disorder. A young female presented with seizures due to acute hemorrhagic stroke secondary to malignant hypertension. On evaluating the cause for hypertension, there was evidence of glomerulonephritis and multiple autoantibodies positivity including dsDNA. A diagnosis of lupus was made based on clinical and laboratory findings. Kidney biopsy revealed mesangial proliferative glomerulonephritis with predominant IgA deposits favouring IgA nephropathy. Additional features in the form of short stature with vertebral abnormalities and bilateral basal ganglia calcification led to evaluation of Type-1 interferonopathies. Sanger sequencing identified a novel compound heterozygous variants c.550C>T (p.Q184*) in exon 3 and c.740T>G (p.L247R) in exon 4 of ACP5 gene. Parents were found to be carriers of the variants in ACP5 gene. Management included antihypertensive agents and symptomatic therapy. On follow-up, there was complete resolution of glomerulonephritis and normalization of blood pressure. This case report documents the classic phenotype comprising autoimmune, skeletal, and neurological abnormalities in spondyloenchondrodysplasia with immune dysregulation with a novel variant on Sanger sequencing in an Indian patient. This report also highlights the rare coexistence of IgA nephropathy in monogenic lupus.
Collapse
Affiliation(s)
- Haseena Sait
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Harikrishnan Gangadharan
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Aviral Gupta
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amita Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Manoj Jain
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shubha R Phadke
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
| |
Collapse
|
7
|
Singh A, Gangadharan H, Gupta V, Patro PS, Misra R, Aggarwal A. Polymorphism of genes involved in methotrexate pathway: Predictors of response to methotrexate therapy in Indian rheumatoid arthritis patients. Int J Rheum Dis 2021; 24:654-662. [PMID: 33780152 DOI: 10.1111/1756-185x.14100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 02/12/2021] [Accepted: 03/06/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The adenosine pathway is one of the ways through which methotrexate (MTX) ameliorates inflammation. We therefore explored an association of polymorphism of genes involved in adenosine and MTX metabolic pathways with response to MTX. METHODS Association of polymorphism in 7 genes (rs2236225 [MTHFD1 1958G>A], rs17602729 [AMPD1 G>A], rs1127354 [ITPA C>A], rs1431131 [TGFBR2 A>T], rs2372536 [ATIC C>G], rs11188513 [ENTPD1 C>T] and rs5751876 [ADORA2A T>C]) with efficacy of MTX was studied in Indian rheumatoid arthritis (RA) patients. The patients, classified by European League Against Rheumatology (EULAR)/American College of Rheumatology (ACR) 2010 criteria, were DMARD (disease-modifying antirheumatic drug)-naïve, with Disease Activity Score (DAS28) >3.2. After 4 months of MTX monotherapy, patients were classified as responders (R) or non-responders (NR) based on EULAR response criteria. Genotyping was done by TaqMan 5' nuclease assay and association of gene polymorphisms with response to MTX was determined by Chi-squared test. RESULTS Two hundred and twenty-six patients (86% female, median age 40 [interquartile range, IQR = 17.25] years), with disease duration of 24 (IQR = 38.25) months and DAS28-C-reactive protein score of 4.61 (IQR = 1.34) were enrolled. After therapy, 186 patients were classified as R and 40 as NR. GG genotype of ATIC (P = .01, odds ratio [OR] 2.56, 95% CI, 1.04-6.30) and CC genotype of ITPA (P = .009, OR 1.34, 95% CI 1.02-1.76) genes were found to be associated with the response. On binary logistic regression analysis, GG genotype of ATIC and CC of ITPA genes were independent predictors of the response. CONCLUSION Polymorphisms of ATIC and ITPA genes alone or with clinical variables were associated with response to MTX therapy in Indian RA patients.
Collapse
Affiliation(s)
- Ankita Singh
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Harikrishnan Gangadharan
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Vikas Gupta
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Pradeepta S Patro
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ramnath Misra
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Amita Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
8
|
Gangadharan H, Singh K, Phadke S, Aggarwal A. Clinical Sequencing Solves a Diagnostic Dilemma by Identifying a Novel Pathogenic Variant in USB1 Gene Causing Poikiloderma with Neutropenia. Indian J Pediatr 2021; 88:270-271. [PMID: 32936385 DOI: 10.1007/s12098-020-03502-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/10/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Harikrishnan Gangadharan
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Komal Singh
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Shubha Phadke
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Amita Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| |
Collapse
|
9
|
Gupta L, Muhammed H, Naveen R, Kharbanda R, Gangadharan H, Misra DP, Lilleker JB, Chinoy H, Agarwal V. Insights into the knowledge, attitude and practices for the treatment of idiopathic inflammatory myopathy from a cross-sectional cohort survey of physicians. Rheumatol Int 2020; 40:2047-2055. [PMID: 32880031 DOI: 10.1007/s00296-020-04695-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022]
Abstract
The idiopathic inflammatory myopathies (IIM) are heterogeneous and lead to high morbidity and mortality. Knowledge deficits among healthcare professionals could be detrimental to clinical care. Identifying areas of deficient Knowledge, Attitude and Practice (KAP) of IIM can improve physician education and patient outcomes. To assess the proportion of physicians treating IIM with poor KAP and identify the key areas of deficit. An anonymised and validated e-survey (57 questions) was circulated among physicians treating IIM (purposive sampling). Responses were evaluated using the Likert scale for good (> 70% correct response), poor (> 20% chose > 2 answers) and the rest as intermediate consensus. Descriptive statistics were used. Intergroup comparisons were done using non-parametric tests. Of 80 (9.1% of 883) respondents, 90% were rheumatologists and 37.5% academicians. The knowledge base of treating physicians was good in specific domains such as triggers (80-90%), clinical presentation (MDA5, statin myositis, steroid myopathy, anti-synthetase syndrome) (82-92%), IIM mimics (41-89%), investigations (23-92%) and risk of osteoporosis in IIM (79%). There is also an intermediate knowledge base/consensus for outcome measures (30-56%) and response criteria (30-53%). There was poor knowledge and consensus on trials (27-34%), EULAR/ACR criteria (31%) and exercise-based interventions (17-62%). While 90% agree on the need for muscle biopsy to diagnose polymyositis, only one-third advocated it for juvenile and adult DM. Physicians have a good understanding of the triggers, clinical presentation and mimics of IIM. Poor to intermediate knowledge and consensus exists regarding muscle biopsy, outcome measures, response criteria and exercise-based interventions, which could be addressed through future focussed educational initiatives.
Collapse
Affiliation(s)
- Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Hafis Muhammed
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - R Naveen
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Rajat Kharbanda
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Harikrishnan Gangadharan
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Durga P Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - James B Lilleker
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, Manchester, UK.,National Institute for Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, The University of Manchester, Manchester, UK.,Department of Rheumatology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.
| |
Collapse
|