A Study of Pulmonary Function Tests in Patients with Rheumatoid Arthritis and its Association with Disease Activity.

Rheumatoid arthritis is a chronic inflammatory disease of unknown etiology marked by a symmetrical peripheral polyarthritis. Because it is a systemic disease RA may result in a variety of extra articular manifestations, Pulmonary involvement is a well known extra-articular manifestation of RA which can have myriad presentations and might be the second cause of death after infection. Pulmonary function test(PFTs) are widely used to provide objective measure of lung function for detecting and quantifying impairment of pulmonary function in patients with cardiopulmonary diseases. Although lung disease secondary to pulmonary infection and/or drug toxicity are frequent complications, lung disease directly associated with the underlying RA is more common. Lung involvement in RA carries a worse prognosis. The early recognition of changes in PFT may be used as early marker of pulmonary involvement and help in limiting the mortality and morbidity caused by the disease. Hence need for the study. MATERIAL: Descriptive cross sectional study conducted on 100 cases. INCLUSION CRITERIA: Patients Aged 18-60 years diagnosed with RA according to American college of Rheumatology-European league against rheumatism classification criteria. EXCLUSION CRITERIA: Known smokers, Presence of prior pulmonary disease, Known case of other Collagen vascular diseases and History of pulmonary infection in the last 3 months. Disease activity assessed by both DAS28 and CDAI score. OBSERVATION: Mean age of cases was 43.57 years with 21% males and 79% females. 96% cases had normal FEV1/ FVC ratio with mean DAS28 of 5.12±0.8 and 4% cases had mild obstruction with mean DAS28 in mild restriction being 6.2±0.588. There was statistically significant difference in DAS28 in cases having mild restriction compared to normal cases (P-value=0.0066). Here, we also found that as severity of restrictive pattern increases there was no significant effect on DAS score (P-value=0.3221). But duration of disease and duration of methotrexate use increases as severity of restrictive pattern increases (P-value <0.0001). CONCLUSION: we conclude from our study that there was predominant prevalence of restrictive pattern of PFT in the patients with RA, pulmonary involvement had significant association with duration of disease and duration of methotrexate use, on the contrary disease activity does not have much influence on pulmonary involvement in the diseased individual. Hence PFT alone can't be used as lone modality for early detection of pulmonary involvement in rheumatoid arthritis, additional implementation of DLCO along with spirometry can be tried to assess early involvement of respiratory membrane.

Anaemia in Newly Diagnosed Patients of Rheumatoid Arthritis and its Correlation with Disease Activity.

Aim: To detect frequency of anemia in patients of Rheumatoid arthritis (RA) and to establish relationship between hemoglobin level and disease activity in RA. Method: Fifty nine patients of RA fulfilling 2010 ACR/EULAR criteria of RA having disease duration less than two years were included in the study. Haemoglobin (Hb) levels were measured. Disease activity was assessed by DAS-28 score. Results: Among 40/59 (67.80%) anemic cases, 22/40 (55%) patients had anaemia of chronic disease (ACD), 11/40 (27.50%) patients had Iron deficiency anemia (IDA), 3/40 (7.5%) patients had vitamin B(12) deficiency, 1/40 (2.50%) patient had folate deficiency and 3/40 (7.50%) patients had combined IDA and vitamin B(12) deficiency. Duration of disease, rheumatoid factor positivity and occurrence of erosive disease were not significantly different among anaemic and nonanaemic patients (p>0.05 for each). Mean ESR (p>0.02) and DAS-28 (p>0.001) were statistically significantly different among anaemic and nonanaemic patients. Haemoglobin level had significant negative correlation with disease activity (DAS28) in RA cases (r -0.5533, p<0.0001). Conclusion: Anemia was seen in higher frequency in RA patients. Haemoglobin had significantly negative correlation with disease activity (DAS 28) in RA. . Conclusion: Anemia was seen in higher frequency in RA patients. Haemoglobin had significantly negative correlation with disease activity (DAS 28) in RA.

Seroprevalence of Anti-Citrullinated Protein Antibodies (ACPA) in Patients with Rheumatic Diseases other than Rheumatoid Arthritis.

Objective: To evaluate the prevalence of anti- citrullinated protein antibodies (ACPA) in patients with a variety of rheumatic diseases other than rheumatoid arthritis (RA). Methods: 144 cases of rheumatic diseases other than rheumatoid arthritis (RA) over a period of 1 year were recruited after consenting and followed up for 2 years. Their serum samples were tested for ACPA. Results: ACPA seropositivity of 9.03% was observed in rheumatic diseases other than RA. Conclusion: Whether ACPA seropositivity in non-RA rheumatic diseases indicates a false positive result or an overlap RA syndrome is a mystery yet unsolved. Long term follow ups of these patients will be required to understand the course of rheumatic diseases in relation to ACPA..

Assessment of Pituitary Gonadal Axis and Sperm Parameters in Anemic Eugonadal Males Before and After Correction of Iron Deficiency Anemia.

ABSTRACT: :Iron deficiency anemia (IDA) is one of the most common nutritional anemia worldwide. Anemia imposes a significant hypoxic environment in different organs and tissues including the testes. This study evaluated the effect of treatment of IDA on the pituitary gonadal axis (Serum FSH, LH, Testosterone) and sperm parameters in adult eugonadal males. METHODOLOGY: A hospital based interventional, analytic study was conducted at a tertiary care center among 25 eugonadal males (fully sexually developed, fertile) with newly diagnosed and untreated IDA, admitted in medicine wards and not suffering from any inflammatory disorders (excluded by C-reactive protein) after exclusion of patients having other forms of anemia/ hemoglobinopathies/ any malignancy/having MCV >80 fL, aplastic anemia and primary hypogonadism. Sexual maturation was assessed according to maturity stages 5. Investigations were performed before and 6 weeks after treatment of IDA with intravenous iron sucrose included CBC, peripheral blood smear, serum ferritin, serum iron, TIBC, serum FSH, serum LH, serum Testosterone and semen analysis (Semen volume, Sperm count, Sperm motility and Sperm morphology). RESULTS: The change in mean Hb level before (5.66 ± 1.97gm/dl) and after treatment (11.96 ± 0.87 gm/dl) was statistically significant. (P<0.001) Patients who had subnormal and normal serum level of FSH, LH, Testosterone and sperm parameters before treatment were divided into group A and group B respectively. Serum levels of FSH, LH and testosterone along with sperm parameters significantly improved after correction of anemia (p<0.01). The mean change in these parameters was significantly higher in patients having subnormal value of these parameters before treatment (Group A) than in patients having normal pre-treatment level (Group B) (p<0.01). The level of anemia (hemoglobin) had significant positive correlation with serum FSH, serum LH, serum testosterone levels and sperm parameters (semen volume, sperm count, sperm morphology, RPM and sperm motility) (p<0.001). CONCLUSION: IDA had significant negative association with the pituitary gonadal axis (Serum FSH, LH, Testosterone) and sperm parameters in adult eugonadal males. The serum levels of FSH, LH and testosterone along with sperm parameters significantly improved after correction of anemia, especially in patients having subnormal value of these parameters.

Reticulocyte Hemoglobin Vis-À-Vis Immature Reticulocyte Fraction, as the earliest Indicator of Response to Therapy in Iron Deficiency Anemia.

AIM: To evaluate reticulocyte hemoglobin (RET-Hb) vis-à-vis immature reticulocyte fraction (IRF) as an earliest indicator of response to iron therapy in iron deficiency anemia (IDA), by assessing change in RET-He and IRF at 48 hours after initiation of intravenous iron therapy. MATERIAL AND METHODS: A hospital based interventional, analytic study was conducted among 144 patients (age group 15-65 years) with newly diagnosed and untreated IDA admitted in medicine ward and not suffering from any inflammatory disorders (excluded by C-reactive protein). Patient having other forms of anemia/hemoglobinopathies/ malignancy, MCV >80 fL and pregnant female were excluded. All patients were subjected to automated CBC, RET-He, iron studies and iron staining of bone marrow aspirates. Then intravenous iron sucrose was given along with oral antioxidants. After 48 hours, CBC, RET-He and IRF were repeated for each patient. RESULT: Total 144 patients were included. Of these, 42 patients were excluded due to aparticulate bone marrow aspirate. Remaining 102 patients were classified in to Group A (grade 0 and 1- depleted iron stores) and Group B (grade 2 and 3 - functional iron deficiency). RET-He and IRF increased significantly at 48 hours after initiation of intravenous iron therapy (post therapy) as compared to baseline (pre therapy) in both the two groups as well when all patients were considered together. Post therapy, the mean increase in RET-He was significantly smaller in magnitude in group B than in group A. The increase in IRF was not significantly different between the two groups. CONCLUSION: RET-Hb, a real time indicator of iron supply (hemoglobinization) to the developing RBC's, is the earliest marker of response to iron therapy as compared to IRF (representative of reticulocyte count).

Management of Pregnancy in Lupus Patients.

Systemic lupus erythematosus (SLE) mostly affects young women of reproductive age group. SLE patients may conceive as any normal woman but complication may occur in these patients if the disease is active. Pregnancy in SLE may lead to 1. Aggravation of SLE (Lupus flare) 2. Pre-term delivery, intrauterine growth retardation and foetal loss (in presence of antiphospholipid antibodies) 3. Neonatal lupus especially in presence of Anti-Ro / La antibody. For a successful pregnancy, both from maternal and foetal aspects, disease should be quiescent for at least six months before the conception. Lupus patients with pregnancy require specific management to improve the maternal and fetal outcomes. Many safe drugs are available for the management of pregnancy in SLE.

Stiff Person Syndrome.

Stiff-person syndrome or Moersch-Woltmann is a very rare and disabling neurologic disorder characterized by muscle rigidity and episodic spasms involving axial and limb musculature. It is an autoimmune disorder resulting in a malfunction of aminobutyric acid mediated inhibitory networks in the central nervous system. We describe a patient of stiff person syndrome.

Systemic Lupus Erythematosus with Deep Vein Thrombosis and Cutaneous Ulcer.

We are reporting a case of systemic lupus erythematosus (SLE) with left upper limb and lower limb deep vein thrombosis (DVT) due to protein S deficiency which was aggravated by anticoagulants. Oral anticoagulant-induced skin necrosis also developed in this patient. This patient was negative for anti-phospholipid antibodies (APLA). Such a case is rarity where SLE patient without APLA has protein S deficiency.

Peripheral Neuropathy in Systemic Lupus Erythematosus: Clinical and Electrophysiological Properties and their Association with Disease Activity Parameters.

AIM: To study clinical and electrophysiological properties of peripheral neuropathy (PN) in systemic lupus erythematosus (SLE) and their association with disease activity parameters. METHODS: A hospital-based observational study done among 50 SLE patients after informed consent. History and clinical examination including a detailed neurological examination was carried out. Blood and urine investigation were done and modified SLE disease activity index (SLEDAI)-2000 score was calculated. RESULTS: PN was found in 18 out of 50 (36%) SLE cases as defined electrophysiologically, nine had clinical and nine had subclinical neuropathy. On nerve conduction studies (NCS) 17 patients had axonal pattern. There were significant difference for mean ESR in patients with neuropathy (64.17 ± 42.43 mm/1st hour) and without neuropathy (42.34 ± 27.68 mm/1st hour) (P 0.033) and for mean modified SLEDAI-2000 of patients with neuropathy (15.61 ± 10.09) and without neuropathy (6.84 ± 6.16) (P < 0.05). CONCLUSIONS: The study suggests significant association of peripheral neuropathy in SLE patients with ESR, modified SLEDAI-2000, pyuria, pleurisy and leucopenia.

Carotid intima media thickness as a marker of atherosclerosis in ankylosing spondylitis.

Aim. Increased cardiovascular morbidity and mortality have been observed in ankylosing spondylitis because of accelerated atherosclerosis. We measured carotid intima media thickness (CIMT) as a surrogate marker of atherosclerosis in this study. Methods. In this study 37 cases of AS and the same number of matched individuals were recruited. CIMT measurements were done using B-mode ultrasound. Disease activity was assessed using Bath ankylosing spondylitis disease activity index (BASDAI), Bath ankylosing spondylitis functional index (BASFI), and Bath ankylosing spondylitis metrological index (BASMI) scores and C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels. Results. Mean age of the study groups was 29.43 ± 9.00 years. Average disease duration was 65.62 ± 54.92 months. Twenty-eight (75.68%) of cases were HLA B-27 positive. A significantly increased CIMT was observed in cases as compared to control group (0.62 ± 0.12 versus 0.54 ± 0.04; P < 0.001). CIMT in the cases group positively correlated with age (r = 0.357; P < 0.05), duration of disease (r = 0.549; P < 0.01), and BASMI (r = 0.337; P < 0.05) and negatively correlated with ESR (r = -0.295; P < 0.05). Conclusions. Patients of AS had a higher CIMT than those of the control group. CIMT correlated with disease chronicity.

Estimation of vitamin D levels in rheumatoid arthritis patients and its correlation with the disease activity.

AIM: To detect level of serum vitamin D in patients of Rheumatoid arthritis (RA) and to establish relationship between serum vitamin D level and disease activity in RA. METHOD: Eighty patients of RA fulfilling 1987 revised criteria of the American College of Rheumatology (ACR) of RA classification and eighty healthy controls were included in the study. 25 (OH) vitamin D levels were measured. Disease activity was assessed by DAS-28 score. RESULTS: Ninety percent of RA patients were either vitamin D deficient or insufficient while only seventy percent of healthy controls were either vitamin D deficient or insufficient(p=0.007). Mean serum vitamin D levels of RA patients was significantly low compared to healthy controls (p=0.009). Thirty-one patients had high disease activity (DAS-28 score >5.1, group A), 32 patients had moderate disease activity (DAS 28 score 3.2-5.1, group B) and 17 patients had low disease activity (DAS-28 score <3.2, group C). Vitamin D levels in high disease activity group was significantly low compared to vitamin D level in patients with low and moderate disease activity (p<.001) and vitamin D level had significant negative correlation with DAS28 score (r=-0.604, p<0.001). CONCLUSION: Serum vitamin D levels were significantly low in RA patients than in healthy controls. Vitamin D deficiency was seen in significantly higher numbers of patients and vitamin D had negative correlation with disease activity in RA.

Familial juvenile hyperuricemic nephropathy 1 (FJHN1).

Familial juvenile hyperuricemic nephropathy 1 (FJHN1) is an autosomal dominant disorder characterized by decreased urinary excretion of urate and hyperuricemia, followed by the development of chronic interstitial nephritis most often leading to progressive renal failure and death in middle age. We report a case of FJHN1 presenting as chronic tophaceous gout, hypertension, renal failure and a family history suggestive of autosomal dominant inheritance, for its rarity.