Clinical Features and Outcomes of Coronavirus Disease 2019 in Patients with Inflammatory Bowel Disease and Spondyloarthropathies

Background:We aimed to determine the clinical features, predictive factors associated with severe disease, and outcomes of coronavirus disease 2019 in patients with immune-mediated inflammatory diseases and report data on the comparison of coronavirus disease 2019 between patients with inflammatory bowel disease and spondyloarthropathies.Methods:A total of 101 patients with inflammatory bowel disease and spondyloarthropathies who had confirmed diagnosis of coronavirus disease 2019 were retrospectively analyzed. Demographics, comorbidities, immunosuppressive treatments, and the impact of immunosuppression on negative outcomes were assessed.Results:The median age of the patients was 47 (38-57) years. The most common rheumatologic diagnosis was ankylosing spondylitis (n = 24), psoriatic arthritis (n = 17), and reactive arthritis (n = 1). In the inflammatory bowel disease group, 47 patients had ulcerative colitis, 11 Crohn’s disease, and 1 unclassified. The most commonly used treatments were biologics (55%) in the spondyloarthropathies group and aminosalicylates (66.1%) in the inflammatory bowel disease group. Overall, 18.8% of the patients required hospitalization, 5% developed severe complications, and 2% died. There were no significant differences in coronavirus disease 2019-related negative outcomes between spondyloarthropathies and inflammatory bowel disease patients. The median age was higher in the patients who required hospitalization [57 (46-66) vs 47 (38-57) years, P = .008]. Bilateral opacities on chest radiographs were more common in the patients who required hospitalization in the spondyloarthropathies group [88.9% vs 14.3%, P = .016]. Comorbidity was significantly associated with hospitalization in the inflammatory bowel disease group (P ≤ .05). Baseline therapy with biologics or immunosuppressives was not associated with severe coronavirus disease 2019 outcomes.Conclusion:Older age, comorbidities, and bilateral ground-glass opacities were associated with adverse outcomes, whereas specific immune-mediated inflammatory disease diagnoses or immunosuppressive treatments were not.     

A case report of monoarthritis in a COVID-19 patient and literature review: Simple actions for complex times

Rationale:COVID-19 presentation is multifaceted and up to 44% of patients affected by COVID-19 experience musculoskeletal complaints, mostly in the form of diffuse aspecific arthromyalgias. Nevertheless, only a few cases of arthritis following SARS-CoV2 infection are reported.Patient concerns:A 27-year-old man affected by nail psoriasis presented with monoarthritis 2 weeks after being diagnosed with COVID-19.Diagnoses:Diagnostic work-up and differential diagnosis were made difficult by patient isolation, absence of lab tests, and his visit via telemedicine, even though signs of first metacarpophalangeal joint involvement were clear.Interventions:Due to the inefficacy of acetaminophen and nonsteroidal anti-inflammatory drugs, the patient was prescribed oral steroids with a rapid benefit.Outcomes:The patient''s response to oral steroid was prompt and maintained even after therapy tapering. Even so, a formal diagnosis was not possible due to a difficult diagnostic work-up and lack of a long-term follow-up.Lessons:Like many other viral diseases, SARS-CoV2 can play as a causative agent or as a trigger for inflammatory arthritis development in predisposed individuals.     

Pattern of psoriatic arthritis in an Asian population (Malaysia)

Objective: To profile the pattern of psoriatic arthritis (PsA) and its relationship to disease duration. Methods: Forty‐six consecutive patients with PsA were entered into a cross‐sectional study. Demographic data, disease duration and disability were recorded. Joint involvement was documented at 6 months from onset and at presentation. X‐rays of the sacroiliac (SI) joints, thoracolumbar spine, and hands were taken. HLA B27 typing was done. Results: The male : female ratio was 2.3 : 1, mean age at onset of arthritis was 35.8 years and mean duration of PsA was 4.2 years. Oligoarticular involvement predominated (63%) at onset. Progression from oligoarthritis to polyarthritis occurred largely in the second year; 65.2% reported asymmetrical disease at onset while 50% had asymmetrical disease when disease duration was > 1 year. The frequency of involvement at onset was as follows: sausage toes, metatarsophalangeals (MTPs) and interphalangeals (IPs) in 50% (each), proximal interphelangeals (PIPs) in 47.8%, sausage fingers 34.7% and knees 30%. With mean duration of 4.2 years it was: sausage toe 71.1%, IP 69.5%, PIP and MTP 63%, knees 60.8%, distal interphalangeals (DIPs) 54.3%, sausage finger 52.1%, wrist 47.8%, followed by neck and back pain. Disability related to lower limb functions predominated and occurred early. Forty‐one percent had radiological sacroiliatis/spondylitis and 46% had erosive arthritis in the hands; 10.2% were HLA B27 positive. Conclusion: PsA was progressive, starting predominantly as an asymmetrical oligoarthritis and becoming largely polyarticular within 2 years from onset. Lower limb disability was evident early and erosive changes in hand X‐rays were seen in more than half the patients after 1 year.     

幼年脊柱关节病的早期特征和治疗

复习近期有关幼年脊柱关节病(JSpA、早期特征和治疗的文献。肌腱端炎、关节炎、腊肠趾及血清阴性肌腱端病和关节病综合征是本病特征性表现。儿童通常出现某一临床表现，发展到某特定型脊柱关节病需要一段时间。JSpA的治疗主要为非甾体类抗炎药、甲氨蝶呤和柳氮磺吡啶。严重的肌腱端炎可用小剂量泼尼松。反应停、TNF拮抗剂和二膦酸盐对JSpA的疗效有待验证。     

Apsoriatic psoriatic arthritis

Numerous features distinguish psoriatic arthritis (PsA) from other arthropathies, including the presence of psoriasis, distal interphalangeal (DIP) joint involvement, nail dystrophy, enthesitis, dactylitis and spinal involvement. Two decades ago, the presence of psoriasis was mandatory in the diagnosis of PsA. Up to 15% of patients had joint disease preceding psoriasis. In this group of patients, it may have been years after the onset of arthritis before the definitive diagnosis of PsA could be made. With advancements in treatment modalities, an accurate and proper diagnosis is relevant to the management of PsA. In their case report appearing in this issue, Taniguchi and Kamatani present a case with classical PsA without skin and nail lesions for 21 years. It may not be that unusual to encounter this in clinical practice, but we think it an opportune time to review the classification criteria and illustrate how the diagnosis of PsA can be made earlier.     

Case series analysis of psoriatic arthritis: a two‐centre experience

Aim: To provide the first case series analysis for psoriatic arthritis (PsA) in Malaysia. Methods: Patient records were studied from rheumatology clinics in Universiti Kebangsaan Malaysia Hospital and Putrajaya Hospital in Malaysia. Results: Thirty‐one patients from two rheumatology centres were studied. Thirteen patients (41.9%) were male and 18 patients (58.1%) were female. Nineteen patients (61.3%) were Malays, four (12.9%) were Chinese, seven (22.6%) were Indians and one (3.2%) was a Sikh. The majority of patients were in the > 50 years age‐group (11 [35.5%]) followed by the 41–50 years age‐group (10 [32.3%]). Thirteen patients (41.9%) had the disease since 41–50 years of age. Twenty‐three patients (77.4%) had no family history of PsA. Twenty‐three patients (74.2%) had psoriasis first, seven (22.6%) had arthritis first and one (3.2%) developed psoriasis and arthritis at the same time. Twenty‐four patients (77.4%) had positive activity correlation for skin and arthritis. The majority of patients had symmetrical arthritis (20 [64.5%]) and chronic plaque‐like lesions (22 [71.0%]). These patients were on NSAIDS and methotrexate (14 [45.2%]). One patient (3.6%) needed surgery for joint replacement. Conclusion: Patients who were diagnosed as having PsA were Malays, age group of more than 50, disease onset at 41–50 years of age, no family history, had symmetrical and chronic plaque lesions, had psoriasis first and needed NSAIDS and methotrexate.     

A case of psoriatic arthritis without the appearance of psoriatic skin or nail lesions for 21 years

In some patients with psoriatic arthritis, arthritis may precede psoriatic skin lesions. In fact, psoriatic skin lesions may not develop for more than 10 years after the onset of arthritis. Making diagnostic and therapeutic decisions in such patients is therefore challenging. We describe a case with classic features of psoriatic arthritis without psoriatic skin or nail lesions for 21 years. We suggest that recognition of psoriatic arthritis sine psoriasis is important for selecting appropriate therapy to prevent joint damage.     

Predictive factors in early arthritis: long-term follow-up

BACKGROUND: Because recent-onset inflammatory arthritis exhibits considerable clinical and prognostic variability, it is important to attempt to predict which patients are likely to have a poor prognosis as early as possible. Most prognostic studies have looked at patients who fulfilled proposed criteria for a definite diagnosis of rheumatoid arthritis (RA) or other well-defined conditions; less information exists concerning predictive factors for other types of early arthritis. OBJECTIVES: To examine prognosis in early arthritis, the authors assessed the long-term outcome in a cohort of patients who presented with inflammatory arthritis of short duration. Associations between outcome and patient clinical characteristics were analyzed to determine possible prognostic factors. METHODS: Since 1968, patients were selected to be followed up in 2 early-arthritis clinics if they had evidence of inflammatory joint disease and symptom duration was <1 year. Length of follow-up was variable, but was at least 1 year. At last follow-up, patients were classified as being in remission or as having persistent disease. Factors associated with a poor outcome were identified by using formal statistical methods. RESULTS: A total of 121 patients were included in this analysis. Mean disease duration to the first evaluation was 3 months, and median follow-up was 5 years (range, 1 to 30 months). Twenty-one patients (17%) had transient disease defined as total duration of <6 weeks. Sixty-three patients (52%) were in remission at final follow-up, with unclassified patients doing the best. Patients meeting criteria for RA or spondylarthropathies had more persistent disease. Polyarticular disease predicted more persistent disease (P <.05). In multivariable analyses, patients with initial hand involvement were much less likely to achieve remission of their disease (odds ratio, 0.18; 95% confidence interval, 0.05 to 0.66). Only 4 patients had either class 4 function or joint replacement. CONCLUSIONS: Our findings indicate that prognosis in early inflammatory arthritis is generally good, with more than half of all patients achieving remission in our cohort. Patients with unclassified arthritis fared better than those meeting criteria for RA or spondylarthropathy. Of the many clinical variables examined as possible prognostic factors, hand involvement was the strongest predictor of a poor outcome. RELEVANCE: The long follow-up of these patients with early arthritis provides clues for the clinician to the likely course and shows that many patients will do well.     

Post Chlamydial reactive arthritis in a case of Vogt-Koyanagi-Harada syndrome (VKH) with negative HLA-B27: An association or just coincidence

BackgroundVogt-Koyanagi-Harada (VKH) syndrome is a multisystem disorder characterized by granulomatous panuveitis with exudative retinal detachments that is often associated with neurologic and cutaneous manifestations.Aim of the workThe aim of this case report is to describe a rare case with Vogt-Koyanagi-Harada syndrome that developed an explosive form of reactive arthritis shortly after attack of Chlamydial urethritis. An association between Vogt-Koyanagi-Harada and ulcerative colitis was previously described in several case reports. The case is described in detail and the literature was reviewed.Case reportIn this report we described a male patient with long standing Vogt-Koyanagi-Harada syndrome, who developed aggressive reactive arthritis two weeks after an attack of Chlamydial urethritis. Clinically the patient presented with bilateral sacroiliitis, peripheral arthritis, and wide spread enthesitis. The patient had positive family history of scleroderma in his first degree relative and HLA-B27 testing was negative.ConclusionIn this report we theoretically proposed a possible relationship between VKH and Seronegative spondyloarthropathy group of disorders.     

Juvenile ankylosing spondylitis—is it the same disease as adult ankylosing spondylitis?

Objectives Juvenile and adult forms of ankylosing spondylitis (AS) have been shown to have different clinical presentation and outcome in Caucasians. We did this retrospective analysis to see if similar differences exist in the Indian population.Patients and methods Case records of 210 Indian patients diagnosed with AS according to modified New York criteria were reviewed. Data were collected regarding age of onset, clinical features, drug treatment, and outcome at last follow-up. Patients with onset before 17 years of age were classified as having juvenile AS (JAS) and the rest with adult AS (AAS).Results There were 150 patients with AAS and 60 with JAS. The latter had higher male preponderance, more frequent onset with peripheral arthritis, and greater involvement of hip and knee joints. Valvular dysfunction was seen only in patients with JAS.Conclusion In this group of subjects, juvenile AS had onset more often with oligoarthritis and enthesitis than with spinal disease. Hip and knee joint involvement was more common in JAS than AAS.     

The effectiveness of a traditional therapeutical approach in early psoriatic arthritis: results of a pilot randomised 6-month trial with methotrexate

Thirty-five patients with Early Psoriatic Arthritis (EPA) (17 female and 18 male; mean age 25.6 years) entered this randomised 6-month study. At the enrolment, all patients were on non-steroidal anti-inflammatory drug (NSAID) therapy on demand and were divided in two matched groups (A and B). Group A continued NSAID therapy at full dosage in the following 3 months and then added methotrexate (MTX) for another 3 months. Group B was under the combination of NSAID and MTX for the entire 6-month period. Clinical and laboratory assessment included the count of tender joints and/or entheses (TJC), the count of swollen joints and/or entheses (SJC), patient's global assessment (PGA), physician's global assessment (PhGA), patient's assessment of pain (VAS), erythrocyte sedimentation rate (ESR) and serum concentration of C-reactive protein (CRP). All variables were done at baseline (T0), at 3 (T3) and at 6 months (T6). In both group A and in group B, there was a significant improvement of all variables at T3 and T6. However, in comparison to the patients of group A, patients included in group B showed a more rapid and marked improvement of TJC and SJC, which was statistically significant at T3 (p < 0.05). In contrast, the improvement of PGA, PhGA, VAS, ESR and CRP was not significantly different between groups. The early use of MTX in EPA patients markedly improves TJC and SJC. In fact, at T3, other markers used to quantify EPA disease activity, in particular PGA, PhGA, VAS, ESR and CRP, did not show significant differences in EPA patients treated with either NSAIDs or MTX. This finding suggests an incomplete control under MTX of the pathogenetic process and stimulates further interest on early use of other therapeutical approaches capable of modifying the course of disease.     

New onset sarcoid-like granulomatosis developing during anti-TNF therapy: an under-recognised complication

Tumour necrosis factor-alpha (TNF-a) antagonists have advanced the treatment of inflammatory arthropathies, and are even considered for use in refractory sarcoidosis with some success. Paradoxically, cases of new onset sarcoidosis-like diseases are increasingly reported in patients receiving TNF-a antagonists. Here, we report three cases of sarcoid-like granulomatosis that developed during treatment with TNF-a antagonists. Review of the Biologics clinic data base at Westmead, Sydney, Australia identified three patients whom, during anti-TNF therapy, developed non-caseating granulomas consistent with sarcoidosis. These three cases are described with review of the literature from 2000 to 2009 using PubMed. One hundred and sixty-nine patients within our data base were reviewed for the period 2003–2009. Sarcoidosis-like granulomas developed in three patients within a period of 3 to 36 months of treatment with etanercept and/or adalimumab. All cases demonstrated non-infective, non-caseating granulomas on renal or lymph node biopsy. Improvement was seen in two cases upon cessation of TNF-a antagonist and steroid therapy. Interestingly, clinical deterioration was noted upon re-challenge with the same TNF-a antagonist in one patient. To date, a total of 37 cases of sarcoid-like granuloma development after anti-TNF therapy have been reported in the literature. Development of sarcoidosis-like granulomatosis in patients treated with TNF-a antagonists is a phenomenon previously under-recognised. All three anti-TNF agents have been observed to cause this phenomenon, suggesting a ‘class effect’ rather than being drug specific.