Predictors of inflammatory arthritis among new rheumatology referrals: a cross-sectional study.

Objectives: Early diagnosis and treatment of inflammatory arthritis (IA) is essential to optimize disease control. We aimed to identify variables that distinguish IA from non-inflammatory arthropathy by performing a cross-sectional study of rheumatology referral letters and visit records. Further work describes time to assessment and documentation of variables within referral letters. Methods: We reviewed rheumatology referral letters and new patient visits over a 6-month period. The diagnosis of IA was based on the clinical judgement of the assessing rheumatologist. IA diagnoses included RA, SpAs, unspecified IA, PMR, crystalline arthropathies and remitting seronegative symmetrical synovitis with pitting oedema. Univariate analysis was performed for each variable. Multivariable logistic regression was performed on statistically significant variables. Results: Of 697 patients referred for arthralgia, 25.7% were diagnosed with IA. Variables predictive of IA included tenderness and swelling on examination and ≥1 h of morning stiffness. Increasing arthralgia duration, fatigue and brain fog were negative predictors. The median time from referral to IA diagnosis was 55 days and 20.7% of these patients were seen within 6 weeks. Among referral letters, documentation of arthralgia duration, morning stiffness or joint examination findings was uncommon (31%, 20.5% and 56.7%, respectively). Conclusion: We identified positive and negative predictors of IA. Referral letters often missed key information required for the triaging process. Future efforts will be directed towards build a triaging tool to improve the referral quality and capture of those patients with IA who need earlier access to rheumatology care.

Neurosarcoidosis: Phenotypes, Approach to Diagnosis and Treatment.

PURPOSE OF REVIEW: The aim of this review is to provide an update of clinical presentation, diagnosis, differential diagnoses, and treatment according to recent evidence. RECENT FINDINGS: Neurosarcoidosis remains a diagnosis of exclusion, with infectious and malignant etiologies recognized as important mimickers. Corticosteroids remain as first-line therapy. In recent years, however, studies have demonstrated the effectiveness of anti-tumor necrosis factor (anti-TNF) therapy in the treatment of neurosarcoidosis, leading to improved outcomes. Neurosarcoidosis is a granulomatous disease with protean manifestations that may affect any part of the central and peripheral nervous system. It has many mimickers, and potentially devastating complications necessitating long-term follow-up. Early initiation of treatment, particularly with anti-TNF therapy, may lead to better outcomes and fewer relapses. There is an unmet need for randomized controlled trials that provide robust data to guide therapy and the long-term management of neurosarcoidosis patients.

A Spotlight on Drug-Induced Vasculitis.

PURPOSE OF REVIEW: Drug-induced vasculitis (DIV) is a rare form of vasculitis related to the use of various drugs. DIV primarily affects small to medium size vessels, but it can potentially involve vessels of any size. Differentiating between primary systemic vasculitis and DIV can be challenging; however, it is crucial, so that the offending agent can be discontinued promptly. RECENT FINDINGS: The clinical phenotype of DIV is protean and depends on the size of the affected vessels. It ranges from arthralgias, to an isolated cutaneous rash, to severe single or multi-organ involvement. While withdrawal of the offending drug is the most important step in management, a significant number of patients require immunosuppressive therapy for varying periods of time. DIV can affect any vascular bed size, leading to protean vasculitic syndromes. Increased awareness among general practitioners, specialty, and subspecialty physicians is crucial for early recognition, and withdrawal of drug for better outcomes.

Recurrence rate of venous thromboembolic events in granulomatosis with polyangiitis.

Objective: The incidence of first-time venous thromboembolic events (VTEs) is high in granulomatosis with polyangiitis (GPA). The incidence of recurrent VTEs is unknown. We aimed to describe the recurrence rate of second VTEs in patients with GPA. Methods: Retrospective chart review was performed in patients with GPA and at least one VTE at a single centre from 2002 to 2016. Inclusion criteria were 1990 ACR criteria or 2012 Revised International Chapel Hill nomenclature for GPA, at least two follow-up visits, at least one VTE during the study period, and VTE occurrence after or within 3 months before GPA diagnosis. Second VTE event-free survival rates were estimated. Results: Out of 147 patients initially screened for GPA and with at least one VTE, 84 met inclusion criteria. Median age at first VTE was 57 years. Incidence rate for second VTE was 8.4 events per 100 patient-years (95% CI: 5.7, 12.3). Eighty-three point three per cent of first VTEs and 57.7% of second VTEs occurred when disease was active (P < 0.001). Renal involvement and constitutional symptoms at the time of first VTE were associated with VTE recurrence. Conclusion: GPA has a high rate of VTE recurrence compared with the reported data in the general population with unprovoked VTE. Our results suggest that VTE in GPA is a recurrent co-morbidity, not always during active vasculitis, and more so in those with renal involvement and constitutional symptoms at the time of first VTE.

Isolated Myeloperoxidase-Antineutrophil Cytoplasmic Antibody-Associated Hypertrophic Pachymeningitis.

ABSTRACT: A 65-year-old man with no pertinent medical history presented with 1 month of progressive holocephalic positional headaches (worse supine), photophobia, progressive gait instability resulting in multiple falls (ambulatory to walker in only 2 months), and weight loss. Testing found positive ANCA 1:160 perinuclear patter, myeloperoxidase >8.0. Cerebrospinal fluid found lymphocytic pleocytosis. We present his neuroimaging of isolated hypertrophic pachymeningitis with clinicoradiographic resolution after immunomodulatory pharmacotherapy along with histology from his meningeal biopsy. Isolated vasculitic myeloperoxidase-antineutrophil cytoplasmic antibody hypertrophic pachymeningitis is quite rare.

Noninfectious Autoimmune Scleritis: Recognition, Systemic Associations, and Therapy.

PURPOSE OF REVIEW: The aim of this review is to provide the information necessary for recognizing scleritis in rheumatology patients, recognize associated systemic diseases in scleritis patients referred to rheumatology, and choose the best conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic therapy, based on the most recent data. RECENT FINDINGS: Scleritis is most often associated with systemic conditions, particularly autoimmune conditions. Rheumatologists should be most vigilant about rheumatoid arthritis and ANCA-associated vasculitis. A recent systemic association has been found with IgG4-related disease as well. Most of the therapeutic decisions are based on observational data. Most recently, there is increasing evidence of the role of rituximab for refractory disease. Scleritis is a severe inflammatory ocular condition that leads to complications including vision loss. It can precede a systemic autoimmune disease diagnosis, especially in the case of vasculitis. Prompt recognition and adequate therapy are needed in order to avoid serious ocular complications. There is an unmet need for (1) head-to-heat trials on csDMARDs and biologic drugs for the treatment of idiopathic scleritis and (2) randomized controlled trials on the treatment of refractory cases.