Clinical Diagnosis of Chikungunya Infection: An Essential Aid in a Primary Care Setting Where Serological Confirmation Is Not Available.

BACKGROUND: Chikungunya virus (CHIKV) diagnosis has become a challenge for primary care physicians in areas where the Zika virus and/or Dengue virus are present. Case definitions for the three arboviral infections overlap. METHODS: A cross-sectional analysis was carried out. A bivariate analysis was made using confirmed CHIKV infection as the outcome. Variables with significant statistical association were included in an agreement consensus. Agreed variables were analyzed in a multiple regression model. The area under the receiver operating characteristic (ROC) curve was calculated to determine a cut-off value and performance. RESULTS: 295 patients with confirmed CHIKV infection were included. A screening tool was created using symmetric arthritis (4 points), fatigue (3 points), rash (2 points), and ankle joint pain (1 point). The ROC curve identified a cut-off value, and a score ≥ 5.5 was considered positive for identifying CHIKV patients with a sensibility of 64.4% and a specificity of 87.4%, positive predictive value of 85.5%, negative predictive value of 67.7%, area under the curve of 0.72, and an accuracy of 75%. CONCLUSION: We developed a screening tool for CHIKV diagnosis using only clinical symptoms as well as proposed an algorithm to aid the primary care physician.

The burden of the most common rheumatic disease in Colombia.

BACKGROUND: Estimating the burden of rheumatic diseases (RDs) requires proper evaluation of its lethal and nonlethal consequences. In Colombia, it is possible to find local data and Global Burden of Disease (GBD) reports that collect information from varied contexts and apply complex statistical models, but no on-site estimations are available. METHODS: This was a descriptive study on the burden of RD based on occurrence and mortality data in the general population during 2015, including information and prevalence estimations from the Community Oriented Program for the Control of Rheumatic Diseases (COPCORD) study. Disability-adjusted life years (DALYs) were estimated by combining measures of years of life lost (YLL) and years lived with disability (YLDs). For disability weight estimations among cases, different COPCORD responses were mapped using flowcharts to show the severity distribution according to GBD. All model parameters and results were validated through an expert consensus panel. RESULTS: Low back pain (LBP) was the RD with the greatest burden of disease, costing 606.05 (95% CI 502.76-716.58) DALYs per 100,000 inhabitants, followed by osteoarthritis (292.11; 95% CI 205.76-386.85) and rheumatoid arthritis (192.46, 95% CI 109.7-239.69). CONCLUSIONS: The burden of RD is as high in Colombia as in other countries of the region. The results offer an interesting tool for optimizing healthcare system design as well as for planning the distribution of human and economic resources to achieve early diagnosis and adequate care of these diseases.

Can presence of HLA type I and II alleles be associated with clinical spectrum of CHIKV infection?

Host immune response and virulence factors are key to disease susceptibility. However, there are no known association studies of human leukocyte antigen (HLA) class I and II alleles with chikungunya virus (CHIKV) infection in the Latin American population. Here, we aimed to identify HLA alleles present in patients with CHIKV infection versus healthy controls as well as the allelic association with the clinical spectrum of the disease. We conducted a cross-sectional analysis of a community cohort and included patients aged 18 years and older with serologically confirmed CHIKV infection. HLA typing of HLA-A, HLA-B, and HLA-DRB1 alleles was performed. Two-by-two tables were used to establish associations between allele presence and clinical characteristics. Data from 65 patients with confirmed CHIKV infection were analyzed for HLA typing. CHIKV infection was significantly associated with the presence of HLA-A*68 [p = .005; odds ratio (OR): 8.90; 95% confidence interval (CI): 1.88-42.13], HLA-B*35 (p = .03; OR: 2.01; 95% CI: 1.06-3.86), HLA-DRB*01 (p <.001; OR: 5.70; 95% CI: 1.95-16.59), HLA-DRB1*04 (p <.001; OR: 7.37; 95% CI: 3.33-16.30), and HLA-DRB1*13 (p = .004; OR: 3.75; 95% CI: 1.50-9.39) alleles in patients versus healthy subjects. A statistically significant relationship was found between the presence of a rash on the face or abdomen and the presence of HLA-DRB1*04 (p = .028; OR: 3.2; 95% CI: 1.11-9.15 and p = .007; OR: 4.33; 95% CI: 1.45-12.88, respectively). Our study demonstrated that, in our cohort, HLA type I and type II alleles are associated with CHIKV infection, and an HLA type II allele is associated with dermatological symptoms. Further research is needed to establish a path for future investigation of genes outside the HLA system to improve knowledge of the pathophysiology of CHIKV infection and its host-pathogen interaction.

Comparison of quality of life in patients with musculoskeletal symptoms, those with other comorbidities, and healthy people, in a Colombian open population study / Comparación de la calidad de vida de pacientes con síntomas musculoesqueléticos, comorbilidades asociadas y personas sanas en un estudio abierto de población colombiano

A b s t r a c t Purpose: To describe health-related QOL (HRQOL) in patients with musculoskeletal symptoms, compared to a population with other comorbidities, and a healthy population. Methods: A cross-sectional study was carried out on an open population involved in a community-oriented program for control of rheumatic diseases (COPCORD) study in Colombia, using EQ-5D-3L for estimating QOL, and the health assessment questionnaire disability index (HAQ-DI) for functional capacity. Results: Out of the total 4020 individuals evaluated, 2274 had rheumatic diseases, 642 had non-rheumatic diseases, and 1104 were healthy subjects. Spondyloarthritis (SpA) and rheumatoid arthritis (RA) patients had more complaints regarding pain/discomfort and mobility. As for daily activities, the diseases that mostly affected them were systemic lupus erythematosus (SLE) and RA. RA and fibromyalgia (FM) patients had the worst scores as regards anxiety/depression and self-care dimensions. FM patients had the lowest QOL measured by EQ-VAS (57.7 ± 26.2). The most frequent non-rheumatic diseases were cardiovascular and mental disorders, with 20% of these patients having a moderate level of pain/discomfort and anxiety/depression. The rheumatic patients reported a decrease in functional capacity (HAQ: 0.49), in contrast to the healthy population (0.01), and the population having other diseases (0.06). Conclusion: Rheumatic disease patients in Colombia had the worst QOL compared to the healthy population and patients with other comorbidities. Rheumatic patients had greater functional limitations, even more so when having comorbidities. This study revealed potential factors of interest requiring the attention of public health authorities, and for improving patients' QOL.

RESUMEN Objetivo: Describir la calidad de vida relacionada con la salud en pacientes con síntomas musculoesqueléticos, en comparación con pacientes con enfermedades no reumáticas y una población sana. Métodos: Se realizó un estudio transversal en comunidad abierta, en personas involucradas en un programa orientado a la comunidad para el control de enfermedades reumáticas (COP-CORD) en Colombia, utilizando el EQ-5D-3L para estimar la calidad de vida y el cuestionario de evaluación de la salud (HAQ- DI) para la capacidad funcional. Resultados: Se evaluaron 4.020 individuos; 2.274 tenían enfermedades reumáticas, 642 tenían enfermedades no reumáticas y 1.104 eran sujetos sanos. Los pacientes con espondiloartritis (SpA) y artritis reumatoide (AR) tuvieron mayores quejas con respecto al dolor/malestar y la movilidad. En cuanto a las actividades diarias, los enfermos con lupus eritematoso sistémico (LES) y AR fueron los más afectados. Los pacientes con AR y fibromialgia (FM) tuvieron las peores puntuaciones en ansiedad/depresión en las dimensiones de cuidado personal. Los pacientes con FM tuvieron la calidad de vida más baja medida por EQ-VAS (57,7 ± 26,2). Las enfermedades no reumáticas más frecuentes fueron los trastornos cardiovasculares y mentales; el 20% de estos pacientes tenía un nivel moderado de dolor/malestar y ansiedad/depresión. Los pacientes reumáticos reportaron una disminución de la capacidad funcional (HAQ: 0,49); en contraste con la población sana (0,01) y la población con otras enfermedades (0,06). Conclusión: Los pacientes con enfermedades reumáticas en Colombia tuvieron la peor calidad de vida en comparación con la población sana y los pacientes con otras enfermedades. Los pacientes reumáticos tuvieron una mayor limitación funcional, incluso más que los que tenían otras enfermedades. Este estudio reveló posibles factores relacionados con las enfermedades reumáticas que requieren la atención de las autoridades de salud pública con el objetivo de mejorar la calidad de vida de los pacientes.

Pharmacogenetic aspects of methotrexate in a cohort of Colombian patients with rheumatoid arthritis.

Methotrexate (MTX) is the most commonly used disease-modifying antirheumatic drug for the treatment of rheumatoid arthritis (RA). However, over time, ~40% of patients may experience therapeutic failure or drug toxicity. The genetic variability of the enzymes involved in the MTX metabolic pathway seem to serve an important role in the eventual therapeutic failure or drug toxicity. Depending on the enzymes affected, the toxicity or the therapeutic response may change. The present study reports some of the polymorphisms identified in enzymes in the MTX metabolic pathway that are present in a group of Colombian patients with RA, and assesses the associations of these polymorphisms with toxicity or therapeutic response to the medication. A total of 400 patients with RA were evaluated, of which 76% were women. the average age was 60.7±13.9 years and the duration of the disease was 13.2±10.9 years. The disease activity scoring method, DAS28-CRP, was used to evaluate the therapeutic response. Toxicity was determined based on reports of adverse events during the evaluation of the patients. The single nucleotide polymorphisms (SNPs) assessed using reverse transcription-PCR in the present study were MTHFR C677T, A1298C, ATIC C347G, RFC-1-G80A, FPGS-AG and DHFR-CT. The SNPs of MTHFR C677T (P=0.05) and A1298C (P=0.048) were significantly associated with the efficacy of MTX, and DHFR-CT (P=0.01) and ATIC C347 (P=0.005) were significantly associated with documented toxicity. Haematological, hepatic or renal toxicity was not associated with any of the SNPs. The results obtained in Colombian patients with RA receiving MTX are similar to those reported in other populations; however, the SNPs associated with a lack of response previously reported in the literature were not observed in our data. The SNPs identified in the present study may be used as biomarkers to predict response to MTX in terms of efficacy and toxicity in Colombian patients with RA.

Demographic and clinical characteristics of chikungunya patients from six Colombian cities, 2014-2015.

In 2014, the chikungunya virus reached Colombia for the first time, resulting in a nationwide epidemic. The objective of this study was to describe the demographics and clinical characteristics of suspected chikungunya cases. Chikungunya infection was confirmed by enzyme-linked immunosorbent assay and 548 patients where included in the study. Of these patients, 295 were positive for antibodies against chikungunya (53.8%), and 27.6% (151/295) were symptomatic for chikungunya infection, with a symptomatic:asymptomatic ratio of 1.04:1. Factors associated with infection included low income and low socio-economic strata (odds ratio [OR]: 1.8; 95% confidence interval [CI]: 1.0-3.2, p = 0.003 and OR: 2.1; CI: 1.3-3.4, p = 0.002, respectively). Confirmed symptomatic cases were associated with symmetric arthritis (OR: 11.7; CI: 6.0-23.0, p < 0.001) of ankles (OR: 8.5; CI: 3.5-20.9, p < 0.001), hands (OR: 8.5; CI: 3.5-20.9, p < 0.001), feet (OR: 6.5; CI: 2.8-15.3, p < 0.001), and wrists (OR: 17.3; CI: 2.3-130.5, p < 0.001). Our study showed that poverty is associated with chikungunya infection. Public health strategies to prevent and control chikungunya should focus on poorer communities that are more vulnerable to infection. The rate of asymptomatic infections among confirmed cases was 48.8%. However, those with symptoms displayed a characteristic rheumatic clinical picture, which could help differentiate chikungunya infection from other endemic viral diseases.

Adecuación y validación transcultural del cuestionario COPCORD: Programa Orientado a la Comunidad para el Control de las Enfermedades Reumáticas en Colombia / Cross-cultural adaptation of the Community Oriented Program for the Control of Rheumatic Diseases (COPCORD) in a Colombian population

RESUMEN Introducción: La validación de cuestionarios es fundamental en el proceso de medición de cualquier estudio de investigación. El cuestionario Community Oriented Program for Control of Rheumatic Diseases (COPCORD) es útil como tamizaje para la detección de enfermedades reumáticas. Objetivo: Adecuar y validar la metodología y el cuestionario COPCORD en población colom biana. Materiales y métodos: Se realizó un estudio de validación de metodología COPCORD que incluyó: 1) adecuación transcultural del cuestionario COPCORD del español mexicano, y 2) validación de los cuestionarios: COPCORD, cuestionario de nivel socioeconómico, uso de servicios de salud y un instrumento de calidad de vida (EQ-5D-3L), siguiendo las guías internacionales. Resultados: Participaron 329 sujetos de 6 ciudades de Colombia, 10 en la primera fase del estudio y 309 en la segunda; un 67,3% fueron mujeres, con una edad promedio de 46,4 años, con una escolaridad entre básica y media (77%). Los participantes residían en Bogotá (29,4%), Barranquilla (22%), Cali (20,3%), Medellín (15,2%), Bucaramanga (6,4%) y Cúcuta (6,4%). Repor taron dolor musculoesquelético en los últimos 7 días el 43,6% y dolor histórico el 68,9%. En 127 (41,1%) se estableció un diagnóstico reumatológico: osteoartrosis (9,3%), síndrome de dolor regional (5,5%), lumbalgia (5,1%) y artritis reumatoide (0,9%). La validez interna fue de 0,70. Al comparar el cuestionario COPCORD con la revisión por el reumatólogo, tuvo una sensibilidad del 70,8%, una especificidad del 35%, una razón de verosimilitud positiva de 1,09 y un área bajo la curva de 0,53. Conclusiones: El cuestionario COPCORD es válido como prueba de tamizaje de detección de malestares musculoesqueléticos y enfermedades reumáticas en población colombiana.

ABSTRACT Introduction: The validation of questionnaires is fundamental in the measurement process of any research study. The Community Oriented Program for Control of Rheumatic Dis eases (COPCORD) questionnaire is useful as a screening tool for the detection of rheumatic diseases. Objective: To adapt and validate the methodology and the COPCORD questionnaire in the Colombian population. Materials and methods: A validation study of the COPCORD methodology was carried out that included: (1) transcultural adaptation of the COPCORD questionnaire of Mexican Spanish, and (2) validation of the questionnaires: COPCORD, socioeconomic level questionnaire, use of health services and a quality of life questionnaire (EQ-5D-3L), following international guidelines. Results: A total of 329 subjects of 6 cities in Colombia participated in the process, with 10 in the first phase and 309 in the second. Approximately two-thirds (67.3%) were women. The mean age was 46.4±18.4 years, with an educational level between basic and medium (77%). Participants resided in Bogota (29.4%), Barranquilla (22%), Cali (20.3%), Medellin (15.2%), Bucaramanga (6.4%), and Cucuta (6.4%). Musculoskeletal pain in the previous 7 days was reported by 43.6%, and historical pain was reported by 68.9%. A rheumatological diagnosis was established in 127 (41.1%) cases: osteoarthrosis (9.3%), regional pain syndromes (5.5%), low back pain (5.1%), and rheumatoid arthritis (0.9%). The internal validity was 0.70. When comparing the COPCORD questionnaire with the diagnosis made by the rheumatologist, it had a sensitivity of 70.8%, specificity 35%, positive likelihood ratio of 1.09 m and area under the curve of 0.53. Conclusions: The COPCORD questionnaire is valid as a screening test to detect musculoskeletal complaints and rheumatic diseases in the Colombian population.

Prevalencia de la enfermedad reumática en Colombia, según estrategia COPCORD-Asociación Colombiana de Reumatología. Estudio de prevalencia de enfermedad reumática en población colombiana mayor de 18 años / Prevalence of rheumatic disease in Colombia according to the Colombian Rheumatology Association (COPCORD) strategy. Prevalence study of rheumatic disease in Colombian population older than 18 years

RESUMEN Introducción: Las enfermedades reumáticas son causa frecuente de discapacidad, deterioran la calidad de vida y causan alto gasto en salud. El modelo COPCORD se ha implementado universalmente para estimar su prevalencia. El objetivo es estimar la prevalencia de las enfermedades reumáticas en la población colombiana mayor de 18 arios. Métodos: Se realizó un estudio de prevalencia utilizando un método probabilístico de muestreo aleatorio estratificado en 3 etapas: selección de los sectores cartográficos en cada ciudad, selección de los bloques de cada sector y del hogar de cada bloque. El cuestionario COPCORD, adaptado para Colombia, fue aplicado por entrevistadores estandarizados. La confirmación del diagnóstico fue hecha por un reumatólogo con acceso a toda la información. Resultados: De un total de 6.693 personas encuestadas el 64% fueron mujeres. El dolor no asociado con trauma fue reportado por el 48% de los participantes. Los sitios más frecuentes fueron rodillas (35%), manos (26%), columna lumbar (20%) y hombros (16%). El malestar musculoesquelético no específico, la osteoartritis, el síndrome de dolor regional apendicular y la lumbalgia no inflamatoria fueron las enfermedades más prevalentes. La artritis reumatoide y la lumbalgia crónica inflamatoria fueron las condiciones inflamatorias más comunes. La fiebre chikungunya afectó al 6,68% de la población. Conclusión: La prevalencia de la artritis reumatoide en Colombia es mayor a lo comúnmente reportado, menor para fibromialgia y gota, y similar para osteoartritis, lupus eritematoso sistémico y espondiloartritis. En Colombia, estas enfermedades representan un problema de salud pública sin que exista conciencia de su impacto en la población general.

ABSTRACT Introduction: Rheumatic diseases are the leading cause of permanent disability. The COP-CORD model is an effective tool in the determination of the prevalence of diseases. The objective of this study is to estimate the prevalence of rheumatic disease in a Colombian population over 18 years of age. Methods: A prevalence study was carried out using a probabilistic method of stratified random sampling in three stages: cartographic sectors in each city, selection of the blocks of each sector, and the households of each block. The COPCORD questionnaire adapted for Colombia was applied by standardised interviewers. Confirmation of the diagnosis was made by a rheumatologist with access to all the information. Results: Out of a total of 6,693 patients that completed the questionnaire, 64% were women. Pain not associated with trauma was reported by 48% of the participants. The most frequent locations were: knees 35%, hands 26%, lumbar spine 20%, and shoulders 16%. Nonspecific skeletal muscle discomfort, osteoarthritis, regional appendicular syndrome, and non-inflammatory low back pain, were the most prevalent diseases. Rheumatoid arthritis and chronic inflammatory low back pain were the most common inflammatory conditions. The prevalence of Chikungunya fever was estimated at 6.68%. Conclusion: The prevalence of rheumatoid arthritis in Colombia is higher than commonly reported, lower than for fibromyalgia and gout, and similar for osteoarthritis, systemic lupus erythematosus and spondylarthritis. In Colombia these diseases are a public health problem without awareness of their impact on the general population.

Dickkopf 1 protein circulating levels as a possible biomarker of functional disability and chronic damage in patients with rheumatoid arthritis.

Rheumatoid arthritis (RA) is an inflammatory disease characterized by joint destruction, deformity, lower functionality, and decrease in life expectancy. Wingless signaling pathway (Wnt) has been recently involved in bone homeostasis. Studies suggest that overexpression of the pathway inhibitors, like the Dickkopf 1 protein (DKK1), has been implicated in bone destruction. The objective of this study is to compare circulating levels of DKK1 in different groups of patients with disease activity (remission, low, moderate, high activity,) and functionality status. Three hundred seventy-nine patients with RA were evaluated between March 2015 and November 2016. Disease activity was evaluated by disease activity score 28 with C-reactive protein (DAS28CPR), simplified and clinical disease activity scores (SDAI, CDAI), routine assessment of patient index data 3 (RAPID3), functional status using Multidimensional Health Assessment Questionnaire (MD-HAQ), and the Steinbrocker functional classification. DKK1 levels were measured by ELISA. The mean age was 60.7 ± 13.9 years. Disease duration was 13.2 ± 10.9 years. Higher levels of DKK1 were not associated with disease activity by CDAI (p = 0.70), SDAI (p = 0.84), DAS28CRP (p = 0.80), or RAPID3 (p = 0.70). Interestingly higher levels of DKK1 were significantly associated to lower functional status evaluating by the Steinbrocker classification (p = 0,013), severe disability by MD-HAQ (p = 0,004), and variables associated with joint destruction like osteoporosis, higher titles of rheumatoid factor, smoking, and increased hospital admissions related to RA. Higher levels of DKK1 were found in patients with lower functional status. This association was not found in patients with greater disease activity by CDAI, SDAI, DAS28, and RAPID3. This could be explained by more structural damage; DKK1 could be used as a biomarker of joint destruction in RA.

Capacidad funcional medida por HAQ en los pacientes con enfermedades reumáticas en Colombia / Functional capacity measured by HAQ in the patients with rheumatic diseases in Colombia

Introducción y objetivo: La capacidad funcional se encuentra comprometida en diferentes patologías y es susceptible de ser reversible si es intervenida en etapas tempranas. Las enfermedades reumáticas se pueden asociar con grados variables de discapacidad a largo plazo a consecuencia de la limitación funcional. Métodos: En el marco del estudio de prevalencia de la enfermedad reumática en Colombia, se evaluó la capacidad funcional mediante el instrumento HAQ (Health Assesment Questionnarie), a través del cual se considera como mayor limitación funcional un puntaje de 3 y ninguna limitación un puntaje de cero. Resultados: Se evaluaron 4020 individuos. Los pacientes con enfermedades reumáticas (n=2274) reportaron un mayor grado de discapacidad respecto a los individuos sanos (n=1104) o con enfermedades no reumáticas (n=642). Especialmente los pacientes con artritis reumatoide (AR) con una media de 0,88 en comparación con 0,06 y 0,01 de la población con enfermedades no reumáticas y sanos, respectivamente (p<0,001). Estrechamente se encuentran los pacientes con lupus eritematoso sistémico (LES) (0,67) seguido por los pacientes con osteoartrosis (OA), fibromialgia y espondiloartritis (0,59, 0,56 y 0.52 en orden) (Figura 1). Conclusiones: En comparación con población sana y enfermos no reumáticos, los enfermos reumáticos tienen una menor capacidad funcional. Los pacientes con AR referencian mayor grado de discapacidad seguido por pacientes con LES y OA.

Reporte de EQ-5D-3L en población sana, enfermos reumáticos y enfermos no reumáticos / Report of EQ-5D - 3L in healthy population, rheumatic patients and not rheumatic patients

Introducción y Objetivo: El EQ-5D de 3 niveles es uno de los instrumentos más empleados para estimar la calidad de vida. Dentro de las estrategias de salud pública, la calidad de vida es un factor fundamental de intervención. Métodos: Para estimar el estado de salud de la población, se empleó la encuesta EQ-5D-3L en 6,693 personas de 6 ciudades de Colombia. Se desarrolló un estudio analítico. Resultados: En general, la población sana refirió no tener problemas según el EQ-5D-3L. De los enfermos no reumáticos, el 20% manifestaron un compromiso moderado de dolor y malestar, así como de ansiedad y depresión. El 20% (n=53) de los pacientes con ECV tenían limitación moderada para la movilidad y en los pacientes con epilepsia un 10% (n=11) tenían compromiso severo (Tabla 1). Llamativamente en los pacientes con enfermedades cardiovasculares había más dificultades para las actividades cotidianas. Los pacientes con enfermedades reumáticas manifestaron diversos grados de dificultades en la movilidad y las actividades cotidianas.

Calidad de vida evaluada por EQ-5D-3L de los enfermos reumáticos en Colombia / Quality of life assessed by EQ-5D-3L of rheumatic patients in Colombia

Introducción y Objetivo: La calidad de vida de los pacientes con enfermedades reumáticas se ve afectada por la discapacidad y dolor crónico secundario. Se evaluó este aspecto dentro del estudio COPCORD. Métodos: Se evalúo una población abierta en las ciudades de Bogotá, Medellín, Cali, Barranquilla, Bucaramanga y Cúcuta. Se empleó el instrumento EQ-5D-3L para evaluar la calidad de vida. Resultados: De un total de 4020 individuos, se identificaron 2274 enfermos reumáticos. De acuerdo con las dimensiones del EQ-5D-3L, una cuarta parte de los pacientes con espondiloatritis (SpA) y artritis reumatoide (AR) (25% (n=32) y 26% (n=68)) manifestaron no tener dolor o malestar en comparación con casi la totalidad de la población sana y enfermos no reumáticos (P<0,0001).

Comorbilidades en los pacientes con enfermedades reumáticas en Colombia / Comorbidities in patients with rheumatic diseases in Colombia

Introducción y Objetivo: Las comorbilidades asociadas a las enfermedades reumáticas pueden condicionar mayor mortalidad por lo que su diagnóstico e intervención conjunta es fundamental para mejorar la expectativa de vida de esta población. Métodos: A partir de datos de la población estudiada bajo la estrategia COPCORD en las ciudades de Bogotá, Medellín, Cali, Barranquilla, Bucaramanga y Cúcuta, se describe la frecuencia de enfermedades no reumáticas en 2274 pacientes con enfermedades reumáticas. Resultados: Los enfermos reumáticos colombianos reportaron en un 69% (n=1571) tener alguna comorbilidad. La más frecuente fue la hipertensión arterial (HTA) en 20,95% (n=330), seguido por migraña 19,11% (n=300) e insuficiencia venosa 17,69% (n=278). Los trastornos mentales, en términos de ansiedad y depresión, se registró en un (17,3%) (n=273).

Prevalencia de las enfermedades reumáticas en Colombia / Prevalence of rheumatic diseases in Colombia

Introducción y Objetivo: Conocer la prevalencia de las enfermedades reumáticas permite diseñar estrategias de intervención pública para su atención integral y disminuir los costos derivados de las potenciales complicaciones de estas enfermedades. Métodos: Se realizó un estudio bajo la estrategia epidemiológica COPCORD diseñada para la identificación, prevención y control de las enfermedades reumáticas en países en desarrollo. Permite la identificación de los pacientes con síntomas osteo-músculo articulares de origen no traumático mediante una entrevista directa. Resultados: Se evaluaron 6693 personas de seis ciudades de Colombia.

Possible steroid-resistant IgG4-related pachymeningitis treated with parenteral methotrexate / Posible paquimeningitis relacionada con IgG4, resistente a los esteroides tratada con metotrexato parenteral

Abstract Pachymeningitis is an uncommon disease with multiple etiologies with fibrosis of leptomeninges. One type of this disease is related to immunoglobulin G4 (IgG4). The most frequent manifestations include chronic cephalgia and focal neurological deficits. The case of a 31-year-old man with chronic cephalgia localized to the left hemicranium and left dysmetria is presented. Nuclear magnetic resonance imaging showed image hyperintensity and perilesional edema located at the infratentorial and left parietal occipital levels. The results of cerebral angiography and a cerebrospinal fluid examination were normal. A biopsy of the central nervous system (CNS) ruled out neoplastic lesions, granulomatous lesions, infection, and arteriovenous malformation and indicated thickened meningeal fragments. Elevated serum IgG4 levels were found. The antinuclear antibodies (ANAs), antibodies to extractable nuclear antigens (ENAs), anti-native DNA antibodies (anti-DNA), topoisomerase I antibodies (Scl-70), antibodies to cyclic citrullinated peptides (anti-CCP), and rheumatoid factor (RF) were negative. After an initial diagnosis of idiopathic hypertrophic cranial pachymeningi-tis, the patient received treatment with high doses of glucocorticosteroids for two years, without response, and developed Cushing's syndrome, cataracts, and osteoporosis. During the follow-up, dactylitis, distal upper limb sclerosis, and Raynaud's phenomenon occurred. A capillaroscopy indicated capillaries with dilated loops, microhemorrhaging, disorganization of the capillary architecture, and megacapillaries, which led to a diagnosis of limited systemic scleroderma. Although an association between scleroderma and pachymeningitis was originally proposed, review of the literature suggests that these are two different entities. Treatment with methotrexate, 25 mg weekly, allowed the withdrawal of glucocorticoids and resolution of neurological symptoms.

Resumen La paquimeningitis es el compromiso fibrosante de las leptomeninges poco común y de múltiple etiología. Una de ellas, la enfermedad relacionada a inmunoglobulina IgG4. Las manifestaciones clínicas más frecuentes son la cefalea crónica de difícil tratamiento y el déficit neurológico focal. Se presenta el caso de un hombre de 31 años, con cefalea crónica localizada en el hemicráneo izquierdo y disimetría izquierda, resonancia nuclear magnética con imagen hiperintensa y edema perilesional ubicada a nivel infratentorial y parieto-occipital izquierda, angiografía cerebral y estudio de líquido cefalorraquídeo normales. La biopsia del sistema nervioso central (SNC) descartó lesiones neoplásicas, granulomatosas, infección y malformación arteriovenosa, y reportó fragmentos meníngeos engrosados. A nivel sérico se encontraron altos niéveles de IgG4. ANA, ENA, anti-DNA, SCL-70, CCp y FR, negativos. Con el diagnóstico presuntivo inicial de paquimeningitis craneal hipertrófica idiopática, recibió tratamiento con dosis elevadas de glucocorticoides por espacio de 2 anos, sin buena respuesta y el desarrollo de síndrome de Cushing iatrogénico, cataratas y osteoporosis. Durante el seguimiento se documentó dactilitis, esclerosis distal de miembros superiores, síndrome de Raynaud y con capilaroscopia con asas dilatadas, microhemorragia, desorganización de la arquitectura capilar y megacapilares, configurándose el diagnóstico de esclerodermia sistémica limitada. Aunque se propuso inicialmente la asociación entre estas 2 condiciones, la revisión de la literatura indica que se trata de 2 entidades fisiopa-tológicamente diferentes. El tratamiento con metotrexato a dosis de 25 mg semanal permitió el retiro de los glucocorticoides y la resolución completa de los síntomas neurológicos.

Interobserver Agreement in Magnetic Resonance of the Sacroiliac Joints in Patients with Spondyloarthritis.

Background. Clinical, laboratory, and radiologic parameters are used for diagnosis and classification of spondyloarthritis (SpA). Magnetic resonance imaging (MRI) of sacroiliac (SI) joints is being increasingly used to detect early sacroiliitis. We decided to evaluate the interobserver agreement in MRI findings of SI joints of SpA patients between a local radiologist, a rheumatologist, and an expert radiologist in musculoskeletal diseases. Methods. 66 MRI images of the SI joints of patients with established diagnosis of SpA were evaluated. Agreement was expressed in Cohen's kappa. Results. Interobserver agreement between a local radiologist and an expert radiologist was fair (κ = 0.37). Only acute findings showed a moderate agreement (κ = 0.45), while chronic findings revealed 76.5% of disagreement (κ = 0.31). A fair agreement was observed in acute findings (κ = 0.38) as well as chronic findings (κ = 0.38) between a local radiologist and a rheumatologist. There was a substantial agreement between an expert radiologist and a rheumatologist (κ = 0.73). In acute findings, a 100% agreement was achieved. Also chronic and acute plus chronic findings showed high levels of agreement (κ = 0.73 and 0.62, resp.). Conclusions. Our study shows that rheumatologists may have similar MRI interpretations of SI joints in SpA patients as an expert radiologist.

Association of human leukocyte A, B, and DR antigens in Colombian patients with diagnosis of spondyloarthritis.

There is substantial evidence that non-B27 major histocompatibility complex (MHC) genes are associated with spondyloarthritis (SpA). Studies in Mexican and Tunisian populations demonstrated the association of SpA and human leukocyte antigen (HLA) B15. The purpose of this study was to evaluate the association of HLA-A, B, and DR antigens in a group of Colombian patients with a diagnosis of SpA. A total of 189 patients and 100 healthy subjects were included in the present study. All subjects underwent a complete characterization of HLA alleles A, B, and DR. Of the 189 studied patients, 35 were reactive arthritis (ReA), 87 were ankylosing spondylitis (AS), and 67 undifferentiated SpA (uSpA). According to the Assessment of Spondyloarthritis International Society (ASAS) criteria, 167 were axial SpA (axSpA) and 171 were peripheral SpA (pSpA). 63.8% were men, with a mean age of 35.9 ± 12.7 years. 40.7% (77/189) of patients were HLA-B27 positive of which 52.9% had AS and 42.5% axSpA. 23.2% (44/189) of patients were HLA-B15 positive: 23.8% were uSpA, 12.57% were axSpA, and 11.7% were pSpA. In addition, HLA-DRB1*01 was associated with AS (58.6%) and axSpA (42.5%). Also, HLA-DRB1*04 was present in 62 patients with AS (71.2%) and in 26 with axSpA (15.5%). In this population, we found a strong association between the presence of HLA-B27 and the diagnosis of axSpA and AS, but the HLA-B15 is also significantly associated with all subtypes of the disease, predominantly with pSpA. Additionally, HLA-DR1 and DR4 were associated in a cohort of patients with SpA from Colombia.

Correlation between rapid-3, DAS28, CDAI and SDAI as a measure of disease activity in a cohort of Colombian patients with rheumatoid arthritis.

The objective of this study is to correlate the patient-driven tool Routine Assessment of Patient Index Data 3 (RAPID-3) with other common tools used in daily practice to measure disease activity in rheumatoid arthritis (RA).One hundred nineteen RA patients according to 1987 American College of Rheumatology criteria who consecutively attended a RA outpatient clinic between August and December 2015 were evaluated. Data was stored in an electronic form that included demographic information, comorbidities, concomitant medication, and laboratory results. The disease activity was determined by tender and swollen joint count, pain and disease activity visual analog scales (VAS), disease activity score 28 (DAS28), Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI), and multidimensional health assessment questionnaire (MDHAQ). Correlations between RAPID-3 and other disease activity tools were assessed. Mean age was 61 ± 13.8 years with a median disease duration of 14 years (IQR 5-21), 77% were females. Median scores were MDHAQ 0.5 (IQR 0.1-1.2), DAS 28 3.8 (IQR 2.7-5.1), and RAPID-3 12.3 (IQR 6-19). A strong correlation was obtained between RAPID-3 and DAS 28 (r 0.719, p < 0.001), CDAI (r 0.752, p < 0.001), and SDAI (r 0.758, p < 0.001). RAPID-3 had a high correlation with tools regularly used for disease activity assessment of RA patients in daily practice. The ease of its application favors routine use as it does not require laboratory results and joint counts.

Síndrome de May-Thurner como diagnóstico diferencial en trombosis a repetición / May-Thurner syndrome as a differential diagnosis in recurrent thrombosis

El síndrome de May-Thurner es una anomalía anatómica que genera insuficiencia venosa y episodios trombóticos recurrentes de los miembros inferiores. Se presenta el caso de una paciente de 29 años, con cuadro de trombosis venosas profundas en miembros inferiores a repetición desde los 20 años, sin factores de riesgo identificados, en quien se realizan estudios de extensión para neoplasia y trombofilia con resultados negativos, además de estudios para patología reumatológica con anticuerpos antinucleares (ANAS) positivo a títulos bajos como único hallazgo, con lo que se hace diagnóstico de enfermedad del tejido conectivo no diferenciado y se instaura manejo con anticoagulación plena; sin embargo, ante la persistencia de eventos trombóticos se realiza angio-TAC, la cual reporta obstrucción de la vena ilíaca izquierda, por lo cual se realiza una venografía más cavografía documentándose obstrucción de la vena ilíaca externa izquierda y la común estableciéndose el diagnóstico de síndrome de May-Thurner, el cual debe considerarse dentro de los diagnósticos diferenciales de los episodios trombóticos recurrentes.(Acta Med Colomb 2016; 41: 67-70).

The May-Thurner syndrome is an anatomic abnormality generating venous insufficiency and recurrent thrombotic episodes of lower limbs. The case of a 29 years old patient with clinical picture of recurrent deep venous thrombosis in lower limbs since the age of 20 years is presented. No risk factors were identified; extension studies for neoplasia and thrombophilia were performed with negative results, as well as studies for rheumatic disease with positive anti-nuclear antibodies (ANAs) at low titers as unique finding, being diagnosed as undifferentiated connective tissue disease and management with full anticoagulation is established. However, at the persistence of thrombotic events, an angio-CT which reports obstruction of the left iliac vein and the common vein is performed whereby a venography and cavography are done establishing the diagnosis of May Thurner syndrome, which should be considered within the differential diagnosis of recurrent thrombotic events. (Acta Med Colomb 2016; 41: 67-70).

Pioderma gangrenoso como síndrome paraneoplásico de un tumor tipo Phyllodes Borderline / Pyoderma gangrenosum as paraneoplastic syndrome of a Phylloides tumor, Borderline type

Se presenta el caso de una paciente de 65 años con una masa en su seno izquierdo y una úlcera en el tobillo izquierdo. La paciente consulta por úlcera crónica sin resolución, a pesar de múltiples tratamientos. Al realizar estudio histológico de las dos lesiones, se estableció que la masa en la mama correspondía a un tumor Phyllodes Borderline y la úlcera del tobillo a un pioderma gangrenoso. El pioderma gangrenoso es generalmente secundario a otras condiciones. En este caso se estableció que era un síndrome paraneoplásico del tumor Phyllodes. Esta relación es poco frecuente, debido a que en el mundo sólo se han reportado cuatro casos con la asociación pioderma gangrenoso y tumores de mama. Ninguno de ellos en Colombia. (Acta Med Colomb 2014; 39: 207-210).

The case of a 65 year old patient with a mass in her left breast and an ulcer on the left ankle, is presented. The patient consults for a chronic ulcer unresolved despite multiple treatments. When histological study of the two lesions was performed, it was established that the breast mass corresponded to a Phyllodes Borderline tumor and the ankle ulcer to a pyoderma gangrenosum. Pyoderma gangrenosum is usually secondary to other conditions. In this case it was established that it was a paraneoplastic syndrome of Phyllodes tumor. This relationship is rare because only four cases with association of pyoderma gangrenosum and breast tumors have been reported worldwide. None of them in Colombia. (Acta Med Colomb 2014; 39: 207-210).