Prevalence and predictors of hand involvement in Thai patients with systemic sclerosis.

AIM: Data regarding the clinical and radiographic hand involvement in Asian patients with systemic sclerosis (SSc) are limited. Thus, we determined the prevalence of clinical and radiographic hand involvement in Thai SSc patients, comparing diffuse cutaneous SSc (dcSSc) and limited cutaneous SSc (lcSSc). We also determined the factors associated with arthritis, contracture of fingers and digital ulcers. METHOD: SSc patients seen at the Rheumatology Clinic, Chiang Mai University, Thailand, from December 2012 to June 2013 were consecutively invited to enroll in the study. After study entry, demographic data, clinical features and hand radiographs were evaluated. RESULT: We studied 110 SSc patients (73 dcSSc) with mean ± SD age of 53.2 ± 9.2 years and disease duration from non-Raynaud's phenomenon of 4.9 ± 4.8 years. The prevalence of arthritis, finger contractures and digital ulcers were 10 (9.1%), 47 (42.7%), and 14 (12.7%), respectively. DcSSc patients had significantly more of the following hand complications than lcSSc patients: digital pitting scar (53.4% vs. 27.0%, P = 0.008), digital ulcer (17.8% vs. 2.7%, P = 0.032), traumatic ulcer (27.4% vs. 0%, P < 0.001), acrolysis (45.2% vs. 18.9%, P = 0.007) and flexion contracture (60.3% vs. 8.1%, P < 0.001). Radiographic finger contractures were more prevalent in the dcSSc subset. In multivariate logistic regression analysis, a positive rheumatoid factor was associated with arthritis; dcSSc, arthritis and modified Rodnan skin score (MRSS) > 18 were associated with contracture of fingers. Furthermore, hand MRSS > 4 was associated with digital ulcers. CONCLUSION: Our results confirm that dcSSc patients had more severe clinical hand complications than lcSSc. However, radiographic findings were similar among subgroups, except that more finger contractures were seen in dcSSc. Finally, the presence of rheumatoid factor is associated with arthritis, and high MRSS is associated with finger contractures and digital ulcers.

Iron overload in non-transfusion-dependent thalassemia: association with genotype and clinical risk factors.

In the present study, we sought to determine the prevalence of iron overload in patients with non-transfusion-dependent thalassemia (NTDT) and its association with genotype and other clinical risk factors, and to evaluate the correlation between serum ferritin (SF) and liver iron concentration (LIC). Myocardial and liver iron concentration was measured by MRI using a T2* gradient multi-echo sequence in NTDT patients, aged 10-50 years. Of 91 patients, 54 (59 %) had hepatic iron overload. None had cardiac iron overload. The clinical risk factors for hepatic iron overload were age >20 years (adjusted OR 30.2, 95 % CI 4.5-203, p < 0.001), hemoglobin level <7 g/dL (adjusted OR 6.3, 95 % CI 1.01-39.5, p = 0.049), and cumulative RBC transfusion >10 units (adjusted OR 53.6, 95 % CI 3.2-884, p = 0.005). Beta-thalassemia genotype was associated with higher risk of iron overload by univariate analysis, but the association was not significant when adjusted for other clinical factors. The correlation coefficient between SF and LIC was 0.60 (p < 0.001). In conclusion, the prevalence of hepatic iron overload is high in NTDT. Older age, lower hemoglobin level, and higher cumulative RBC transfusion are significant risk factors. SF and LIC show a significant positive correlation.

Deforming Arthropathy in Thai Patients With Systemic Lupus Erythematosus.

OBJECTIVE: The aim of this study was to determine the prevalence, spectrum, and clinical, radiological, and serologic findings as well as hand functions among Thai systemic lupus erythematosus (SLE) patients with deforming arthropathy. METHODS: All SLE patients attending the rheumatology clinic between January and December 2012 were interviewed, with their complete history and a physical examination being taken. Those with hand deformities were invited to join the study. RESULTS: Forty (8.7%) of 458 SLE patients had deforming arthropathy, with 13 (2.8%) of them having erosive arthritis (EA group) and 27 nonerosive arthropathy (NEA group) (8 [1.8%] with Jaccoud arthropathy [JA subgroup] and 19 [4.1%] with mild deforming arthropathy [MDA subgroup]). Three of 13 EA patients (0.7% of all SLE patients) had high titer of rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies that might represent true overlapping between rheumatoid arthritis and SLE. There were no statistically significant differences in autoantibodies, RF, or anti-CCP between the EA and NEA groups or the JA and MDA subgroups, except for discoid rash that was seen more commonly in the MDA subgroup. Rheumatoid factor and anti-CCP were not present in the JA subgroup. Hand joint destruction and deformities were seen more commonly in the EA group and JA subgroup. The hand grip and palmar pinch strength decreased moderately, with hand functions quite well preserved in all groups. CONCLUSIONS: Deforming arthropathy was not uncommon in Thai SLE patients, but true overlapping between rheumatoid arthritis and SLE was rare. Despite significant hand joint deformities and moderately decreased hand grip and palmar pinch strength, preservation of hand functions was generally apparent.

Periodontal disease in Thai patients with rheumatoid arthritis.

AIM: To evaluate the prevalence and severity of periodontal disease in patients with rheumatoid arthritis (RA) who attended a rheumatology clinic in a university hospital. METHODS: All consecutive patients with RA who attended the rheumatology clinic between June 2009 and January 2010 were asked to enroll in this study. All participants answered questionnaires, which included demographic data, medical history, medications used and smoking habits. A full mouth periodontal examination, including gingival index, plaque index, probing pocket depth and clinical attachment level was performed. Only cases that had at least 20 teeth were included in this study. Rheumatoid arthritis parameters, including number of tender and swollen joints, erythrocyte sedimentation rate, the presence of rheumatoid factor (RF), hand radiographs, Disease Activity Index (DAS) and health status using the Thai Health Assessment Questionnaire (HAQ), were determined. The association between RA parameters and periodontal condition was examined. RESULTS: There were 196 participants (87.2% female) with a mean age of 51.7 ± 9.70 years, mean disease duration of 9.62 ± 7.0 years and mean DAS score of 4.64 ± 1.25. Eighty-two per cent were RF-positive. Moderate and severe periodontitis were found in 42% and 57%, respectively. Higher age, male gender, previous or current smoking and high level of plaque score were associated with severe periodontal disease. No differences in RA parameters were found between groups of patients who had moderate and severe periodontitis. CONCLUSIONS: We found a high prevalence of periodontitis in Thai patients with RA. However, there was no association between RA parameters and periodontal conditions.

Pitfalls in imaging of musculoskeletal infections.

In musculoskeletal infections, imaging helps in the diagnosis and identification of disease extent. Musculoskeletal infections have variable clinical presentations related to host immune responses and virulence of pathogens. Occasionally, infectious process may mimic other entities such as autoimmune inflammatory diseases, tumors, or traumatic injuries, both clinically and radiologically. Identification of the disease extent is sometimes difficult, particularly when infection occurs in the damaged tissue. The key imaging feature of infection is formation of abscesses. Familiarity of the imaging patterns of the infectious process leads to correct diagnosis and appropriate treatment.

Preliminary results of MRI-guided brachytherapy in cervical carcinoma: the Chiangmai University experience.

This study was performed to evaluate the feasibility of magnetic resonance imaging (MRI) in the treatment planning of image-guided brachytherapy for cervical carcinoma. Seventeen consecutive patients with locally advanced cervical cancer were enrolled in the study. Fifteen patients could be evaluated. When comparing the tumor at diagnosis (GTV-Dx) and the tumor at the first brachytherapy (GTV-BT), 11 of 15 patients showed a tumor regression of more than 80% while only four patients had less than 80% tumor regression. The mean D90 of HR-CTV and the calculated D2cc of the bladder, rectum, and sigmoid were 99.2 ± 11 Gy, 87.7 ± 5.7 Gy, 68.4 ± 5.4 Gy and 70.3 ± 6.8 Gy, respectively. No grade 3-4 acute toxicity was observed. The MRI can be a valuable tool for evaluating tumor response after external beam radiotherapy (EBRT) and is very helpful for prognosis prediction by residual GTV evaluation. Furthermore, MRI-guided brachytherapy allowed us to optimize the dose for both the target volumes and the OARs.

Tuberculosis arthritis and tenosynovitis.

The incidence of extrapulmonary tuberculosis (TB) has been rising due to the increasing number of immunosuppressed patients. Musculoskeletal system accounts for 25% of extrapulmonary TB. Most of the musculoskeletal TB involves the spine. TB of peripheral joints and tendons occur infrequently, but if untreated, it can cause serious joint and tendon destruction as well as spread of the infection to the surrounding bursa, muscle, and other soft tissues. The diagnosis of TB of joints and tendons is difficult due to the nonspecific clinical manifestations and imaging features. Concurrent active pulmonary TB is present in <50% of the patients. A positive chest radiographic finding or a positive tuberculin test supports the diagnosis, but negative results do not exclude diagnosis. Although imaging features of TB of joints and tendons are nonspecific, certain findings such as relatively preserved joint space, juxta-articular osteoporosis, cold abscesses, para-articular soft tissue calcification, and rice bodies are suggestive of TB infection. Familiarity with these imaging features can help in making an early diagnosis and facilitating proper management.

Recurrent tibial intra-cortical osteosarcoma: a case report and review of the literature.

INTRODUCTION: Intra-cortical osteosarcoma is the rarest subtype of osseous-producing tumor. Most reported cases present a low-grade histology with slow progression and good oncological control after adequate treatment. In this report, we describe a case and review the literature to propose adequate treatment. CASE PRESENTATION: We present the case of a 21-year-old Thai woman who was thought to have an intra-cortical osteosarcoma of the right tibia. We performed a wide resection and reconstruction with bone transportation using an Ilizarov external fixator. The tumor recurred five years later at the same site with a similar histology. We performed a new resection and reconstruction by ankle arthrodesis with adjuvant chemotherapy. At the last follow-up, she had remained active and free from disease for seven years. CONCLUSION: This case report of recurrent intra-cortical osteosarcoma describes an atypical presentation. The low-grade histology, adequate surgical margin and adjuvant chemotherapy of the recurrent lesion were favorable factors, and our patient has remained free of any tumor recurrence.

Sicca symptoms in Thai patients with rheumatoid arthritis, systemic lupus erythematosus and scleroderma: a comparison with age-matched controls and correlation with disease variables.

This study was performed to determine the prevalence of ocular and oral sicca symptoms in Thai patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and scleroderma (Scl). The ocular symptoms and sign (the Schirmer's 1 test) and the oral sicca symptoms and sign (the Saxon's test) in each of 50 RA, SLE and Scl patients were compared with their age-matched controls. The correlation between the presence of sicca symptoms and signs with their clinical activity was also determined. Ocular sicca symptoms were found more common in patients with RA (38% vs 18%, p < 0.05), SLE (36% vs 14%, p < 0.05) and Scl (54% vs 16%, p < 0.01), and oral sicca symptoms were found more common in SLE (22% vs 0%, p < 0.01), and Scl (16% vs 4%, p < 0.05) than their controls. However, only RA patients had a significantly higher proportion of positive Schimer-1 test compared with their controls (p < 0.01). There was no strong correlation between sicca symptoms or signs and other clinical or laboratory variables (age, disease duration, disease activity, disease severity, and antibody to Ro and La antigens) in these three groups. In conclusion, sicca symptoms were seen significantly more common in Thai patients with connective tissue diseases, but the symptoms did not show a good correlation with the clinical and laboratory variables.