New insights at the interface between leprosy and immune-mediated rheumatic diseases.

Leprosy is an infectious and contagious disease of slow evolution, triggered by Mycobacterium leprae. Arthritis is its third most common manifestation, after cutaneous and peripheral nerve involvement. Since musculoskeletal symptoms may be the initial presentation of the disease, it is important for health professionals to recognize its rheumatic manifestations for early diagnosis and appropriate treatment, especially in endemic areas. In addition, cases of leprosy have increased globally, notably in patients undergoing treatment with TNF-α blockers and due to the increase in migration and travel of people from developing countries to developed countries. This review proposes to discuss the main scenarios of mimicry of different rheumatic diseases by leprosy, as well as the role of immunosuppressive drugs used in rheumatology practice in the treatment of reactional states and in the risk of developing the infection.

Effect of biological disease-modifying antirheumatic drugs on body composition in patients with rheumatoid arthritis: a systematic review and meta-analysis

Abstract Background: Rheumatoid arthritis (RA) generates an inflammatory profile that predisposes to total and visceral fatty accumulation and reduced fat free mass (FFM). This metabolic disorder contributes to poor functionality, increased cardiovascular risk and higher mortality. This study aimed to address a systematic review with meta-analysis to determine the effect of biological and targeted synthetic disease-modifying antirheumatic drugs (bDMARDs and tsDMARDs) on body composition (BC) of patients with RA. Methods: The search was conducted at the electronic databases PubMed, Cochrane Library, Embase, Lilacs and grey literature. This investigation was carried until July 2021. Outcomes of interest were total weight, body mass index (BMI), fat mass (FM) and FFM. A meta-analysis comparing these outcomes in RA patients under bDMARD treatment versus controls was performed. Results: Out of 137 studies reviewed, 18 were selected: fifteen prospective cohorts, two retrospective cohorts, and one cross-sectional study. The studies comprised 1221 patients, 778 on bDMARD treatment and 443 controls, which included RA patients under conventional synthetic DMARD (csDMARD). No study addressing BC analysis in patients using tsDMARD was found. The mean age and duration of the disease was 56.7 years and 6.77 years, respectively. Ten studies demonstrated a significant increase of total weight in 88.2% of patients and 42.3% for BMI. In studies that analyzed BC by double X-ray absorptiometry (DXA), the increase in total weight and BMI correlated positively to the increase in FFM. The meta-analysis carried out in five studies showed no significant difference of the mean difference for total weight 0.12 kg (95% CI − 5.58, 5.82), BMI 0.08 kg/m2 (95% CI − 1.76, 1.92), FM − 0.08 kg (95% IC − 5.31, 5.14), and FFM − 2.08 kg (95% CI − 7.37, 3.21). Conclusion: This systematic review suggests a possible impact of bDMARDs on BC of RA patients, even though, the meta-analysis carried out in a small part of these studies was not able to confirm significant variation in BC components. Trial registration: PROSPERO code: CRD42020206949.

Guidelines on COVID-19 vaccination in patients with immune-mediated rheumatic diseases: a Brazilian Society of Rheumatology task force

Abstract Objective: To provide guidelines on the coronavirus disease 2019 (COVID-19) vaccination in patients with immune-mediated rheumatic diseases (IMRD) to rheumatologists considering specific scenarios of the daily practice based on the shared-making decision (SMD) process. Methods: A task force was constituted by 24 rheumatologists (panel members), with clinical and research expertise in immunizations and infectious diseases in immunocompromised patients, endorsed by the Brazilian Society of Rheumatology (BSR), to develop guidelines for COVID-19 vaccination in patients with IMRD. A consensus was built through the Delphi method and involved four rounds of anonymous voting, where five options were used to determine the level of agreement (LOA), based on the Likert Scale: (1) strongly disagree; (2) disagree, (3) neither agree nor disagree (neutral); (4) agree; and (5) strongly agree. Nineteen questions were addressed and discussed via teleconference to formulate the answers. In order to identify the relevant data on COVID-19 vaccines, a search with standardized descriptors and synonyms was performed on September 10th, 2021, of the MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and LILACS to identify studies of interest. We used the Newcastle-Ottawa Scale to assess the quality of nonrandomized studies. Results: All the nineteen questions-answers (Q&A) were approved by the BSR Task Force with more than 80% of panelists voting options 4—agree—and 5—strongly agree—, and a consensus was reached. These Guidelines were focused in SMD on the most appropriate timing for IMRD patients to get vaccinated to reach the adequate covid-19 vaccination response. Conclusion: These guidelines were developed by a BSR Task Force with a high LOA among panelists, based on the literature review of published studies and expert opinion for COVID-19 vaccination in IMRD patients. Noteworthy, in the pandemic period, up to the time of the review and the consensus process for this document, high-quality evidence was scarce. Thus, it is not a substitute for clinical judgment.

Leptin as an obesity marker in rheumatoid arthritis.

The determination of excess of body fat mass provides a more suitable determinant of obesity in rheumatoid arthritis patients; however, body mass index (BMI) may not be accurate for the quantification of adiposity. To identify a marker of excess adiposity in women with rheumatoid arthritis (RA) using different methods for fat mass evaluation. A cross-sectional study was conducted in adult female patients with RA. Disease activity was assessed by DAS28-ESR, and obesity was determined by waist circumference (WC), BMI and dual-energy X-ray absorptiometry (DXA). The Human Bone Metabolism kit (Merck Millipore, Darmstadt, Alemanha) was used to determine the plasma levels of leptin, TNF-α, IL-6, and IL-1ß by quantification of serum proteins by technical microspheres (LUMINEX, TX, USA). Adiponectin was measured by enzyme-linked immunosorbent assay sandwich kit (R&D Systems, Minneapolis, MN, USA). Eighty-nine female patients, median age of 55.4 (± 11.6) years, and median disease duration of 16.4 (± 14.9) years were included. The frequency of obesity was 33.7% according to BMI, 89.9% with WC, and 56.1% with DXA. The median serum leptin concentration was the only marker that correlated with body fat percentage according to the three methods. This correlation was positive and not influenced by DAS28, C-reactive protein, erythrocyte sedimentation rate, or inflammatory cytokines levels (IL-6, TNF-α, IL-1ß). Analysis of ROC curves determined the cut-off point of 10.3 ng/mL of leptin as an obesity marker, with a sensitivity of 96.43% and a specificity of 23.81%. Serum leptin correlates positively with fat mass and is potentially useful in excess fat mass determination in clinical practice.

Diagnóstico simultâneo de lúpus eritematoso sistêmico e chikungunya / Simultaneous diagnosis of systemic erythematosus lupus and chikungunya

Chikungunya é uma arbovirose caracterizada por febre alta, poliartralgia periférica, exantema, mialgia axial e intensa fadiga. Até 65% dos pacientes apresentam recuperação total dos sintomas em 4 semanas, contudo as dores articulares podem persistir por um período de 12 meses após a infecção em 4,1% dos pacientes e por até dois anos em 1,6% dos indivíduos acometidos. Um ano após a infecção 0,3% dos pacientes podem apresentar artrite inflamatória crônica. Os pacientes que permanecem com dores musculoesqueléticas e artrite pós-infecciosa são frequentemente tratados com drogas imunossupressoras. Por poderem apresentar quadro clínico semelhante e pelo fato de infecção ser comum nos pacientes portadores de doenças reumatológicas, o lúpus eritematoso sistêmico (LES) é uma afecção que deve ser abordada como diagnóstico diferencial em regiões endêmicas para essa arbovirose. Sabendo-se do crescente número de casos de chikungunya no Brasil e da relação fortemente estabelecida entre aumento de morbimortalidade em lúpicos nos quadros infecciosos, faz- se necessária uma ampla discussão dos casos emergentes. (AU)

Chikungunya is an arbovirose characterized by high fever, severe peripheral polyarthralgia, exanthema, axial myalgia and intense fatigue. Up to 65% of patients present complete recovery of symptoms at 4 weeks, however, joint pain may persist for a period of 12 months after infection in 4.1% of patients and for up to 2 years in 1.6% of affected individuals. One year after infection, 0.3% of patients may present with chronic inflammatory arthritis. Patients who remain with musculoskeletal pain and post-infectious arthritis are often treated with Immunosuppressive drugs. Due to the presence of similar clinics and the fact that double infection is common in patients with rheumatologic diseases in some populations, systemic lupus erythematosus (SLE) is a condition that must be addressed during the stipulation of differential diagnosis in regions endemic to arboviruses. Given the increasing number of cases of chikungunya in developing countries and the strongly established relationship between increased morbidity and mortality in lupus in infectious diseases, a broad discussion of emerging cases is required. (AU)

Use of rituximab as a treatment for systemic lupus erythematosus: retrospective review.

OBJECTIVE: To report the experience in three Brazilian institutions with the use of rituximab in patients with different clinical forms of lupus erythematosus systemic in activity. METHODS: The study consisted of a sample of 17 patients with LES, who were already being treated, but that at some stage of the disease showed refractory symptoms. The patients were subdivided into groups according to the clinical manifestation, and the responses for the use of rituximab were rated as complete, partial or no response. Data were collected through a spreadsheet, and used specific parameters for each group. The treatment was carried on by using therapeutic dose of 1g, and repeating the infusion within an interval of 15 days. RESULTS: The clinical responses to rituximab of the group only hematological and of the group only osteoarticular were complete in all cases. In the renal group there was a clinical complete response, two partial and one absent. In the renal and hematological group complete response, there was one death and a missing response. The pulmonary group presented a complete response and two partial. CONCLUSION: The present study demonstrated that rituximab can bring benefits to patients with lupus erythematosus systemic, with good tolerability and mild side effects; it presented, however, variable response according to the system affected.

Assessment of endothelial function in pregnant women with preeclampsia and gestational diabetes mellitus by flow-mediated dilation of brachial artery.

PURPOSE: To compare endothelial function, as assessed by flow-mediated dilation (FMD) in pregnant women with preeclampsia (PE), gestational diabetes mellitus (GDM) and healthy pregnant women. METHODS: We conducted a cross-sectional study of eighty women who were selected and divided into three groups: Group A comprising 42 pregnant women with PE, Group B (control) consisting of 19 normotensive pregnant women with no comorbidities and Group C consisting of 19 pregnant women with GDM. The women underwent FMD and the results were compared between groups. The data were obtained from the Center for Fetal Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Brazil (CEMEFE-HC-UFMG) after approval by the Ethics and Research Committee on June 4, 2008 under no CAAE-0280.0.203.000-08. RESULTS: Nonparametric variance analysis showed no statistically significant difference between the characteristics of the three groups. The comparison between the results of the mean values of brachial artery FMD groups of pregnant women with preeclampsia (FMD = 5.36 ± 4.61 %), gestational diabetes (FMD = 9,18 ± 5.98 %) and pregnant women in the control group (FMD = 17.55 ± 8.35 %) showed that a statistically significant difference was found between groups using the Dunn test. The comparison between groups PE × GDM was not statistically significant. The group consisting of pregnant women with GDM associated with those with PE had significantly lower results for FMD (6.55 ± 5.33 %) than the control group (17.55 ± 8.35 %, p = 0.00). CONCLUSIONS: The group consisting of pregnant women with GDM or PE showed results for FMD significantly lower than the control group, suggesting possible endothelial injury in these patients.

Use of rituximab as a treatment for systemic lupus erythematosus: retrospective review / Utilização do rituximabe como tratamento para o lúpus eritematoso sistêmico: avaliação retrospectiva

Objective : To report the experience in three Brazilian institutions with the use of rituximab in patients with different clinical forms of lupus erythematosus systemic in activity. Methods : The study consisted of a sample of 17 patients with LES, who were already being treated, but that at some stage of the disease showed refractory symptoms. The patients were subdivided into groups according to the clinical manifestation, and the responses for the use of rituximab were rated as complete, partial or no response. Data were collected through a spreadsheet, and used specific parameters for each group. The treatment was carried on by using therapeutic dose of 1g, and repeating the infusion within an interval of 15 days. Results : The clinical responses to rituximab of the group only hematological and of the group only osteoarticular were complete in all cases. In the renal group there was a clinical complete response, two partial and one absent. In the renal and hematological group complete response, there was one death and a missing response. The pulmonary group presented a complete response and two partial. Conclusion : The present study demonstrated that rituximab can bring benefits to patients with lupus erythematosus systemic, with good tolerability and mild side effects; it presented, however, variable response according to the system affected. .

Objetivo : Relatar a experiência obtida em três instituições brasileiras com o uso do rituximabe em pacientes com diferentes formas clínicas de lúpus eritematoso sistêmico em atividade. Métodos : Estudo composto por amostra de 17 pacientes portadores de lúpus, que já faziam tratamento, mas que, em algum momento da evolução da doença, apresentaram sintomas refratários. Os pacientes foram subdivididos em grupos de acordo com o acometimento clínico que motivou o uso do imunobiológico, e a resposta ao uso do rituximabe foi classificada como completa, parcial ou ausente. Os dados foram coletados por meio de uma planilha padronizada, sendo utilizados parâmetros específicos para cada grupo. O tratamento foi padronizado com dose terapêutica de 1g, com repetição da infusão em um intervalo de 15 dias. Resultados : As respostas clínicas ao rituximabe dos grupos apenas hematológico e do apenas osteoarticular foi completa em todos os casos. No grupo renal, houve uma resposta clínica completa, duas parciais e uma ausente. No grupo renal e hematológico, houve uma resposta completa, um óbito e uma resposta ausente. O grupo pulmonar apresentou um caso de resposta clínica completa e dois parciais. Conclusão : O presente estudo demonstrou que rituximabe pode trazer benefícios aos pacientes com lúpus eritematoso sistêmico, com tolerabilidade boa e efeitos colaterais brandos, apresentando, contudo, resposta variável, de acordo com o sistema acometido. .