Challenging in leprosy relapse with antiphospholipid syndrome diagnosis: A case report.

Key Clinical Message: Infectious diseases like leprosy can cause antiphospholipid antibodies, leading to blood clots. Clinicians should consider this for patients with unusual thrombotic events and prior infectious disease history. Abstract: This case report details the diagnostic challenge of a 42-year-old man with a history of treated leprosy who presented with clinical features suggestive of antiphospholipid syndrome (APS). Vascular angiography revealed thrombosis, and serological tests were positive for APS antibodies. However, the patient subsequently developed symptoms, including thenar atrophy, paresthesia, and hypopigmented skin patches, which prompted further investigation. Electromyography detected sensorimotor polyneuropathy, while a nerve biopsy indicated a resurgence or chronic presence of leprosy. Despite initial APS management, the case evolved into a leprosy relapse confirmation after 20 years of remission, underscoring the diagnostic intricacies when concurrent autoimmune antibodies and infectious disease manifestations are present. This report emphasizes the importance of considering a broad differential diagnosis, including the potential for infectious disease relapse, in the presence of antiphospholipid antibodies. It illustrates the necessity of an interdisciplinary treatment approach in complex clinical scenarios.

Cognitive determinants of weight control by dietary patterns among postmenopausal women with osteoporosis: An application of theory of planned behavior.

Background: In this study, we aimed to assess the cognitive determinants of weight control behaviors by dietary patterns among postmenopausal women with osteoporosis. Methods: This cross-sectional study, based on the theory of planned behavior (TPB) was conducted from July to December 2017 among 240 postmenopausal women with osteoporosis in Tabriz, Iran. A validated and reliable TPB-based instrument, namely Weight-CuRB, and the food frequency questionnaire (FFQ) were used. Results: The results of exploratory factor analysis (EFA) indicated three dietary patterns (total variance explained=24.44%); healthy (n=71), mixed (n=78), and western (n=91). In addition, food items consumed by participants were classified into twenty-two food groups for dietary pattern analysis. In the healthy and western dietary patterns, attitude (ß: 0.140, P <0.001) and subjective norms (SNs) (ß: 0.498, P <0.01) were the only predictors of weight control behavior, respectively. In the women with healthy and western patterns, the TPB-based variables altogether explained 11% and 16% of variations in the behavior, respectively. Among all patients, the TPB-based variables explained 12.2% of variations in weight control behavior, within which SNs were the only significant predictor of the behavior (ß=-0.199, P <0.01). Conclusion: Our findings highlighted the remarkable role of dietary patterns in the associations between weight control and its cognitive determinants. Dietary patterns should be considered while designing weight control educational interventions among women with osteoporosis. In such interventions, promoting SNs and perceived behavioral control (PBC) should be considered as the core strategies to promote the behaviors among the patients who follow an unhealthy diet.

Clinical Significance of Anti-Modified Citrullinated Vimentin Antibodies in Palindromic Rheumatism.

OBJECTIVE: This study evaluated anti-modified citrullinated vimentin (anti-MCV) performance in determining the clinical picture and outcomes of palindromic rheumatism (PR). METHODS: In a retrospective study, patients with PR with at least 1 year of follow-up diagnosed according to clinical criteria were enrolled. Anti-MCV antibodies were measured, and levels >20 IU/mL were considered positive. Disease prognosis was assessed according to patients acquiring remission and preventing PR from developing into rheumatoid arthritis (RA) or other diseases. RESULTS: Seventy-six patients with PR with a mean follow-up of 30.57 months (median = 21 months; minimum = 12 months; maximum = 48 months) were included in the study. Anti-MCV antibodies were positive in 69.7% of patients. Metacarpophalangeal (MCP) joint involvement and positive anti-cyclic citrullinated peptides were significantly higher in patients who were anti-MCV-positive, whereas ankle joint involvement was significantly lower. No significant correlation was observed between the anti-MCV titer and the severity of attacks. Remission in patients who were anti-MCV-positive and negative was 75.5% and 78.3%, respectively, with no significant difference. Evolution to RA was observed in only 3.8% of patients who were anti-MCV-positive. No patients who were anti-MCV-negative developed RA. CONCLUSION: Except for MCP and ankle joint involvement, anti-MCV was not helpful in determining the clinical picture and outcome of PR.

Evaluation of DNA methylation status of toll-like receptors 2 and 4 promoters in Behcet's disease.

BACKGROUND: Altered innate immune function plays an important role in the initiation of inflammatory response in Behcet's disease (BD). Toll-like receptors (TLRs) are the master regulators of the innate immune system. Because the role of TLRs remains unknown in the pathogenesis of BD, the present study aimed to evaluate the expression levels and methylation status of the TLR2 and TLR4 promoters in patients with BD. METHODS: In the present study, Iranian Azeri BD patients (n = 47) with an active (n = 22) and inactive (n = 25) period, and healthy controls (n = 61), were matched according to age, sex and ethnicity. TLR2 and TLR4 genes promoter CpG islands were predicted with the Eukaryotic Promoter Database (https://epd.vital-it.ch). Methylated DNA immunoprecipitation (MeDIP) was conducted. RESULTS: The results showed that mRNA of TLR4 was significantly increased in the peripheral blood mononuclear cells (PBMCs) of BD patients with an active phase compared to the control group. Differences in mRNA of TLR4 between the inactive BD and control groups were not significant. Differences in TLR2 mRNA levels in the PBMCs of the active and inactive phase BD and control groups were not significant. The methylation rate of TLR4 gene promoter was significantly lower in the active and inactive BD groups compared to the control group. The difference between the active and inactive BD groups was not significant. There was no significant difference in the methylation rates of the TLR2 gene between studied groups. CONCLUSIONS: Our preliminary findings suggest that the hypomethylation of TLR4 gene may be involved in the pathogenesis of BD via increasing TLR4 expression.

Clinical characteristics and long-term outcome of Takayasu arteritis in Iran: a multicentre study

Background/aim: This study aimed to evaluate the demographic, clinical, angiographic and prognostic characteristics of Takayasu arteritis (TA) in Iran. Materials and methods: A total of 75 patients with TA based on the American College of Rheumatology 1990 criteria for TA classification referred to the Rheumatology Centres, were followed-up from 1989 to 2019. Demographic, clinical, angiographic and prognostic characteristics were collected at baseline and last visit. Results: The mean age was 31.9 ± 9.8 years at the disease onset. Female to male ratio was 14. The median latency in diagnosis was 24 months. Pulse discrepancy in the arms, blood pressure discrepancy in the arms, limb claudication, hypertension and constitutional symptoms were the most common clinical features. The most common angiographic type at the time of diagnosis was Type I (42.7%). The most frequent arterial lesion was stenosis (89.4%). Subclavian, carotid and aortic arteries were the most commonly involved arteries. New lesions developed in 28.6% of patients during the 5.25-year follow-up. Vasculitis-induced chronic damage was observed in all patients. Disease activity decreased and vascular damage remained stable throughout the follow-up period. Conclusions: The clinical features and angiographic type of TA in Iran are different from most Asian countries. Differences in angiographic and clinical features may lead to delayed diagnosis. The issue of delay in diagnosis should create awareness among health care providers that TA is not a very rare disease in Iranians and failure to pay attention to warning symptoms may delay the diagnosis.

Development and validation of a theory of planned behavior-based weight control behavior questionnaire among postmenopausal women with osteoporosis.

Our aim was to develop a framework-based weight control behavior questionnaire (Weight-CuRB) and test its psychometric properties among a non-probability sample of 240 postmenopausal women with osteoporosis. Appropriate validity, simplicity, functionality and reliability were observed for the Weight-CuRB. The explanatory model fits the data well (χ2 [139] = 245.835, p < .001, CFI = 0.950, NFI = 0.901, IFI = 0.950, RMSEA = 0.057[(0.045-0.068]). To our knowledge, this was the first study to develop and validate a framework-based instrument aiming at cognitive needs assessment of postmenopausal women with osteoporosis. The weight-CuRB may be useful in addressing the core cognitive determinants of weight control among the patients.

Does vitamin D deficiency contribute to higher disease activity in patients with spondyloarthritis?

INTRODUCTION: This study aimed to compare serum vitamin D levels in Spondyloarthritis (SpA) patients and control group and to evaluate the associations between vitamin D and disease activity in SpA patients. METHODOLOGY: In this study, 86 SpA patients according to the International Criteria and 117 age and sex-matched healthy controls were included. In patients, clinical examination was performed and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) were recorded. Serum 25(OH)D3 concentration was measured using ELISA kit. RESULTS: Serum 25(OH)D3 levels in SpA patients were significantly lower than healthy controls (p < 0.001). Vitamin D deficiency and insufficiency frequency in the SpA group was significantly more than control group (p < 0.001). No significant difference was observed in the activity of SpA in different serum levels of 25(OH)D. Also, no significant correlations were observed between serum 25(OH)D3 with clinical findings as well as with BASDAI and BASFI (P > 0.05). DISCUSSION AND CONCLUSION: Although our study revealed lower serum 25(OH)D3 levels in SpA patients compared to healthy controls, there were not any significant correlations between its serum levels with severity of disease. However, correction of vitamin D status may be beneficial in controlling inflammation and disease activity.

Oral administration of alpha-lipoic acid did not affect lipid peroxidation and antioxidant biomarkers in rheumatoid arthritis patients.

Rheumatoid arthritis (RA) is a chronic inflammatory disease in which oxidative stress could play a substantial pathological role. Alpha-lipoic acid (ALA) has been known as a "universal" and "ideal" antioxidant. The purpose of this study was to investigate the effects of oral administration of Alpha-lipoic acid (ALA) on lipid peroxidation and antioxidant biomarkers in Rheumatoid arthritis (RA) patients. The study was a randomized, double-blinded, placebo-controlled clinical trial. 70 RA patients were randomized 1:1 to two groups using blocked randomization method and received 1200 mg/day ALA or placebo for 8 weeks. Fasting blood samples were obtained before and after the intervention to analyze total antioxidant capacity (TAC), antioxidant enzymes [superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and arylesterase (ARE) activities] and malondialdehyde (MDA). We observed significant increase in serum TAC (0.11 mmol/L; p=0.033) and ARE (13.76 U/mL; p=0.046) and significant decline in MDA (-0.36 nmol/L; p=0.002), in ALA group. However, these changes in ALA-treated group were not statistically significant when compared with placebo-treated group (p > 0.05). Also, within- and between-group differences of whole blood SOD and GSH-Px were not statistically significant (p > 0.05). In conclusion, unexpectedly, ALA therapy did not affect the oxidative status of RA patients in the present clinical trial. It seems that more comprehensive clinical trials in RA patients are still warranted to clarify the effectiveness of ALA which has been known as a potent antioxidant.

Determination of mir-155 and mir-146a expression rates and its association with expression level of TNF-α and CTLA4 genes in patients with Behcet's disease.

INTRODUCTION: MicroRNAs (miRNAs) are involved in the pathogenesis of inflammatory diseases. MiR-146 and miR-155 emerged as key regulators of the immune response. This study designed to analyze the miR-146a and miR-155 expression in patients with Behcet's disease (BD) and investigated their association with the expression of tumor necrosis factor-alpha (TNF-α) and cytotoxic T lymphocyte associated antigen-4 (CTLA-4) genes. METHODOLOGY: In a case-control study, 47 Iranian Azeri BD patients and 61 age- and sex matched healthy controls recruited to the study. Peripheral blood mononuclear cells (PBMCs) were isolated from EDTA blood tubes by Ficoll density-gradient centrifugation. Genomic DNA samples of BD and healthy controls were extracted using the rapid genomic DNA extraction method from the peripheral blood collected in tubes containing EDTA. Total RNA was extracted from the PBMCs according to the TRIzol protocol. MiR-146a, miR-155, TNF-α and CTLA-4 expression were studied using real-time PCR. RESULTS: MiR-155 and TNF-α expression was significantly increased, whilst CTLA-4 expression was significantly decreased in the PBMCs of BD patients. There was no significant difference in the miR-146a expression rate between BD patients and controls. A positive correlation between miR-155 and TNF-α expression and negative correlation between miR-155 and CTLA-4 expression were observed. No significant association was observed between the expression of miR-155, miR-146a, TNF-α and CTLA-4 genes with BD activity. MiR-155 and miR-146a expression rate were significantly higher in patients with uveitis and phlebitis, respectively. DISCUSSION AND CONCLUSION: The expression of miR-155 increased in BD and associated with upregulation of TNF-α and downregulation of CTLA-4 genes.

Efficacy and Safety of Mycophenolate Mofetil Versus Intravenous Pulse Cyclophosphamide as Induction Therapy in Proliferative Lupus Nephritis.

INTRODUCTION: Lupus nephritis is a common and severe manifestation of systemic lupus erythematosus that can lead to end-stage renal disease and death. The aim of this study was to compare the efficacy and safety of mycophenolate mofetil (MMF) and cyclophosphamide as induction therapy and subsequently as maintenance therapy for lupus nephritis. MATERIALS AND METHODS: In this retrospective case-control study, 67 patients with proliferative lupus nephritis who were treated with MMF (n = 45) and pulse of intravenous cyclophosphamide (n = 22) were included. Remission of the kidney disease, mortality, and adverse events were evaluated and compared between the two groups. RESULTS: The 45 patients treated with MMF had a mean age of 33.8 ± 10.6 years and 17.1% of them were males. The 22 patients treated with pulse of intravenous cyclophosphamide had a mean age of  38.1 ± 11.1 years and 18.2% of them were males. Complete and partial kidney remission occurred in 40% and 42.2% of the patients treated with MMF and in 31.8% and 59.1% of the patients treated with cyclophosphamide, respectively. No significant differences were observed in complete and partial remission between the two groups. No mortality was reported in the studied patients. There were no significant differences in the frequency of adverse events between the two groups. CONCLUSIONS: The efficacy of MMF in long-term treatment of lupus nephritis was comparable to that of cyclophosphamide, and there is no significant differences in the rate of side effects between the two regimens.

Long-term follow-up of 76 Iranian patients with idiopathic inflammatory myopathies.

AIM: This study aimed to follow up patients with polymyositis (PM) and/or dermatomyositis (DM) to determine survival rate, pattern of disease, response to treatment, malignancy incidence and poor prognostic factors (PPFs). METHOD: A total of 76 patients with PM (n = 47) and/or DM (n = 29) based on Bohan and Peter diagnostic criteria referred to the Imam-Reza Hospital were followed up from 2004 to 2016. The follow-up period was considered from diagnosis to patient's death or last visit. All patients underwent physical examinations and data including age, sex, disease duration, disease subtype, pattern of disease, PPFs and malignancy incidence were collected. RESULTS: Mean age at diagnosis was 45.49 ± 10.88 years and women were predominant (84.2%). Course of disease in the majority of patients (52.6%) was polyphasic, followed by monophasic (31.6%) and chronic-progressive (5.3%). The 1-, 5- and 10-year survival rates were 96%, 93% and 92%, respectively. Delay in treatment and dysphagia were common PPFs in the present study. The majority of patients responded to treatment (88.2%) and there were significant differences in cancer and dysphagia between responders and non-responders to treatment (P < 0.05). The most common cause of death was cancer in four of eight deaths. There was significant difference in survival rates between patients with and without pulmonary involvement (P = 0.001). Moreover, the survival rates were significantly lower in patients with malignancy (P = 0.001). CONCLUSION: Presence of dysphagia and cancer were associated with poor response to treatment. Pulmonary involvement and cancer incidence significantly affect survival rate. Furthermore, since cancer is the most common cause of death, so this study emphasizes the importance of careful cancer screening in these patients.

Effectiveness of self-management program on arthritis symptoms among older women: A randomized controlled trial study.

We aimed to determine the effectiveness of a self-management program amongst older women with rheumatoid arthritis. The intervention group (n = 40) received a six-week arthritis self-management program. Assessments were recorded prior to and after the program using a demographic questionnaire, Visual Analogue Scale, Arthritis Self-Efficacy Scale, and self- reported questions regarding mobility. Significant improvements in self-efficacy for functional ability and pain management were found in the intervention group compared to those before the intervention and the control group. Our trial indicates that the program used in conjunction with exercise interventions for aged patients may lead to benefits perceived self-efficacy.

Vitamin K1 Supplementation Did Not Alter Inflammatory Markers and Clinical Status in Patients with Rheumatoid Arthritis.

Background: Rheumatoid arthritis (RA) is an inflammatory disorder in which the disease severity might be decreased by anti-inflammatory agents. There are several lines of evidence which support anti-inflammatory effects of vitamin K. The aim of this study was to examine whether vitamin K is a useful strategy for reducing inflammation in RA subjects. Materials and methods: In this double-blind placebo controlled trial, 58 patients with definitive RA were randomly allocated into two groups to receive vitamin K1 as phylloquinone [10 mg/day] or placebo pills for 8 weeks. Clinical status using disease activity score-28 (DAS-28) and serum concentrations of some inflammatory markers (IL-6, hs-CRP, TNFα) were assessed at baseline and at the end of intervention. Results: There were no significant differences between the two groups regarding any of the baseline characteristics. In the vitamin K1 group, a 27 % decrease in serum levels of IL-6 (P = 0.006) and a 13 % decrease in DAS-28 (P = 0.041) were observed. However, after adjusting for relevant confounders, i. e.; duration of RA, intake of folic acid supplements, energy intake, weight and baseline values of each variable, by comparing the two groups, we found no significant reduction in these markers. Conclusion: Vitamin K1 supplementation at 10 mg/day for 8 weeks had no significant effects on blood biomarkers of inflammation and disease severity of patients with rheumatoid arthritis compared with the placebo group.

Demographic and clinical features of Behcet's disease in Azerbaijan.

AIM: Behcet's disease (BD) is a multisystem inflammatory disease characterized by recurrent aphthous ulcers, genital ulcers and uveitis. Demographic and clinical features of BD are different in various countries. Due to these ethnic discrepancies, we decided to consider the clinical picture of BD in the Azeri population of Iran and compare it with other ethnic groups. METHODS: This cross-sectional cohort study was carried out at the Connective Tissue Diseases Research Center of Tabriz University of Medical Sciences, Tabriz, Iran from 2006 to 2013. We considered the demographic and clinical findings in 166 patients with BD. Disease activity was measured by the Iranian Behcet's Disease Dynamic Activity Measure (IBDDAM) and Total Inflammatory Activity Index (TIAI). RESULTS: The male-to-female ratio was 1.7 : 1.0; the age of disease onset was 25.8 ± 8.9 years. Recurrent oral aphthous ulcers were the initial manifestations of BD in 83.1% of patients. Panophthalmitis and panuveitis were the most common ophthalmic manifestations of disease. Blindness occurred in 7.1% of patients. This study showed no difference between the two genders in mean age of disease onset and clinical manifestations. However, IBDDAM in men was higher than women. Retinal vasculitis in men was more common than women. CONCLUSIONS: BD in the Azeri population of Iran starts in the third decade and has a male predominance. The activity of the disease and retinal vasculitis in men is more predominant than women in Azerbaijan.

Adherence to treatment in patients with Behçet's disease.

AIM: Behçet's disease (BD) is a chronic, inflammatory disease with multisystem involvement. Adherence to treatment is low in chronic diseases as well as inflammatory and autoimmune diseases. This study assessed factors associated with non-adherence to treatment in patients with BD. METHODS: All the patients with BD who visited in the outpatient clinic of Connective Tissue Diseases Research Center in Tabriz University of Medical Sciences were included in the study. Adherence to treatment was evaluated by the consideration of medication compliance and appointment-keeping behavior. The relationships between adherence rate and six groups of variables were examined. A regression analysis was performed. RESULTS: A total of 137 patients (84 male and 53 female) were included. Totally, 50.7% of the patients were non-adherent to treatment. Side effects of medications and the high cost of treatment were the most frequent causes of non-adherence. Non-adherence was significantly more common in men, patients with low income, patients who were unaware of the disease complications, employed persons, and in patients who were on treatment with non-steroidal anti-inflammatory drugs (NSAIDs). CONCLUSIONS: Non-adherence is common in patients with BD. Male sex, low income, low knowledge about the disease, being employed and being on treatment with NSAIDs are the main risk factors for non-adherence.

Prevalence of musculoskeletal disorders in Azar cohort population in Northwest of Iran.

Musculoskeletal disorders (MSDs) are considered as major public health problems. The purpose of this study was to determine the prevalence of MSDs in Azar cohort population in northwest of Iran. Azar cohort study is a state level of a national cohort project (PERSIAN) which began in 2014. All adults over 35 years old in Khamene city in East Azarbaijan province were recruited for the pilot phase of the Azar cohort. For the purpose of the current study, a total of 952 subjects age range of 35-70 who completed the Community Oriented Program for the Control of Rheumatic Disease (COPCORD) questionnaire as supplementary were included. 299 subjects had MSDs and were introduced to the rheumatologist, only 237 of them referred for further assessment. 33.4% of subjects had MSDs within the past 7 days. The most frequent complaint was pain and the most common sites of complaints were knee, lumbar spine, and shoulder, respectively. Osteoarthritis was the most common rheumatic disease (53.2%) and the knee was the most common region affected (47.7%) followed by low back pain (28.2%). Osteoarthritis and knee osteoarthritis were present in 56.1 and 51.8% of females and 46.6 and 38.4% of males, respectively. Furthermore, low back pain was present in 32.9% of males and 26.2% of females. Peri-arthritis was more prevalent in males (12.3%), whilst fibromyalgia, psychologic pain, and heel spur were prevalent among females (9.1, 5.1, and 1.2%, respectively). Rheumatoid arthritis was observed in 1.4% of males and 1.8% of females, respectively. Prevalence of MSDs is very high in this area. Therefore, it calls for action by heath officials and professionals to plan for appropriate programs of prevention and management of MSDs in society.

A double-blind randomized comparative study of triamcinolone hexacetonide and dexamethasone intra-articular injection for the treatment of knee joint arthritis in rheumatoid arthritis.

Intra-articular glucocorticoid (GC) injection has been used for more than half a century in the treatment of refractory synovitis in patients with rheumatoid arthritis (RA). There are limited data about the efficacy of intra-articular injection of various preparations of GCs on inflamed joint. The aim of this study was to compare the efficacy and side effects of intra-articular injection of dexamethasone (DEX) and triamcinolone hexacetonide (TH) in the treatment of knee joint arthritis in RA. In a double-blind randomized clinical trial, 70 patients with RA and knee joint arthritis were recruited to the study. Swelled knee joints were injected with 40 mg TH or 8 mg DEX randomly. The primary outcome measures were reduction of knee joint swelling and pain 1 and 3 weeks after joint injection. The secondary outcome measures were relapse of knee arthritis at 2, 4, and 6 months after injection and side effects of intra-articular injection. Difference in the knee circumferences between DEX and TH groups at weeks 1 and 3 was not significant. The average times of pain reduction after injection were 3.4 ± 2.3 and 2.3 ± 1.8 days in TH and DEX, respectively. There were no differences of knee pain between the two groups. Relapse of knee arthritis was occurred in two (6.7 %) and three (9.4 %) patients in the DEX and TH groups, respectively. Intra-articular injection of DEX like TH causes rapid and long-term reduction of knee pain and swelling in patients with RA and is safe.

Long-term efficacy and safety of interferon α-2a therapy in severe refractory ophthalmic Behcet's disease.

Ophthalmic involvement is the most debilitating complication of Behcet's disease (BD). The aim of the current study is to report on the efficacy and safety of a long-term use of interferon alpha-2a (IFNα-2a) in the treatment of refractory ophthalmic BD in the Azari population of Iran. We retrospectively analyzed the clinical data of 12 patients with ophthalmic BD who were under IFNα-2a therapy. All these patients had previously been treated unsuccessfully with corticosteroid and at least one conventional immunosuppressive drug. IFNα-2a was administered at a daily dose of 6 million IU (MIU). After controlling the symptoms, a dose of 6 MIU three times per week was applied for 8-12 weeks, and then, a dose of 3 MIU was administered three times per week as a subcutaneous injection. Visual acuity and total inflammatory activity index (TIAI) were used in order to assess the response to the treatment. Response to the treatment and complete eye remission were obtained in 10 (83.3 %) and 7 (58.3 %) patients, irrespectively. Improvement or stabilization of visual acuity was observed in 18 (81.8 %) out of 22 eyes. After a mean period of 29.6 months, the use of IFNa-2a was discontinued in eight (66.7 %) patients. Unaltered vision for 2 years after IFNa-2a discontinuation happened in eight (100 %) patients. IFNa-2a is probably effective and safe in the treatment of refractory sight-threatening ophthalmic BD in the Azari population of Iran.