Wunderlich syndrome as a rare complication of polyarteritis nodosa: a case report

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient's admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

Pulmonary sarcoidosis and immune-mediated necrotizing myopathy: an uncommon coincidence

INTRODUCTION

Immune-mediated necrotizing myopathy (IMNM) is characterized by acute or subacute, severe proximal muscle weakness and myofiber necrosis with minimal inflammatory cell infiltrate observed on muscle biopsy. On the other hand, sarcoidosis is characterised by the presence of non-caseating granulomas that can develop in several organs.

CASE REPORT

We present the unique case of a 49-year-old woman, with no previous medical history, who had a rare concomitant occurrence of IMNM and pulmonary sarcoidosis. This condition was successfully treated with a combination of corticosteroids and rituximab along with rehabilitation program.

DISCUSSION

This association has been reported in only two previous case reports. This highlights the importance of further research on the connection between sarcoidosis and other forms of inflammatory myopathies.

Renal involvement in Behçet´s Disease: a rare clinical challenge

Although Behçet´s disease (BD) is a systemic inflammatory disease, renal involvement is uncommon and ranges from mild asymptomatic urinary abnormalities to severe disease with progressive renal failure. We describe the case of a 30 years-old woman with multiorgan BD, under ustekinumab, who presented with proteinuria, hematuria and impaired renal function. Kidney biopsy revealed histological findings of active renal vasculitis in the context of IgA nephropathy and tubulointerstitial nephritis and the patient was treated with corticosteroids and cyclophosphamide with excellent response. Our case highlights the importance of recognizing a possible renal involvement in BD patients, reinforcing the need for monitoring renal function and urinalysis in these patients.

Portuguese recommendations for the use of biological and targeted synthetic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis - 2020 update

OBJECTIVE

To update the recommendations for the treatment of rheumatoid arthritis (RA) with biological and targeted synthetic disease-modifying antirheumatic drugs (bDMARDs and tsDMARDs), endorsed by the Portuguese Society of Rheumatology (SPR).

METHODS

These treatment recommendations were formulated by Portuguese rheumatologists taking into account previous recommendations, new literature evidence and consensus opinion. At a national meeting, in a virtual format, three of the ten previous recommendations were re-addressed and discussed after a more focused literature review. A first draft of the updated recommendations was elaborated by a team of SPR rheumatologists from the SPR rheumatoid arthritis study group, GEAR. The resulting document circulated among all SPR rheumatologists for discussion and input. The level of agreement with each of all the recommendations was anonymously voted online by all SPR rheumatologists.

RESULTS

These recommendations cover general aspects such as shared decision, treatment objectives, systematic assessment of disease activity and burden and its registry in Reuma.pt. Consensus was also achieved regarding specific aspects such as initiation of bDMARDs and tsDMARDs, assessment of treatment response, switching and definition of persistent remission.

CONCLUSION

These recommendations may be used for guidance of treatment with bDMARDs and tsDMARDs in patients with RA. As more evidence becomes available and more therapies are licensed, these recommendations will be updated.

AB0769 THE IMPACT OF BODY MASS INDEX ON DISEASE ACTIVITY AND ENTHESITIS IN PSORIATIC ARTHRITIS

Background:

Overweight/obesity has increased exponentially in the last decades, becoming a huge Public Health problem. Moreover, an increase in adipose tissue is associated with an increased production of several proinflammatory cytokines and acute phase reactants. Higher BMI has been related with new bone formation including syndesmophytes and enthesophytes. In fact, besides rheumatologic conditions including Psoriatic Arthritis (PsA), enthesopathy can be a consequence of several clinical conditions including metabolic syndrome, mechanical injuries and degeneration.

Objectives:

To evaluate the effect of body mass index (BMI) on disease activity scores and enthesitis scores in Psoriatic Arthritis.

Methods:

Retrospective study including all the patients with PsA meeting the CASPAR criteria, beginning first-line biologic therapy at our centre. Demographic and clinical data were collected from the Portuguese database Reumapt. Statistical analysis was performed with SPSS. Continuous variables were compared through Spearman/Pearson correlations.

Results:

The mean BMI was 26.8 (SD 0.5). In our sample of 119 PsA patients, 21.5% were overweight and 8.3% were obese. The mean age of patients was 46.3 ± 1.03 years; 60 female and 59 male. The median disease duration was 6.8 (0.3-33.8) years. At baseline mean (SD) disease activity variables were: DAS 28 4vESR 4.9 (0.2), ESR 33.2 (2.3) mm/h; CRP 2.35 (0.3) mg/dL, BASDAI 6.6 (0.2), ASDAS 3.9 (0.1), BASMI 3.7 (0.2), BASFI 5.8 (0.3), MASES 1.9 (0.3), SPARCC 2.3 (0.3). There were statistically significant positive correlations between BMI and MASES at baseline (p=0.024, r=0.411) but there weren’t with SPARCC, DAS 28 4vESR, ESR, CRP, BASDAI, ASDAS, BASMI and BASFI.

Conclusion:

The data showed that patients with higher BMI values had higher enthesitis scores suggesting that overweight/obesity may have a negative impact on enthesopathy. Further studies are still needed to further understand that possible relationship.

References:

[1]Bakirci S, Dabague J, Eder L, McGonagle D, Aydin SZ. The role of obesity on inflammation and damage in spondyloarthritis: a systematic literature review on body mass index and imaging. Clin Exp Rheumatol. 2019 Apr 29.

Disclosure of Interests:

Sara Ganhão: None declared, Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Filipe Pinheiro: None declared, Maria Rato: None declared, Eva Mariz: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0416 ENTHESITIS AND CLINICAL RESPONSE IN PSORIATIC ARTHRITIS: REAL-LIFE DATA

Background:

Psoriatic arthritis (PsA) is an inflammatory arthritis that is characterized by a broad spectrum of clinical conditions, including axial skeletal involvement, enthesitis, dactylitis, uveitis and arthritis. Among those, enthesitis, the inflammation of the junction where the tendon, ligament or joint capsule inserts into the bone, is assigned to be the hallmark, affecting 35–50% of patients. Several clinical methods have been developed to measure it, including The Maastricht AS Enthesitis Score (MASES) index, which tests 13 entheses and the Spondyloarthritis Research Consortium of Canada (SPARCC) index that assesses 16.

Objectives:

To assess the relationship between enthesitis and clinical response in psoriatic arthritis.

Methods:

Retrospective study including all the patients with PsA meeting the CASPAR criteria, beginning first-line biologic therapy at our centre. Demographic and clinical data including age, gender, body mass index (BMI), smoking status, physical examination findings such as presence of enthesitis, dactylitis, chronic back pain, tender and swollen joint counts (TJC/ SJC), ESR, CRP, DAS 28 4vESR, BASDAI, BASFI, BASMI, ASDAS, HAQ, patient VAS score, MASES and SPARCC were collected from the Portuguese database Reumapt. Statistical analysis was performed with SPSS. Continuous variables were analysed through Spearman correlations.

Results:

We included 119 patients with PsA (60 female), of which 14.9% were active smokers. The mean age of patients was 46.3 ± 1.03 years. The median disease duration was 6.8 (0.3-33.8) years and the mean BMI was 26.8 ± 0.5 Kg/m2.

Enthesitis, dactylitis, inflammatory back pain, peripheral arthritis, ungueal distrophy, and psoriasis were present in 53 (45.7%), 45 (38.8%), 76 (65.5%), 109 (94%), 45 (38.8%), 104 (89.7%) patients, respectively.

At baseline, mean (SD) disease activity parameters were: DAS 28 4vESR 4.9 (0.2), ESR 33.2 (2.3) mm/h; CRP 2.35 (0.3) mg/dL, HAQ 1.3 (0.1), BASDAI 6.6 (0.2), ASDAS 3.9 (0.1), BASMI 3.7 (0.2), BASFI 5.8 (0.3), MASES 1.9 (0.3), SPARCC 2.3 (0.3). Median (min-max) values of TJC, SJC and patient VAS score at baseline were 4 (0-28), 3 (0-19), 76 (0-100), respectively.

There were statistically significant positive correlations (0-12 months) between ΔMASES and ΔDAS 28 4vESR (p=0.02, rho=0.432), Δpatient VAS score (p=0.027, rho=0.307), ΔHAQ (p=0.02, rho=0.411), ΔBASDAI (p=0.025, rho=0.326), ΔBASFI (p=0.037, rho=0.315), ΔASDAS (p=0.023, rho= 0.331). Correlations between ΔSPARCC and ΔDAS 28 4vESR (p=0.023, rho=0.332), Δpatient VAS score (p=0.003, rho=0.402), ΔHAQ (p=0.012, rho=0.440), ΔBASDAI (p=0.011, rho=0.368), ΔBASFI (p=0.001, rho=0.445), ΔASDAS (p=0.002, rho= 0.437), ΔCDAI (p=0.039, rho=0.320) and ΔSDAI (p=0.039, rho=0.319), were also significant. However, there weren’t strong correlations between ΔMASES neither ΔSPARCC and PsARC response at 12 months.

Conclusion:

Our results suggest that enthesitis is correlated with clinical response in PsA, supporting the idea that it is a major determinant of disease activity. It should be given more importance, namely by incorporating it in daily clinical practice, due to its major role, both in establishing an early diagnosis and in assessing treatment response.

References:

[1]Sunar I, Ataman S, Nas K, Kilic E, Sargin B, Kasman SA, et al. Enthesitis and its relationship with disease activity, functional status, and quality of life in psoriatic arthritis: a multi‑center study. Rheumatol Int. 2019 Nov 26. doi: 10.1007/s00296-019-04480-9.

Disclosure of Interests:

Sara Ganhão: None declared, Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Eva Mariz: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

Haemophagocytic syndrome in Systemic Lupus Erythematosus - clues to an early diagnosis

Macrophage activation syndrome (MAS) is a rare life-threatening condition that involves excessive activation of inflammatory cells and overproduction of different cytokines. It is characterized by persistent fever, hepatosplenomegaly, cytopenias and coagulopathy. Other prominent features are hyperferritinemia and findings of activated macrophages in haemopoietic organs, often associated with multi-organ impairment. Its occurrence has been linked to numerous triggers such as viral agents, malignancy and rheumatic diseases. With overlap of clinical features, distinguishing MAS from autoimmune disease flare or sepsis can represent a major challenge. Therefore, a high degree of suspicion is necessary to prompt diagnosis and treatment. Our purpose is to highlight important clinical aspects for an early and differential recognition of this syndrome.

Autoimmune hepatitis and anti-tumor necrosis factor alpha therapy: A single center report of 8 cases

This article describes cases of anti-tumor necrosis factor (TNF)-α-induced autoimmune hepatitis and evaluates the outcome of these patients in relation to their immunosuppressive strategy. A retrospective analysis of medical records was performed in our center, in order to detect cases of autoimmune hepatitis (AIH) associated with anti-TNF biologic agents. We describe and analyze eight cases of AIH following anti-TNF therapy, 7 with infliximab and 1 with adalimumab. A distinction should be made between induction of autoimmunity and clinically evident autoimmune disease. Liver biopsy is useful in detecting the role of the TNF-α antagonist in the development of AIH. The lack of relapse after discontinuing immunosuppressive therapy favors, as in this case series, an immune-mediated drug reaction as most patients with AIH have a relapse after treatment is suspended. Although AIH related to anti-TNF therapy is rare, a baseline immunological panel along with liver function tests should be performed in all patients with autoimmune disease before starting biologics.

Vitamin D - immunomodulatory actions and new potentialities

The authors intend to make a brief scientific review about the immunoregulatory potentialities underlying vitamin D providing an insight in areas such as multiple sclerosis, disorders of cognitive function, response to infection and neoplasia.

Nasal type extranodal NK/T cell lymphoma diagnosed in a patient with rheumatoid arthritis under methotrexate

Rheumatoid arthritis (RA) patients have increased risk of lymphoma which seems associated mainly with high inflammatory state and disease activity, but also with immunosuppressive agents or Epstein-Barr virus (EBV) infection. Many case reports describe lymphoproliferative lesions arising during methotrexate therapy, often EBV positive with possible regression after methotrexate withdrawal. The authors report the case of an 85-year-old patient with erosive and seronegative RA, in remission under methotrexate who developed a midfacial destructive lesion with epistaxis and local inflammatory signs. The magnetic resonance imaging showed a large nasal septum defect. Anti-neutrophil cytoplasmic antibodies titres and angiotensin converting enzyme were normal. Biopsies of the lesion identified a NK/ T nasal type lymphoma. EBV latent membrane protein research on the lesion was negative. Polymerase chain reaction analysis of the bone marrow aspirate showed EBV DNA positivity. Withdrawal of methotrexate was performed without tumour regression. The authors described the single case of a patient with RA in stable remission under methotrexate who presented a rare type of lymphoma, a nasal type NK/T. EBV active replication was found in the bone marrow.

[Practical guide for the use of biological agents in rheumatoid arthritis - December 2011 update]

The authors review the practical aspects of biological therapy use for rheumatoid arthritis patients, commenting safety issues before and after treatment initiation and the best treatment strategies to optimize efficacy.

Vasculitic neuropathy

Vasculitic neuropathy corresponds to the occurrence of vasculitis at the level of vasa nervorum, resulting in ischemic damage of the peripheral nerve and axonal degeneration. Vasculitic neuropathy commonly occurs in association with systemic diseases and may be the initial manifestation or arise in the course of established disease. Although rare, vasculitis can be confined to the peripheral nervous system - non-systemic vasculitic neuropathy. This paper aims to review the classification, diagnosis and treatment of vasculitic neuropathy.

Amyloidosis secondary to rheumatic diseases - 16 cases

INTRODUCTION

Secondary amyloidosis (SA) results of tissue deposition of an acute phase reactant protein produced by chronic inflammation. Its incidence appears to be declining, following the improvement of medical care to primary diseases. Our aim is to assess a group of Portuguese patients with amyloidosis secondary to inflammatory rheumatic diseases, and their evolution over the past 10 years.

METHODS

The study comprised 16 patients with SA confirmed by tissue biopsy, hospitalized in the Rheumatology Department of Hospital São João in Oporto in the last 10 years. We made a protocol on epidemiological, clinical and analytical data focusing the rheumatic disease and SA, and possible elements of connection between them.

RESULTS

Of the 16 patients, mainly women (81,2%), with mean age at entry of 56 years, 68,8% had rheumatoid arthritis. Amyloidosis was diagnosed in average at 13,5 years of primary rheumatic disease, and its main manifestation was kidney involvement, which together with infection and orthopaedic surgery or its complications, were the leading causes of hospitalization. In this time interval, 6 patients died. They were older, with longer duration and lower rate of treatment of the primary rheumatic disease, and had SA diagnosed 1,5 years before death (different of the 5 years of those that still alive). They had higher rate of gastrointestinal, neurological and serious kidney involvement, and hospitalizations.

CONCLUSIONS

Improving medical care in rheumatic inflammatory diseases has reduced the incidence of SA. Also, biotherapy appears to be achieving positive results in established amyloidosis, whatever the mechanisms involved. Our data, on Portuguese patients, seems to follow this trend.

Severe gram positive bacterial infection in an ulcerative colitis patient treated with Infliximab

Tumour necrosis factor-alpha (TNF-α) inhibitors represent an important treatment advance for a number of inflammatory conditions, including inflammatory bowel disease. Since their introduction in 1999, it has become clear that some biological therapies may be associated with an increased risk for bacterial infections. Herein we present the first case of septic arthritis and spine empyema, caused by S. aureus, in a 63 year-old patient with ulcerative colitis, who was under treatment with Infliximab and with 40mg per day of prednisolone.

[Tuberculosis in rheumatic patients treated with tumour necrosis factor alpha antagonists: the Portuguese experience]

In Portugal, 13 cases of tuberculosis (TB) were reported, in the period between 1999 and 2005, in 960 patients exposed to anti-TNFalpha treatment (1.35%), 8 females and 5 males. Mean age was 46.7 +/- 13.8 years. 9 patients had rheumatoid arthritis (RA), in 639 exposed patients (1.4%), 3 had ankylosing spondylitis (AS), in 200 exposed patients (1.5%) and 1 had psoriatic arthritis (PA), in 101 exposed patients (1%). The anti-TNFa used was in 8 cases infliximab (in 456 patients exposed, 1.5%), in 4 adalimumab (in 171 patients exposed, 2.3%) and in 1 etanercept (in 333 exposed, 0.3%). Treatment with a biological agent was started 11.1 +/- 8.7 months (min 3 and max 50) before TB onset. Tuberculin skin test (TST) was performed in 9 out of the 13 patients (the other 4 had started biological therapy before 2002). In 3 cases the TST response was 0 mm, in 3 less than 10 mm, in one was 14 mm and in two 20 mm. In the 3 cases with a TST response superior to 10 mm, isoniazid treatment 300 mg/d was prescribed, during 9 months. The time between first symptoms and TB diagnosis was 2.6 +/- 2.9 months. TB involvement was pulmonary in 6 patients, lymph node disease in 2, peritoneal and pulmonary in 2, osteoarticular in one case, lymph node disease and splenic in another and miliar TB in the last case. One death was reported; all of the other cases had a good outcome after anti-TB treatment. In two cases (one treated with adalimumab and the other with infliximab), paradoxical response to treatment occurred. None of the patients has restarted biological therapy after TB treatment.