Recomendaciones sobre el manejo de pacientes adultos con enfermedades reumáticas en el contexto de la infección por SARS-CoV-2/COVID-19. Asociación Colombiana de Reumatología / Recommendations on the management of adult patients with rheumatic diseases in the context of SARS-CoV-2/COVID-19 infection. Colombian Association of Rheumatology

OBJETIVO: Generar las recomendaciones para la atención de pacientes con enfermedades reumáticas que reciben terapias inmunomoduladoras e inmunosupresoras (fármacos convencionales, biológicos y moléculas pequeñas) durante la pandemia por COVID-19. MATERIALES Y MÉTODOS: Las recomendaciones se realizaron utilizando el método Delphi como herramienta de acuerdo. Se conformó un panel de expertos con trayectoria académica y experiencia en investigación en reumatología. Se realizó la búsqueda de la literatura y se generó el cuestionario del ejercicio Delphi conformado por 42 preguntas. El grado de acuerdo se logró con el 80% de aprobación de los participantes. RESULTADOS: Se conformó un grupo de 11 reumatólogos de 7 ciudades del país. La tasa de respuesta fue del 100% para las 3 rondas de consulta. En la primera ronda se logró acuerdo en 35 preguntas, en la segunda ronda 37 y en la tercera ronda se logró el acuerdo de las 42 preguntas. CONCLUSIÓN: La recomendación para la mayoría de los tratamientos inmunomoduladores utilizados en reumatología es continuar con las terapias en pacientes que no tengan la infección y suspenderlas en aquellos con diagnóstico de SARS-CoV-2/COVID-19

OBJECTIVE: To produce recommendations for patients with rheumatological diseases receiving immunomodulatory and immunosuppressive therapies (conventional drugs, biologicals, and small molecules) during the COVID-19 pandemic. MATERIALS AND METHODS: The recommendations were determined using the Delphi method as an agreement tool. A panel of experts was formed, with academic backgrounds and research experience in rheumatology. A literature search was conducted and 42 questions were generated. The level of agreement was made with 80% of approval by the participants. RESULTS: A group of eleven rheumatologists from 7 cities in the country participated. The response rate was 100% for the three consultation rounds. In the first round, agreement was reached on 35 questions, on 37 in the second round, and on 42 questions in the third round. CONCLUSION: The recommendation for the majority of the pharmacological treatments used in rheumatology is to continue with immunomodulatory or immunosuppressive therapies in patients who do not have the infection, and to suspend it in patients with a diagnosis of SARS-CoV-2/COVID-19

Recomendaciones sobre el manejo de pacientes adultos con enfermedades reumáticas en el contexto de la infección por SARS-CoV-2/COVID-19. Asociación Colombiana de Reumatología / Recommendations on the management of adult patients with rheumatic diseases in the context of SARS-CoV-2/COVID-19 infection. Colombian Association of Rheumatology

RESUMEN Objetivo: Generar las recomendaciones para la atención de pacientes con enfermedades reumáticas que reciben terapias inmunomoduladoras e inmunosupresoras (fármacos convencionales, biológicos y moléculas pequeñas) durante la pandemia por COVID-19. Materiales y métodos: Las recomendaciones se realizaron utilizando el método Delphi como herramienta de acuerdo. Se conformó un panel de expertos con trayectoria académica y experiencia en investigación en reumatología. Se realizó la búsqueda de la literatura y se generó el cuestionario del ejercicio Delphi conformado por 42 preguntas. El grado de acuerdo se logró con el 80% de aprobación de los participantes. Resultados: Se conformó un grupo de 11 reumatólogos de 7 ciudades del país. La tasa de respuesta fue del 100% para las 3 rondas de consulta. En la primera ronda se logró acuerdo en 35 preguntas, en la segunda ronda 37 y en la tercera ronda se logró el acuerdo de las 42 preguntas. Conclusión: La recomendación para la mayoría de los tratamientos inmunomoduladores utilizados en reumatología es continuar con las terapias en pacientes que no tengan la infección y suspenderlas en aquellos con diagnóstico de SARS-CoV-2/COVID-19.

ABSTRACT Objective: To produce recommendations for patients with rheumatological diseases receiving immunomodulatory and immunosuppressive therapies (conventional drugs, biologicals, and small molecules) during the COVID-19 pandemic. Materials and methods: The recommendations were determined using the Delphi method as an agreement tool. A panel of experts was formed, with academic backgrounds and research experience in rheumatology. A literature search was conducted and 42 questions were generated. The level of agreement was made with 80% of approval by the participants. Results: A group of eleven rheumatologists from 7 cities in the country participated. The response rate was 100% for the three consultation rounds. In the first round, agreement was reached on 35 questions, on 37 in the second round, and on 42 questions in the third round. Conclusion: The recommendation for the majority of the pharmacological treatments used in rheumatology is to continue with immunomodulatory or immunosuppressive therapies in patients who do not have the infection, and to suspend it in patients with a diagnosis of SARS-CoV-2/COVID-19.

Recommendations on the management of adult patients with rheumatic diseases in the context of SARS-CoV-2/COVID-19 infection. Colombian Association of Rheumatology. / Recomendaciones sobre el manejo de pacientes adultos con enfermedades reumáticas en el contexto de la infección por SARS-CoV-2/COVID-19. Asociación Colombiana de Reumatología.

OBJECTIVE: To produce recommendations for patients with rheumatological diseases receiving immunomodulatory and immunosuppressive therapies (conventional drugs, biologicals, and small molecules) during the COVID-19 pandemic. MATERIALS AND METHODS: The recommendations were determined using the Delphi method as an agreement tool. A panel of experts was formed, with academic backgrounds and research experience in rheumatology. A literature search was conducted and 42 questions were generated. The level of agreement was made with 80% of approval by the participants. RESULTS: A group of eleven rheumatologists from 7 cities in the country participated. The response rate was 100% for the three consultation rounds. In the first round, agreement was reached on 35 questions, on 37 in the second round, and on 42 questions in the third round. CONCLUSION: The recommendation for the majority of the pharmacological treatments used in rheumatology is to continue with immunomodulatory or immunosuppressive therapies in patients who do not have the infection, and to suspend it in patients with a diagnosis of SARS-CoV-2/COVID-19.

Vértebra limbus, rara causa de dolor lumbar en jóvenes / Limbus vertebra as a rare cause of lumbar pain in young people

RESUMEN La vértebra limbus es una rara condición poco descrita en la literatura médica. Se caracteriza por una herniación marginal intracorporal del núcleo pulposo que resulta en la separación de un fragmento óseo de forma triangular. Usualmente se presenta en niños o adolescentes, principalmente en la columna lumbar, y ocasiona dolor que, en la mayoría de los casos, mejora con el tratamiento con antiinflamatorios.

A B S T R A C T The limbus vertebra is a rare condition poorly described in the medical literature. Marginal intrabody herniation of the nucleus pulposus resulting in the separation of a triangular bone fragment. It usually occurs in children or adolescents mainly in the lumbar spine and causes pain that in most cases improves with treatment with anti-inflammatories.

Eosinofilia y síntomas sistémicos por sulfasalazina / Sulphasalazine-induced eosinophilia and systemic symptoms: a case report

RESUMEN La reacción a drogas con eosinofilia y síntomas sistémicos es una condición debida a una lista extensa de medicaciones, entre las que se encuentra la sulfasalazina. El compromiso es muy variado, desde rash cutáneo hasta afectación visceral acompañado de eosinofilia, que en ocasiones puede llevar a la muerte. El pilar del tratamiento es la suspensión del medicamento agresor y el uso de corticosteroides orales e intravenosos dependiendo de la severidad del cuadro.

ABSTRACT Drugs reactions with eosinophilia and systemic symptoms can be caused by an extensive list of medications, including sulphasalazine. The compromise is very varied, from skin rash to visceral involvement, accompanied by an eosinophilia that can sometimes lead to death. The cornerstone of the treatment is the suspension of the aggressive medication and the use of oral and intravenous corticosteroids, depending on the severity of the condition.

Enfermedad de Camurati-Engelmann: reporte de un caso y revisión de la literatura / Camurati-Engelmann disease: case report and review of literature

La enfermedad de Camurati-Engelmann es una entidad poco común debida a mutaciones en el gen que codifica el TGF-(3. Se caracteriza por hiperostosis de huesos largos y cráneo, acompañada de dolor óseo intenso, ocasionalmente debilidad muscular, marcha de pato. El tratamiento se basa en el uso de glucocorticoides en dosis altas y en casos severos la descompresión quirúrgica está indicada. Desde nuestro conocimiento este es el primer caso reportado en Colombia

Camurati-Engelmann disease is a rare entity due to mutations in the gene encoding the TGF-(3. It is characterised by hyperostosis of long bones and skull, accompanied by severe bone pain, and occasionally muscular weakness and a waddling gait. The treatment is based on the use of high doses of glucocorticoids, and in severe cases surgical decompression is indicated. As far as we know, this is the first case reported in Colombia

[Peripheral corneal melting syndrome in psoriatic arthritis treated with adalimumab]. / Síndrome da ceratomalácia (Corneal Melting) periférica na artrite psoriásica tratada com adalimumabe.

Peripheral corneal melting syndrome is a rare immune condition characterized by marginal corneal thinning and sometimes perforation. It is associated with rheumatic and non-rheumatic diseases. Few cases of peripheral corneal melting have been reported in patients with psoriasis. The pathogenesis is not fully understood but metalloproteinases may play a pathogenic role. Anti-TNF therapy has shown to decrease skin and serum metalloproteinases levels in psoriasis. We report a 61-year-old man with peripheral corneal melting syndrome associated with psoriatic arthritis who received Adalimumab to control skin and ocular inflammation. To our knowledge, this is the first case report of peripheral corneal melting syndrome in psoriatic arthritis treated with Adalimumab showing resolution of skin lesions and complete healing of corneal perforation in three months.

Síndrome da ceratomalácia (Corneal Melting) periférica na artrite psoriásica tratada com adalimumabe / Peripheral corneal melting syndrome in psoriatic arthritis treated with adalimumab

RESUMOA síndrome do corneal melting periférica é uma rara condição imune caracterizada por afinamento da margem da córnea e, às vezes, perfuração. Está associada a doenças reumáticas e não reumáticas. Poucos casos de síndrome do corneal melting periférica foram relatados em pacientes com psoríase. A patogênese não foi completamente entendida, mas as metaloproteinases podem ter papel patogênico. A terapia Anti-TNF diminuiu os níveis de metaloproteinases na pele e no sangue em psoríase. Reportamos o caso de um homem de 61 anos com síndrome do corneal melting periférica associada à artrite psoriásica que recebeu adalimumabe para controlar a inflamação na pele e no olho. Pelo que sabemos, este é o primeiro caso de síndrome do corneal melting periférica em artrite psoriática tratado com adalimumabe mostrando evolução nas lesões cutâneas e cura total da perfuração da córnea em três meses.

ABSTRACTPeripheral corneal melting syndrome is a rare immune condition characterized by marginal corneal thinning and sometimes perforation. It is associated with rheumatic and non-rheumatic diseases. Few cases of peripheral corneal melting have been reported in patients with psoriasis. The pathogenesis is not fully understood but metalloproteinases may play a pathogenic role. Anti-TNF therapy has shown to decrease skin and serum metalloproteinases levels in psoriasis. We report a 61-year-old man with peripheral corneal melting syndrome associated with psoriatic arthritis who received adalimumab to control skin and ocular inflammation. To our knowledge, this is the first case report of peripheral corneal melting syndrome in psoriatic arthritis treated with adalimumab showing resolution of skin lesions and complete healing of corneal perforation in three months.

[Colonic perforation due to invasive amebic colitis during anti-TNF therapy for spondyloarthritis]. / Perfuração do colo por colite amebiana invasiva durante terapia anti-TNF para espondiloartrite(§)

TNF blockade has been successful in the treatment of some rheumatic diseases such as spondyloarthritis. Many infectious complications have been reported with anti-TNF therapy, mainly bacterial, mycobacterial, viral and fungal infections. Entamoeba histolytica is an extracellular protozoan parasite that mainly causes colitis and hepatic abscess; bowel perforation is an uncommon complication with high mortality. TNF is considered the principal mediator of cell immunity against amebiasis. Initially, it is chemotactic to E. histolytica, enhancing its adherence to enterocyte via galactose inhibitable lectin, and then activating macrophages to kill ameba though the release of NO, so that TNF blocking could be harmful, increasing amebic virulence. We describe the case of a 46-year-old woman with spondyloarthritis who presented a colonic perforation due to invasive amebic colitis during anti-TNF use.

Perfuração do colo por colite amebiana invasiva durante terapia anti-TNF para espondiloartrite / Colonic perforation due to invasive amebic colitis during anti-TNF therapy for spondyloarthritis

O bloqueio do TNF tem tido sucesso no tratamento de algumas doenças reumáticas, como a espondiloartrite. Relatam-se muitas complicações infecciosas com a terapia anti-TNF, principalmente infecções bacterianas, micobacterianas, virais e fúngicas. A Entamoeba histolytica é um protozoário extracelular que causa principalmente colite e abscesso hepático, sendo que a perfuração intestinal é uma complicação rara, com alta mortalidade. O TNF é considerado o principal mediador da imunidade celular contra a amebíase. Inicialmente, é quimiotático para a E. histolytica, potencializando sua adesão ao enterócito por meio da lectina galactose-inibível, e depois ativando os macrófagos para matarem a ameba pela liberação de NO; assim, o bloqueio do TNF poderia ser prejudicial, aumentando a virulência amebiana. Descreve-se o caso de uma mulher de 46 anos com espondiloartrite que apresentou uma perfuração do colo por colite amebiana invasiva durante uso de anti-TNF.

TNF blockade has been successful in the treatment of some rheumatic diseases such as spondyloarthritis. Many infectious complications have been reported with anti-TNF therapy, mainly bacterial, mycobacterial, viral and fungal infections. Entamoeba histolytica is an extracellular protozoan parasite that mainly causes colitis and hepatic abscess; bowel perforation is an uncommon complication with high mortality. TNF is considered the principal mediator of cell immunity against amebiasis. Initially, it is chemotactic to E. histolytica, enhancing its adherence to enterocyte via galactose inhibitable lectin, and then activating macrophages to kill ameba though the release of NO, so that TNF blocking could be harmful, increasing amebic virulence. We describe the case of a 46-year-old woman with spondyloarthritis who presented a colonic perforation due to invasive amebic colitis during anti-TNF use.

Complete heart block in ankylosing spondylitis.

Ankylosing spondylitis (AS) is a chronic rheumatic disease of young men that affects mainly the axial skeleton and is associated with HLA-B27 in 90% of the cases. Incidence of cardiovascular involvement in AS ranges between 10%-30%; conduction disturbances have been described in 1%-9% of the patients with AS. The majority of the series show a relationship with longstanding disease. To our knowledge, this is the first report of complete heart block in early AS.

Monoartritis aguda de rodilla como manifestación de fractura por estrés del platillo tibial / Acute knee monoarthritis as a manifestation of stress fracture of the tibial plateau

Las fracturas por estrés (FPE) pueden ocurrir en pacientes con hueso normal o metabólicamente débil. Habitualmente se presentan en personas deportistas o en aquellas que recientemente han cambiado la duración e intensidad del ejercicio. La síntomatología clínica a menudo se confunde con otras condiciones musculo-esqueléticas, por lo tanto la imaginología juega un papel crucial en el diagnóstico de esta patología. Se describe a continuación el caso de una mujer de 21 años, no deportista, que luego de un esfuerzo mínimo presentó una monoartritis de rodilla derecha de tipo hemorrágica, quien mediante una RNM se confirmó una FPE del platillo tibial.

Stress fractures may occur in patients with normal bone or metabolically weak. They usually present associated with sports or those who have recently changed the duration and intensity of exercise. The clinical symptoms are often mistaken with other musculoskeletal conditions, thus imaging plays a crucial role in the diagnosis of this condition. We describe the case of a woman of 21 years old, non-athlete who after a minimal effort presented a right knee monoarthritis hemorrhagic type, the MRI findings confirmed a stress fracture of the tibial plateau.

Vasculopatía livedoide debida a síndrome antifosfolípido / Livedoid vasculopathy due to antiphospholipid syndrome

La vasculopatía livedoide es una entidad rara y crónica que afecta predominantemente los miembros inferiores. La etiología de la enfermedad es desconocida, pero en la histopatología se observa trombosis en la dermis sin compromiso inflamatorio de la pared del vaso. Se manifiesta por lesiones petequiales y por ulceraciones que sanan con cicatrices hiperpigmentadas alternando con áreas blanquecinas. Se han empleado múltiples tratamientos hasta el momento, sin total éxito.

Livedoid vasculopathy is a rare, chronic disease that affects predominantly the lower limbs. The etiology of the disease is unknown, but histopathology shows thrombosis in the dermis without inflammatory changes in the vessel wall. It is manifested by petechial lesions and ulcerations that heal with scarring hyperpigmentation alternating with white areas. Multiple treatments have been used so far, without total success.

Gota y sus manifestaciones dermatológicas / Gout and its dermatological manifestations

La gota es la artritis más común en hombres entre los 40 y los 60 años de edad. Es causada por el depósito de cristales de urato monosódico en las articulaciones y en otros tejidos luego de un tiempo prolongado de hiperuricemia. Afecta al 1% de la población estadounidense adulta y su prevalencia se viene aumentando por el incremento en la longevidad y por el uso de diuréticos y ácido acetilsalicílico. La gota es considerada como una de las manifestaciones del síndrome metabólico. Por lo tanto, no es raro encontrar algunas manifestaciones cutáneas durante el curso de la enfermedad.

Evaluación económica del tratamiento de artritis reumatoide con terapia biológica anti TNF en Colombia / Economic evaluation of the treatment of rheumatoid arthritis with anti-TNF biological therapy in Colombia

Introducción: la artritis reumatoide (AR) es una enfermedad crónica de alto costo para el sistema de salud, en particular cuando se requiere terapia biológica. Objetivos: diseñar un modelo económico para la toma de decisiones entre adalimumab (ADA), etanercept (ETA) e infliximab (INF) en el contexto colombiano. Metodología: se diseñó un modelo de Markov, con un horizonte temporal de dos años, una perspectiva de un tercero pagador, que midiera efectividad clínica (en proporción de pacientes con respuesta ACR50 o mayor), abandono de terapia, eventos adversos, calidad de vida en AVAC (años de vida ajustados por calidad) y costos directos de tratamiento en pesos colombianos. Resultados: la suspensión de la terapia fue mayor para INF y menor para ETA. La ganancia en AVAC fue ligeramente más alta para ETA y para ADA que para INF. Los costos anuales promedio de la terapia con INF fueron $44.8 millones, para ADA $41.0 millones, y $39.0 millones para ETA. El costo promedio por mes logrado en ACR50 o superior fue de $9.37; $8.83 y $13.5 millones, respectivamente, para ADA, ETA e INF. Conclusiones: dadas las limitaciones y los supuestos del modelo, se podría concluir que, en el paciente colombiano "caso tipo" con AR, ETA es dominante sobre ADA e INF al tener un costo global total menor, y una efectividad superior a INF y por lo menos igual a la de ADA (Acta Med Colomb 2011; 36: 24-29).

Introduction: rheumatoid arthritis (RA) is a chronic illness that implies high direct and indirect costs for the health system, in particular when biological therapy is prescribed. Objectives: the aim of this study was to design an economic model for decision-making between adalimumab (ADA), etanercept (ETA) and infliximab (INF) in the Colombian context. Methods: we designed a Markov model with a time horizon of two years and a third party payer perspective, measuring the effectiveness (as proportion of patients with ACR50 response or better) discontinuation of therapy, adverse events, quality of life in QALY (quality adjusted life years) and direct cost represented in Colombian pesos (1 US$ = Col$1800 pesos, aprox). Results: discontinuation of therapy was highest for INF, and lowest for ETA. The gain in QALYs was somewhat higher for ETA and ADA, compared with INF. The total annual costs of the therapy with INF was $44.8 million, $41.0 million for ADA, and $39.0 for ETA. The cost per month with ACR50 or higher was $9.37; $8.83 and $13.5 million, respectively for ADA, ETA and INF. Conclusion: given the limitations and given the assumptions of this model, we conclude that in the average Colombian patient with AR, ETA is dominant over ADA and INF, by having a lower total cost and at least the same effectiveness as ADA and higher than INF (Acta Med Colomb 2011; 36: 24-29).

Calcinosis tumoral de rodilla / Tumoral calcinosis of the knee

La calcinosis tumoral o síndrome de Teutschlander es una condición benigna y rara caracterizada por la presencia de masas calcificadas de ubicación periarticular en la cadera, hombro, codo y menor frecuencia en pies, tobillos y rodillas. Se cree que hay una alteración genética en el GALNT3 y FGF23 que regulan la absorción renal de fosfato. Usualmente esta lesión es asintomática y rara vez puede dar síntomas producto de compresión de estructuras vecinas. La imaginología permite habitualmente realizar el diagnóstico. Hasta el momento no hay tratamiento médico exitoso y se sigue recomendando la escisión quirúrgica aunque hay recurrencias (Acta Med Colomb 2010; 35: 185-186).

Tumoral calcinosis or Teutschlander syndrome is a rare and benign condition characterized by the presence of calcified masses around the hip, elbow, and less frequently feet, ankles and knees. It is believed that there is a genetic alteration in GALNT3 and FGF23 which regulate the renal absorption of phosphate. Usually it is an asymptomatic lesion and occasionally it produces symptoms of compression to peripheral tissues. Imaging permits the diagnosis. There is no successful medical treatment and surgical excision is recommended although recurrences are frequent (Acta Med Colomb 2010; 35: 185-186).

Sinovitis villonodular pigmentaria. Revisión de la literatura a propósito de un caso / Pigmented villonodular synovitis. A case report and review of the literature

La sinovitis villonodular pigmentaria es una neoplasia benigna con proliferación sinovial y depósito de hemosiderina. Se presenta usualmente entre la tercera y cuarta década de la vida. Típicamente es monoarticular y puede afectar cualquier articulación, pero más frecuentemente compromete las grandes articulaciones de la extremidad inferior. El tratamiento se basa en la erradicación del tumor mediante cirugía o radioterapia.

Pigmented villonodular synovitis is a benign neoplasm with synovial proliferation and hemosiderin deposition. It occurs usually between 3th and 4th decades of life. Typically, it is monoarticular and can affect any joint but most commonly involves the large joints of the lower extremity. Treatment is based on the eradication of the tumor by surgery or radiotherapy.

Manifestaciones cutáneas de la dermatomiositis / Cutaneous manifestations of dermatomyositis

La dermatomiositis es una enfermedad que hace parte de las miopatías inflamatorias, cuyo hallazgo distintivo es la afectación cutánea. En la mayoría de los casos el compromiso cutáneo precede a la afección muscular; por lo tanto, es de vital importancia para el dermatólogo el reconocimiento de la manifestaciones cutáneas en dermatomiositis, con el fin de hacer un diagnóstico oportuno de la enfermedad y emprender un tratamiento efectivo para evitar complicaciones futuras.