Efficacy of a gluten-free diet in reducing the widespread pain index and symptom severity scale in patients affected by fibromyalgia.

OBJECTIVE: Dietary interventions to improve fibromyalgia (FM) symptoms reported conflicting results. This study aimed to treat FM patients with a gluten-free diet (GFD), alternated with a non-restricted gluten-containing diet, followed by a rechallenge of the GFD. METHODS: Twenty postmenopausal women with FM and no history of celiac disease participated. A GFD was assigned for 6 months. This was followed by 3 months of a non-restricted gluten-containing diet and then a new GFD for another 6 months. At each visit, the widespread pain index (WPI) and the symptom severity scale (SS) scores were evaluated. RESULTS: The mean age of the patients enrolled was 53.9±10 years. None of the patients had a diagnosis of irritable bowel disease, although they reported vague gastrointestinal symptoms. After 6 months of a GFD, a statistically significant reduction was observed for the WPI (10.3±1.8 vs 7.7±1.4; p<0.0001) and the SS scale (6.4±1.8 vs 4.15±1.6; p=0.0002). The D percentage reduction of the WPI after 6 months of GFD was -24%±9%, while for the SS scale, it was -36%±21%. The following reintroduction of a gluten-containing diet brought about a statistically significant rise in the absolute SS scale and WPI, as well as a D modification of the WPI (21%±13%) and of the SS scale (74%±90%). The rechallenge of the GFD showed a significant improvement in absolute and D WPI (-24%±7%) and SS (-36%±11%). No modifications to the body mass index were found. CONCLUSIONS: A GFD improved FM symptoms evaluated with WPI and SS. This was confirmed for the first time, also with a rechallenge of the GFD that followed a non-restricted gluten-containing diet.

Anti-tumor necrosis factor α: originators versus biosimilars, comparison in clinical response assessment in a multicenter cohort of patients with inflammatory arthropathies.

OBJECTIVE: To compare etanercept and adalimumab biosimilars (SB4 and ABP501) and respective bioriginators in terms of safety and efficacy in a real-life contest. METHODS: We consequently enrolled patients affected by rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, treated with SB4, and ABP501, or with corresponding originators, belonging to the main biological prescribing centers in the Lazio region (Italy), from 2017 to 2020. Data were collected at recruitment and after 4, 8, 12, and 24 months of therapy. RESULTS: The multicenter cohort was composed by 455 patients treated with biosimilars [SB4/ABP501 276/179; female/male 307/146; biologic disease-modifying anti-rheumatic drug (b-DMARD) naïve 56%, median age/ interquartile range 55/46-65 years] and 436 treated with originators (etanercept/adalimumab 186/259, female/ male 279/157, b-DMARD naïve 67,2%, median age/interquartile range 53/43-62 years). No differences were found about safety, but the biosimilar group presented more discontinuations due to inefficacy (p<0.001). Female gender, being a smoker, and being b-DMARD naïve were predictive factors of reduced drug survival (p=0.05, p=0.046, p=0.001 respectively). The retention rate at 24 months was 81.1% for bioriginators and 76.5% for biosimilars (median retention time of 20.7 and 18.9 months, respectively) (p=0.002). Patients with remission/low disease activity achievement at 4 months showed a cumulative survival of 90% to biosimilar therapy until 24 months (p=0.001); early adverse reactions instead represented a cause of subsequent drug discontinuation (p=0.001). CONCLUSIONS: Real-life data demonstrated a similar safety profile between biosimilars and originators, but a reduced biosimilar retention rate at 24 months. Biosimilars could be considered a valid, safe, and less expensive alternative to originators, allowing access to treatments for a wider patient population.

Biclonal gammopathy of undetermined significance in a patient with systemic lupus erythematosus and antiphospholipid syndrome.

The case of a patient suffering from systemic lupus erythematosus with associated antiphospholipid antibody syndrome is described. In this patient, on protein electrophoresis, two monoclonal immunoglobulin G λ and k peaks were seen, defining a condition of biclonal gammopathy of undetermined significance (BGUS). This condition is extremely rare, especially in chronic inflammatory rheumatic diseases. The criteria of a BGUS are defined. We also underline how this condition can be the expression of a concomitant unrecognized cancer, a possible amyloidosis or an infectious process.

Efficacy of gluten-free diet in patients with rheumatoid arthritis.

Recent research has increasingly shown that depending on the foods we eat, gut flora may be affected by an inflammatory or anti-inflammatory response, thus playing an important role in inflammatory autoimmune diseases, such as rheumatoid arthritis or gastroenterological disorders. Gluten seems to be a glycoprotein with a clinically relevant inflammatory effect. Several observational studies and anecdotal cases reported a correlation between gluten and various diseases, including autoimmune diseases, such as rheumatoid arthritis. This study aimed to evaluate whether gluten-free diet could be effective in controlling inflammation and ongoing rheumatoid arthritis symptoms. We report 4 cases of patients with long-standing rheumatoid arthritis with no response to several conventional and biotechnological drugs, treated with a gluten-free diet concurrently with the drug therapy. Our patients presented different degrees of response to the diet, in terms of disease remission and improvement of symptoms. Our cases confirm that a gluten-free diet may improve symptoms of rheumatoid arthritis, even in patients resistant to conventional drug therapies.

Psoriatic spondyloarthritis and Sjögren syndrome: a casual association?

The association between Sjögren syndrome (SS) and psoriatic arthritis (PsA) is rare. Herein, we report a case of SS in a PsA patient with the mutilans variant. A 67-year old woman developed PsA with progressive articular destruction up to the typical deformation of 'telescoping fingers' in the distal phalanges. Psoriatic onychopathy presented ten years after the osteolytic damage in the hands. This late appearance led to delayed diagnosis and therapy, and, consequently, worsened the articular destruction. Thereafter, the patient developed a typical SS with clinical symptoms, such as xerophthalmia and xerostomia. This diagnosis was confirmed by positive diagnostic tests, such as Schirmer test, ANA, and anti-SSA/Ro and anti-SSB/La antibodies. A potential association between the two diseases is discussed.

Therapeutic effectiveness of minimal doses of rituximab in a patient with rheumatoid arthritis.

We report the case of a man suffering from rheumatoid arthritis, resistant to common DMARDs and anti-TNF-alpha, who received an excellent response, in terms of effectiveness and depletion of CD20 positive B-lymphocytes, to minimal doses of anti-CD20 monoclonal antibody (rituximab). The dose used was only 100 mg, repeated after 2 weeks. Already after the first infusion of rituximab, a profound depletion of CD20 B-lymphocytes and an improvement of clinical symptoms were evident. The patient, after 4 months from the first two infusions, maintained an accentuated lymphocyte depletion and obtained a low disease activity, passing from an initial DAS28 of 6.3 to a DAS28 of 2.8. The possible practical implications of this observation are taken into consideration.

Rheumatoid arthritis: a complication of aromatase inhibitor therapy?

We report the case of a 56-year-old woman treated with aromatase inhibitors for a breast cancer. Following one year of such therapy, the patient presented with widespread osteoarthrealgia. The clinical picture worsened 3 years later when the pain became more severe with swelling and stiffness involving several joints in a symmetric fashion. Biochemical analysis showed an increase of ESR, CRP and rheumatoid factor, as well as of anti-CCP antibodies. The x-ray was compatible with a diagnosis of rheumatoid arthritis (RA). Therapy with methotrexate, prednisol one, bisphosphonates and vitamin D was started, achieving a quick clinical remission. Aromatase inhibitors have been shown to alter the distribution of Th1/Th2 lymphocytes and increase the level of RANKL. A possible role of aromatase inhibitors in RA development has been further addressed.

Spondylodiscitis as the only clinical manifestation of the onset of psoriatic spondyloarthritis.

We report the case of a 47-year-old man with insidious onset of progressively disabling back pain in the dorsal region. The patient had minimal dermatitic lesions to the elbows and behind the ears, which were attributed to minimal psoriasis. An initial MRI of the spine, one month after the onset of symptoms, showed an alteration in the D7-D8 vertebrae as from bone marrow edema. The successive CT scan of the spine, after about six months, showed a significant osteolytic process of the D7 and D8 vertebrae and extensive swelling of surrounding tissues. A contemporary lung CT scan showed opacity in the right lung. A first hypothesis of lung cancer with vertebral metastases was ruled out by the negative bronchoscopy and the subsequent disappearance of lung opacity after antibiotic therapy. A CT-guided needle biopsy of the spine gave negative results for granulomatous and infectious tumor pathology. The later appearance of peripheral polyarthritis and the presence of initial bone marrow edema justified the diagnosis of psoriatic spondylodiscitis. Therapy with anti-TNF-alpha (Eternacept) was initiated, with which both the painful symptomatology and the radiological damage were quickly resolved. This is the first case in literature about spondylodiscitis as the manifestation of the onset of psoriatic spondyloarthritis.

Efficacy of cyclosporine in the treatment of a case of infliximab-induced erythrodermic psoriasis.

A clinical case is described of infliximab-induced erythrodermic psoriasis resistant to conventional topical therapy and high-dose corticosteroids. Cyclosporine therapy for some months resolved the severe psoriasis picture. Pathogenetic mechanisms are considered through which anti-TNF agents could induce psoriasis. An activation of T lymphocytes with cutaneous overexpression of a CXCR3 subset and, mainly, an increase in IFN-alpha due to the blockage of TNF-alpha could be the causes for this paradoxical adverse event of biological agents. Cyclosporine can work in psoriasis induced by biological agents thanks to its peculiar suppressive activity on T lymphocytes and the concomitant specific action on keratocytes and angiogenesis.

Unexpected and persistent depletion of B lymphocytes CD20 following a minimum dose of anti-CD20 antibody (Rituximab).

This study describes a woman patient suffering from rheumatoid arthritis which was resistant to treatment with the most commonly used DMARDs and anti-TNF alfa drugs, however following the administration of a minimum dose of Rituximab the patient showed a persistent and complete depletion of CD 20 lymphocytes. The dose of Rituximab administered to the patient was halted at 50 mg due to the onset of an allergic reaction. Based on these observations, a number of important speculations are possible, which however would require a larger number of case histories for their confirmation.

[Diffused suberitrodermic psoriasis induced by infliximab]. / Psoriasi suberitrodermica diffusa indotta da infliximab.

The case of a young male is described, affected by Crohn disease with reactive Spondylarthritis essay with Infliximab to the dose of 3 mg/kgs. After 15 days from the third infusion, the patient developed a first psoriasis eruption to the palm of the hands and the plant of the feet, for which was begun topical therapy with cortisone. After an initial improvement, the patient suffered a diffusion of the psoriasis eruption to the whole trunk and the limbs with a suberitrodermic aspect. The possible pathogenesis of this paradoxical effect of the anti-TNF is considered. Also being still partly the causes, is important the inhibition of the TNF-alpha with consequent expansion of the INF-alpha, in turn potential inductor of psoriasis.

Spondylodiscitis (Andersson lesion) in psoriatic spondyloarthritis: a rare event successfully treated with an anti-TNF therapy.

Spondylodiscitis (Andersson lesion) is an infrequent and late complication of advanced ankilosing arthritis. Scanty data on the efficacy of anti-TNF therapy for these lesions are available. To our knowledge, only few cases of spondylodiscitis occurring in patients with psoriatic arthritis were reported in literature. We describe the case of a patient with psoriatic arthritis who early developed Andersson lesions successfully treated with infliximab plus methotrexate therapy.

[Risk indices in stroke and cerebral TIA: a retrospective analysis in hospitalized patients]. / Indici di rischio nello stroke e nel TIA cerebrale: analisi retrospettiva in pazienti ospedalizzati.

In a group of 936 patients admitted to our Hospital for ischemic stroke and transient ischemic attack we studied the association with three diseases which have been identified as risk factors by several international trials: diabetes mellitus, hypertension, atrial fibrillation. We found diabetes mellitus in 24.1% of our patients, hypertension in 44.3%, atrial fibrillation in 17%. We also found a significative difference between men and women for hypertension and atrial fibrillation; respectively 39.6% versus 49.1% (p < 0.01), and 11.4% versus 22.6% (p < 0.01).

[Neoplastic pericarditis secondary to ovarian adenocarcinoma. Report of a clinical case]. / Pericardite neoplastica secondaria ad adenocarcinoma ovarico. Descrizione di un caso clinico.

The pericardial metastatic disease is rare in genital cancers but is frequent in all other cancer. The authors report the case of a female affected by both papillary ovarian cancer and pericardial metastatic disease. Carcinomatous pericarditis began with cardiac tamponade. This pericarditis is very rare during ovarian cancer and there is little informations in the literature about it. The clinical picture showed an acuteness that cleared up with many pericardial tapping paracenteses, and after six cycles of polychemotherapy we obtained the disappearance of pericardial effusion and metastasis with total disappearance of abdominal metastases and the total remission of the cancer.

Asymptomatic multiple duodenal diverticulosis. A rare case report.

The authors report the case of a patient with an unusually high number of diverticular formations (at least five), distributed along the entire duodenal tract. Following a review of the literature on this subject, the authors focus on the lack of symptoms manifested by duodenal diverticula, even if they are numerous and large in size, and on the extremely rare reports of multiple diverticula, as in this case.

[Monoclonal antibodies in cirrhotic cancer]. / Monoclono nella cancro-cirrosi.

In five out of nine cases of cancer in cirrhotic livers protein electrophoresis demonstrated the presence of a monoclone. This finding is compared with thirty cases of liver cirrhosis in which paraproteinemia was not found. The authors come to the conclusion that the appearance of a monoclone in a cirrhotic patient must raise the suspicion of cancer in the cirrhotic liver.

[SIADH and hypoglycemia in pulmonary microcytoma]. / SIADH ed ipoglicemia in corso di microcitoma polmonare.

The case is described of a patient suffering from pulmonary microcytoma the initial symptoms of which were attributable to the ectopic production of the different hormonal substances by the neoplastic cells. In fact, the patient presented the classical picture of inappropriate ADH secretion associated with hypoglycemic crises caused y hyperinsulinemia. The extreme rarity of the twofold paraneoplastic syndrome in the course of malignant disease and the peculiarity of microcytoma associated with inappropriate ADH secretion and hypoglycemia is stressed.

Radiological outcomes in randomized controlled trials on biologic therapies for rheumatoid arthritis: a narrative review.

Several scores are currently used to estimate the radiologic progression of patients affected by rheumatoid arthritis. Modified Sharp score, Genant-modified Sharp score and van der Heijde-modified Sharp score are actually the most commonly used scores in randomized controlled trials on biologic drugs actually available in scientific literature. An intensive literature search (EMBASE, PubMed, MEDLINE) was performed in order to identify randomized controlled studies reporting on the efficacy of biologic drugs on radiologic progression in rheumatoid arthritis by means of approved scoring methods such as Sharp score variants. All studies were evaluated for their approach to radiologic outcome, and a global evaluation of trends towards radiologic evaluation was performed. Eighteen studies were identified and analyzed, and data from such randomized controlled trials (RCTs) were reported and described regarding their approach to radiologic outcomes. The use of three different scoring methodologies generated similar but non-comparable data; although a big part of the studies reported good efficacy profiles of several biologic drugs on radiologic progression, data from such studies are not comparable as the three different scoring methods are not convertible from one to another. At present, there is no standardization for the evaluation of radiologic outcomes, thus preventing comparison of results obtained by different drugs. The use of a single, standardized and widely approved scoring method would grant the possibility of comparing such data.