Background:Recently evolved from a monochromic flu-like disease to a polysyndromic “spectrum of disease”, our understanding of coronavirus disease 2019 (COVID-19) is still far from being complete [1]. Hyperinflammation involving not only the lungs but also the musculoskeletal system, skin, cardiovascular, genitourinary systems is immune-mediated resembling the flares of a full-blown rheumatic disease [2,3].Objectives:To describe the prevalence and type of rheumatic manifestations in a cohort of COVID-19 patients hospitalized in the COVID-19 rheumatology department in University Hospital St. Marina, Varna, Bulgaria.Methods:In the present single-center cohort study, а retrospective database analysis was performed among all COVID-19 patients hospitalized from 1 Dec 2020 to 22 Jan 2021. All 243 patients (age 19 - 93 years) were treated for moderate or severe SARS-CoV-2 infection confirmed by laboratory tests, including positive polymerase chain reaction (PCR) test, and imaging modality. Inpatient treatment included antibiotics, dexamethasone, anticoagulants, and antiviral drug remdesevir (optional). Detailed disease history and clinical examination were carried out by a fully certified rheumatologist and/or specialist in internal medicine.Results:Among all 243 COVID-19 patients, those with prominent self-reported myalgia and arthralgia were 26% (n = 63) and 21.3 (n = 52), respectively. We had 4 (1.6%) cases of newly developed cutaneous vasculitis and 2 (0.8%) cases of severe Raynaud’s phenomenon after SARS-CoV-2 infection onset. Two patients experienced severe muscle weakness, had elevated creatine phosphokinase, and were diagnosed with inflammatory myopathy secondary to COVID-19. Lupus-like syndrome was observed in 2 (0.8%) patients.Conclusion:Rheumatic manifestations are part of the heterogeneous spectrum of COVID-19 disease. Amidst the COVID-19 crisis, each newly onset rheumatic manifestation warrants exclusion of SARS-CoV-2 infection. Therefore, a rheumatologist should be a part of a multidisciplinary approach towards the COVID-19 treatment.References:[1]Misra DP, Agarwal V, Gasparyan AY, Zimba O. Rheumatologists’ perspective on coronavirus disease 19 (COVID-19) and potential therapeutic targets. Clin Rheumatol. 2020;39(7):2055-2062[2]Georgiev T, Angelov AK. Complexities of diagnosis and management of COVID-19 in autoimmune diseases: Potential benefits and detriments of immunosuppression. World J Clin Cases. 2020;8(17):3669-3678[3]Ciaffi J, Meliconi R, Ruscitti P, Berardicurti O, Giacomelli R, Ursini F. Rheumatic manifestations of COVID-19: a systematic review and meta-analysis. BMC rheumatology. 2020 Dec;4(1):1-5.Disclosure of Interests:None declared
Introduction: The European League Against Rheumatism updates the recommendations for managing rheumatoid arthritis. Again, it is not specified which DAS28 is there in view (with erythrocyte sedimentation rate or C-reactive protein). Aim: The aim of the study is to check whether Disease Activity Score-28 (erythrocyte sedimentation rate) and Disease Activity Score-28 (C-reactive protein) represent equally the activity of rheumatoid arthritis in the course of treatment with biological agents. Materials and methods: In a retrospective study we analyzed the database of real clinical practice over a 12-month period of biological treatment of rheumatoid arthritis. Disease Activity Score-28 (erythrocyte sedimentation rate) and (C-reactive protein) are compared at the start and at the end of the study. Results: The mean difference between the two variants of disease activity scores at baseline and at the end of the study is significant (p < 0.001). The Disease Activity Score-28 (erythrocyte sedimentation rate) represents a remarkably small proportion of patients with remission and low activity (<3.2) at baseline (18.46%) and at the end of the study (40.51%). Disease Activity Score-28 (C-reactive protein) represents a significantly high proportion of patients in remission and low activity (<3.2) at the end of the study (69.74%). Estimates of activity according to the two variants show significant discrepancy between each other and low level of agreement (kappa = 0.235-0.464). Discrepancies are not related to the type of biological drug (anti-TNF or not). Conclusion: The two DAS28 variants are not interchangeable with the same threshold for low activity in measuring the response to biological therapy.
Background:Systemic lupus erythematosus (SLE) is autoimmune connective tissue disorder of unclear etiology. It is characterized by autoantibody production and a variety of clinical manifestations. The introduction of biological treatment over the past few years provided an opportunity for a disease control.Objectives:The aim was to assess the effectiveness and safety profile of Belimumab in the treatment programs of SLE patients during a 2 year period.Methods:We initiated a prospective observational study of SLE patients in the Rheumatology Department in University Hospital St Marina – Bulgaria. The study comprises data from 26 patients at baseline before Belimumab treatment initiation and data after 6, 12, 18 and 24 months of treatment. All patients were with moderate disease activity according to SELENA – SLEDAI index and were on treatment with immunosuppressive drug (azathioprine) and glucocorticoids (GCs). We observed the change in the dosage of glucocorticoids over the observed period, the number of flares of SLE, as well the SELENA – SLEDAI index change. Safety profile of Belimumab was also registered.Results:We included 26 patients with SLE over a period of 4 years – between 2015 and 2019. The mean age was 45.8 + 11.4 years and 94% were Caucasian females. All patients were on a stable dosage of GCs at least 3 months before the first infusion of Belimumab and azathioprine 100 mg daily. Ninety percent of patients were diagnosed with SLE for more than 6 years according to ACR – SLE criteria. All of SLE patients were with moderate disease activity. Main reasons for biological treatment decision were persistent mucocutaneous manifestations (20%), polyarthritis (15%), haematological disturbances (35%) and persistent immunological markers (30%). One patient was excluded from the study due to infusion- related flush and severe hypotension reaction while the rest 25 completed the observation. We investigated and analyzed haematological results, ANA, anti – ds DNA, anti – Sm autoantibodies and complement fractions at baseline as well on the 12th and 24th month of treatment. The mean SELENA – SLEDAI index changed from 8.9 to 4.5 after 12 months of treatment and remained unchanged until the end of the study. We observed a mean reduction of GCs daily dosage from 12 mg to 6 mg after 18 months.Conclusion:Biological treatment with Belimumab added to the standard treatment with GCs and AZA in patients with non-lupus nephritis SLE patients adds additional benefits. Our results show that there is a reduction in SLEDAI index as well as reduction in daily GCs intake. Safety profile is not different from the one reported previously.Disclosure of Interests:None declared
Background Ankylosing spondylitis (RS) is chronic inflammatory disease that causes inflammation of the joints between the spinal bones, and the joints between the spine and pelvis. It eventually causes the affected spinal bones to join together. Tumor necrosis factor (TNF) has been implicated in a number of arthritic disease states, including rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Adalimumab is the first fully human, high-affinity, recombinant immunoglobulin G1 (IgG1) anti-TNF monoclonal antibody. Objectives To determine whether treatment with Adalimumab improves disease activity, occupational outcomes and increases work productivity in patients with ankylosing spondylitis (AS). Methods During 2009-2011, 178 patients with confirmld diagnosis AS were included in the study. 82.79% were male and 17.21% female, aged 20-75 (mean 42) years. Patients were divided in two subgroups due to disease activity, first group with moderate disease activity (BASDAI 4-7) and second group with severe disease activity (BASDAI 8-10). Patients were treated with Adalimumab for at least 6 months.Changes in functional status and disease activity were assessed using the Bath ASDisease Activity Index (BASDAI), Visual Analog Scale(VAS)and Work Productivity and ActivityImpairment questionnaire in AS (WPAI:SpA). The results were analyzed with regression analysis ANOVA on SPSS. Results Patients with severe activity of AS showed significantly greater reduction of BASDAI score than patients with moderate disease activity(3.4 vs. 1.9) p. Of the 178 patients included in this study, 145 (81.46%) showed clinical response (reduction of BASDAI score by at least 2 points). Clinical responders had significant improvement in work productivity, workday loss and daily activity impairment according to WPAI-SHP scores (presenteeism -21.1, p=0.04; overall work impairment -22.2, p=0.04; daily activity impairment -24.4, p Conclusions Disease activity in patients with AS determine patient’s ability to work. Patients treated with Adalimumab and responded to the treatment had significant reduction in limitations of work and daily activity. Treatment with Adalimumab significantly reduce workday loss among employed patients with AS. References [AB] Abbott Laboratories Press Releases. Abbott announces US and EU regulatory submissions seeking approval of Humira® (adalimumab in ankylosing spondylitis (AS) 2005. Oct 4, Accessed 3 April 2006. Maksymowych WP, Gooch KL, Wong RL, Kupper H, van der Heijde D: Impact of age, sex, physical function, health-related quality of life, and treatment with adalimumab on work status and work productivity of patients with ankylosing spondylitis. J Rheumatol 2010, 37:385-392 Keat AC, Gaffney K, Gilbert AK, Harris C, Leeder J: Influence of biologic therapy on return to work in people with work disability due to ankylosing spondylitis. Rheumatology (Oxford) 2008, 47:481-483. van der Heijde DM, Revicki DA, Gooch KL, Wong RL, Kupper H, Harnam N, Thompson C, Sieper J: Physical function, disease activity, an...
BackgroundRadiologic evidence of sacroiliitis is important for the diagnosis, classification, and management of patients with ankylosing spondylitis (AS)[1]. Conventional radiography (CR) has been the most widely utilized imaging modality for the assessment of sacroiliac involvement in axial spondyloarthritis (AxSpA) because of the low radiation dose, ease of operation, and low expenses. CR is used in both the 1984 modified New York criteria and ASAS criteria for classifying AS and AxSpA but lacks sensitivity for early changes. Though MRI detects early changes of the sacroiliac joints, as well as chronic structural changes, its use is limited by the associated cost, procedural time and certain contraindications. Computed tomography (CT) is a modality that enables visualization of erosions, sclerosis, and new bone formation, with the added benefit of multiplanar cross-sectional imaging.ObjectivesWe aimed to analyze the diagnostic value of computer tomography (CT) features of sacroiliitis for ankylosing spondylitis in patients with inconclusive CR evidence for sacroiliitis.MethodsIn this retrospective monocentric observational study, 50 patients with chronic low back pain (LPB) with a duration longer than three months in the lumbosacral region were included. Using the patient record data were extracted on age, pain duration, and plain radiography. Eligible patients should have had plain radiography without evident radiographic sacroiliitis. All the patients had undergone a CT scan of the sacroiliac joint that a radiologist and rheumatologist evaluated for subchondral osteosclerosis, erosions, joint space narrowing (JSN), subchondral cysts, and ankylosis. Based on the clinical and instrumental findings, including structural changes characteristic of radiographic sacroiliitis, a final decision by a certified rheumatologist was made and a diagnosis of ankylosing spondylitis was set or ruled out.ResultsThe mean age and duration of LBP of the patients were 44.7 (14.7) years and 63.9 months, respectively. Of the 50 included patients, 28 (56%) were females. The mean values of c-reactive protein and erythrocyte sedimentation rate were 13.9 mg/l and 39.4 mm/h. Subchondral osteosclerosis was found in 44 patients (88%), JSN – in 21 patients (42%), erosions – in 17 patients (34%), subchondral cysts – in 10 patients (20%), ankylosis – in 18 patients (36%). Definite CT data for sacroiliitis was seen in 24 patients (48%) and the diagnosis of ankylosing spondylitis was set in 23 patients (46%) of the study group. The likelihood ratios (LR+) for diagnosis of AS were high for erosions (18.4), subchondral cysts (11), ankylosis (6.9) and low for JSN (LR+ 1.9) and ankylosis (LR+ 1.1).ConclusionNearly half of the patients with inconclusive CR evidence for sacroiliitis were diagnosed with AS after CT imaging. Erosions seen on CT increase the likelihood of assuming AS diagnosis. Computed tomography is a useful tool in diagnosing AS, but it is associated with higher ionizing radiation doses.Reference[1]Mandl P, Navarro-Compán V, Terslev L, Aegerter P, van der Heijde D, D’Agostino MA, Baraliakos X, Pedersen SJ, Jurik AG, Naredo E, Schueller-Weidekamm C, Weber U, Wick MC, Bakker PA, Filippucci E, Conaghan PG, Rudwaleit M, Schett G, Sieper J, Tarp S, Marzo-Ortega H, Østergaard M; European League Against Rheumatism (EULAR). EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis. 2015 Jul;74(7):1327-39. doi: 10.1136/annrheumdis-2014-206971. Epub 2015 Apr 2. PMID: 25837448.Acknowledgements:NIL.Disclosure of InterestsNone Declared.
BackgroundThe absence of categorical radiographic evidence of structural changes in the sacroiliac joints serves to distinguish AS from nr-axSpA. Both groups of patients are characterized by active inflammatory changes, established by magnetic resonance tomography (MRI) of the sacroiliac joints, which, with the progression of the disease, are structurally progressive.ObjectivesTo determine whether it is possible to detect erosions, subchondral osteosclerosis and bone marrow metaplasia on a magnetic resonance imaging of the sacroiliac joints in patients with non-radiographic axial spondyloarthritis and symptom duration less than 3 years.MethodsA cross-sectional survey was conducted with rheumatologists and their consulting patients in Bulgaria from February 2012 through April 2019. Patients who had a rheumatologist confirmed diagnosis of nr-axSpA were eligible to participate. All patients met ASAS criteria for IBP with duration from 3 months to 2 years. All patients had no changes reported after the conventional X-ray of the sacroiliac joints and a performed subsequent MRI. Sacroiliac joint inflammation was assessed using the Canadian Spondyloarthritis Research Consortium (SPARCC). The SPARCC scores of sacroiliac joint inflammation and sacroiliac joint structural damage (SSSD) (erosions, bony brain metaplasia and subchondral osteosclerosis) were evaluated by both - a radiologist and rheumatologist.ResultsA total of 98 patients with non-radiographic were included in this analysis. A higher proportion of patients were male patients (51% vs 37%). The mean age was 33.8±7.71 with mean symptoms duration 0.76±0.26 years. MRI showed bone marrow edema (BME) in all 98 patients and at least 1 structural lesion in 32 patients (92.5%). The most prevalent chronic lesions were erosive changes in 7.14% (n = 7) and narrowed joint space in 7.14% (n = 7). Fat metaplasia was found in 5.10% (n = 5) in the patients with nonradiographic spondyloarthritis. The mean values of SPARCC score in patients with the different arm of nr-ax SpA is 22.42 ± 15.18. The burden of disease activity measured by BASDAI, ASDAS-CRP and VAS as well as ASQoL did not differ in patients with SSSD compared with those with BME only (p>0.05)ConclusionPatients with nr-ax SpA are characterized by a short duration of symptoms. Regardless of this recent onset and initially normal X-ray image of the sacroiliac joints, in some patients there are objective data of previous inflammation of the sacroiliac joints that may had not be detected on X-ray. That arise the question of low sensitivity of conventional radiography as well as the presence of risk factors for rapid structural damage and progression in some patients with nr-ax SpA.References[1]Baraliakos X, Hermann K, Landewe R, et al. Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau inversion recovery (STIR) sequences. Ann Rheum Dis 2005; 64: 1141.[2]Du MS, Xiong XQ, Liu H, Qin X, Hu XF, Chen W. The evaluation of bone marrow edema in sacroiliac joint in patients with ankylosing spondylitis using magnetic resonance imaging Dixon sequence. BMC Musculoskelet Disord. 2021 Nov 1;22(1):919.[3]Carita Tsoi, James Francis Griffith, Ryan Ka Lok Lee, Priscilla Ching Han Wong, Lai Shan Tam, Quant Imaging Med Surg. 2019 Feb; 9(2): 318–335.[4]Braun J, Sieper J, Bollow M. Imaging of Sacroiliitis. Clin Rheumatol, 2000; 19, 51–57.Acknowledgements:NIL.Disclosure of InterestsNone Declared.
BackgroundVaccines are one of the most efficient tools to prevent infectious diseases at a population level. Their importance is even greater in immunocompromised patients providing efficient and safe protection against common viral and bacterial infections. According to the current EULAR recommendations based on solid evidence over the recent years, non-live vaccines such as influenza, pneumococcal, tetanus toxoid, and others are safe and can be administered to patients with inflammatory rheumatic diseases during the glucocorticoid and/or disease-modifying antirheumatic drug (DMARD) therapy. Furthermore, influenza and pneumococcal vaccines “should be strongly considered” and the tetanus toxoid vaccination should be received in accordance with the recommendations of the general population¹.ObjectivesWe aimed to investigate the coverage for influenza, pneumococcal, and tetanus toxoid vaccination in a cohort of patients with inflammatory rheumatic diseases on biological or targeted synthetic DMARDs.MethodsTwo hundred and one patients, aged 18 or older, were included in this single-center cross-sectional study after signing an informed consent form. They suffered from rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS) and were on biological or targeted synthetic DMARDs. Individuals with psychiatric or neurological diseases preventing understanding or responding to the questions were excluded from the study. Patients’ anthropometric, clinical, and demographic characteristics were collected via detailed anamnesis and clinical examination. Disease activity was evaluated using DAS28-CRP for patients with RA and peripheral PsA and ASDAS for those with axial disease (AS and axial PsA). All patients were asked to fill in a survey determining their immunization status for influenza, pneumococcal, and tetanus toxoid vaccines and whether they had a preceeding discussion with their rheumatologist about recommended vaccines during their routine medical visits.ResultsOf the 201 included patients, 40.3% (n=81) were females. Patient distribution according to their disease was as follows: 30.3% (n=61) RA patients, 51.7% (n=104) AS patients, and 17.9% PsA patients (n=36). Mean age, disease duration, and body mass index values were 54.62 (14.4) years, 11.04 (8.6) years and 28.2 (5.3), respectively. 27.4% of patients were on concomitant glucocorticoid treatment. Only 13.9% (n=28) and 1.5% (n=3) were vaccinated against seasonal influenza and pneumococcal infections, respectively. Patients who had а preceeding discussion about seasonal influenza and pneumococcal immunization with their rheumatologist had approximately 13 and 32 times higher probability to get vaccinated than people who did not (OR=12.9, p < 0.001 and OR 32.5, p = 0.01, respectively). Regular reimmunizations against diphtheria and tetanus according to the Immunization Calendar of the Republic of Bulgaria were carried out by only 44.8% (n=90) of the studied population.ConclusionCoverage of recommended vaccines in our group of Bulgarian patients on biological or targeted synthetic DMARDs is very low. Discussion about the potential benefits and safety profile of the recommended vaccines may increase patients’ willingness to vaccinate and prevent common infectious diseases in immunocompromised rheumatic patients.Reference[1]Furer V, Rondaan C, Heijstek MW, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases.Ann Rheum Dis. 2020;79(1):39-52. doi:10.1136/annrheumdis-2019-215882Acknowledgements:NIL.Disclosure of InterestsNone Declared.
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