Background Bilateral sacroiliitis at presentation usually prompts a search for an inflammatory disease with the usual suspect being the spondyloarthritides. Infectious diseases and neoplasias, as a rule, affect this joint unilaterally. A worldwide resurgence in tuberculosis and resultant improvement in diagnostic modalities has contributed to unmasking this great masquerader at unusual sites.We present one case. Results A 42 year old female, presented with low back and buttock pain of 3 months duration, along with significant morning stiffness. There was no evidence of other articular or extra-articular manifestations. On the basis of clinical presentation, raised acute phase reactants (APRs) and radiographic bilateral sacroiliitis,she was diagnosed as a case of spondyloarthritis and initiated on daily non steroidal anti-inflammatory drugs (NSAIDs). She reported to our referral center with persistent symptoms despite four weeks of NSAIDs. On examination, she was afebrile, with bilateral sacroiliac joint tenderness and painful spinal movements. Investigations revealed normocytic anaemia with elevated APRs, positive Tuberculin test (18mm) and negative Human Leucocyte Antigen B27. Chest radiograph and abdominal ultrasound was normal. Magnetic resonance imaging of the sacroiliac (SI) joints revealed bilateral effusion with multiple abscesses in gluteal muscles. Polymerase chain reaction for Mycobacterium tuberculosis was positive on computed tomography guided needle aspirate of the SI joint. Patient showed clinical improvement and complete radiographic resolution of abscesses after two months of conventional four drug anti tubercular therapy. Conclusions Tuberculosis of bilateral sacroiliac joints is uncommon with only isolated case reports. There is usually a lesion in the lumbar spine from where a psoas abscess spreads to involve both sacroiliac joints, however no such vertebral lesions were discernable in our case. Diagnosis is usually delayed because of deep pelvic location and absence of clinically discernable joint inflammation. Lack of awareness of the possibility of bilateral SI joint involvement in this infection often leads to diagnostic delay, prolonged management as spondyloarthritis and consequent increased morbidity. References Seddon HJ, Strange FG. Sacroiliac tuberculosis. Br J Surg 1940; 28:193–221 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5329
Background Nail Fold Video Capillaroscopy (NFC) is an indispensible non invasive diagnostic modality used in patients with Raynaud's Phenomenon (RP). Formal NFC is still not being carried out as a routine in most of the rheumatic centers in India and there are limited studies on NFC in Indian patients with various systemic connective tissue disorders. Objectives To characterize the Nail fold capillaroscopic changes in Indian patients using a video capillaroscope and correlate the changes with clinical and immunological profile. Methods All patients with Rayanud's phenomenon were recruited into the study. Baseline clinical characteristics and laboratory profile were recorded. Antinuclear anitbobies (ANA) on patients sera was performed by Indirect Immunofluorescence (IIF) and ANA profile by Line Immunoassay (LIA) in these patients. Patient were classified as Primary or Secondary RP. Nail fold capillaroscopy (NFC) was performed using a video capillaroscope at 200x magnification and following characteristics were noted: presence of enlarged caapillaries, giant capillaries, capillary disorganization, capillary ramifications and non specific changes. Capillary density was recorded using a semi quantitative scale. Statistical analysis using paired t test and Pearson's correlation was performed to find associations between the various NFC findings and clinical and immunological profile of the patients. Results In all 102 patients were included in the study. 89% of the patients had Secondary RP and Systemic sclerosis was the most common CTD present in 36% of these cases. Patients with secondary RP were older (mean age: 40.460±11.81) and had longer disease duration (5.29±5.49) than those with Primary RP (mean age: 28.63 + 3.35 yrs and duration: 2.45±3.20 years respectively). All patients with primary RP were ANA negative and had a normal NFC finding. In patients with secondary RP arthritis or arthralgia was was the most common systemic feature present in 86.81% of patients. Digital ulcers/pitted scars or gangrene was found in 39.56% of patients and the most common visceral involvement was interstitial lung disease (ILD) found in 45.05% of the patients. NFC changes in the form of capillary loss was significantly associated with digital ulcers and also PAHT. The most common ANA pattern was speckled found in 54% of the 89 patients with ANA positivity by IIF. The most common autoantibodies detected were u1SnRNP and SS-A/Ro 60 kd detected in 25.81 and 25.92% of the patients. There were no specific NFC characteristic with a ANA pattern or a particular autoantibody. Patients with SLE had predominantly non specific findings compared to the rest of the patients. Patients with Anticentromere antibodies had more of capillary enlargement and giant capillary than loss of capillaries. There was no significant change in the NFC findings with patients on therapy. Conclusions This study is first of its kind to use a video capillaroscope to characterize NFC changes in Indian patients with RP. Characteristic NFC abnormalities are fo...
Background18F-FDG PET/CT is a unique imaging technique that can assess the metabolic activity of spondyloarthritis. It thus, has a role as an effective imaging biomarker for assessing response to therapy.ObjectivesTo study the role of 18F-fluorodeoxyglucose positron emission tomography, computed tomography (FDG/PET-CT) in quantifying disease activity in patients with spondyloarthritis on anti tumour necrosis factor (TNF) biological disease modifying antirheumatic drugs (bDMARD). To assess the response to therapy with anti TNF bDMARD and to correlate extent of inflammation as quantified by FDG/PET-CT with measures of disease activity as well as treatment responses in the same group of patients.MethodsThis was a prospective observational single center study done at a tertiary care rheumatology centre of Army Hospital Research and Referral, New Delhi. Thirty two adults with moderate to severe active Ankylosing Spondylitis were initiated on anti TNF-α bDMARD Infliximab or Etanercept.Analysis using PET/CT consisted of quantification of 18F-FDG uptake in metabolically active lesions by measurements of their maximum standardized uptake values (SUVmax) at baseline and after 24 weeks of therapy. Change in cumulative SUVmax (CSUVmax) from baseline for each patient was denoted as ΔCSUVmax. This value was correlated with change from baseline in Ankylosing Spondylitis Disease Activity Score (ASDAS), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and Bath Ankylosing Spondylitis Metrology Index (BASMI) linear. Strength of correlation of a post therapy 50% reduction in CSUVmax (CSUVmax50) was sought with ASAS20 (Assessment of SpondyloArthritis international Society 20), ASDAS and BASDAI response.ResultsStatistical significance was established for ΔCSUVmax (mean (SD) = 8.75 (8.0),95% CI of the difference=5.77-11.7; p=0.000) demonstrating significant response to 24 weeks of treatment with anti TNF biologicals. Significant correlation of ΔCSUVmax was established only with ΔBASDAI (p=0.026, r=0.405) and not with ΔASDAS-ESR or ΔASDAS-CRP. Strength of relationship of significance was established between CSUVmax50 and ASAS 20 response (p=0.044, r=4.073), BASDAI response (p=0.019, r=5.468) and ASDAS response (p=0.044, r=4.073). No adverse event related to PET/CT procedure was reported.Conclusions18F-FDG PET is capable of quantifying, both, baseline disease activity in patients and therapeutic response to TNFα inhibitors. CSUVmax 50 response correlates well with ASAS20, BASDAI and ASDAS responses.AcknowledgementsDepartment of Nuclear Medicine, Army Hospital Research and Referral, New Delhi.Disclosure of InterestNone declared
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