ETIOPATHOGENESIS AND MANAGEMENT OF WAJAAL-MAFASIL (RHEUMATOID ARTHRITIS): AN EVIDENCE-BASED COMPREHENSIVE REVIEW

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by symmetrical inflammatory polyarthritis involving small joints of the hand and feet. It has a global prevalence of 0.8 to 1% in Europe and the Indian subcontinent. Rheumatoid arthritis (Waja‘al-Maf?sil) had been broadly described and managed by the Unani scholars since antiquity. Many pharmacological and non-pharmacological treatment methods are available in the classical Unani literature. The treatment differs for different varieties of morbid humour involved in disease pathogenesis. Treatment aims to reduce morbidity and prevent disability, subsequently improving the quality of life. This review article mainly highlights the management of rheumatoid arthritis mentioned in classical Unani literature and supportive scientific evidence of various preclinical and clinical studies suggesting the potential of Unani medicine. This review article aims to explore the concept of rheumatoid arthritis in the Unani system of medicine to provide a better understanding of disease and its management through the holistic policy of Unani medicine. This review may conclude that Unani treatment can form an alternative source to manage RA.

Pulmonary Alveolar Microlithiasis and Rheumatoid Arthritis: A Case Report and Review of the Literature

Pulmonary alveolar microlithiasis is a rare autosomal recessive condition that is characterized by the formation of excessive calcium phosphate microliths in the alveoli. Most patients are diagnosed in adulthood due to the slow progression of the disease. Children with this disease are asymptomatic, and changes in the lung parenchyma are usually discovered incidentally. The diagnosis is made by the combination of a positive chest imaging and histological examination. Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by chronic seropositive symmetrical inflammatory polyarthritis with numerous extra-articular manifestations. It targets the lining of the synovial membranes, frequently affects females more than males, and is treated with the disease-modifying antirheumatic drugs (DMARDs). If left untreated, it leads to increased morbidity, mortality, and socioeconomic burdens. In this case, we report a 19-year-old young man who presented with clinical and radiographic features of PAM associated with RA.

Small joint polyarthritis – An unusual presentation of scrub typhus in a child

Scrub typhus is a common Rickettsial infection which is endemic in tropical regions. It is characterised by fever, eschar, thrombocytopenia, lymphadenopathy and organomegaly. Scrub typhus has significant morbidity and mortality owing to its multisystemic involvement. Non-inflammatory polyarthritis of small joints is an uncommon presentation in paediatric scrub typhus. We discuss a five-year-old boy who presented with fever, small joint polyarthritis, hepatosplenomegaly and pathognomonic eschar with positive scrub IgM ELISA. Arthritis resolved completely with doxycycline therapy without any deformity.

Rare Scar Sarcoidosis: A Dermatologic Masquerader

Infiltration of sarcoid granuloma in old cutaneous scars is one of the uncommon cutaneous manifestations of sarcoidosis. Here we report the case of a 32-year-old female who presented with swelling and irritation in a 9-month-old appendicectomy scar. An incisional scar biopsy was done and it revealed non-caseating granuloma. On query she had inflammatory polyarthritis and persistent dry cough for last two months. High resolution CT (HRCT) revealed right paratracheal, both hilar, paraaortic, and subcarinal lymphadenopathy with pulmonary nodular densities in both lung fields. FNAC from mediastinal node revealed non-caseating granuloma consistent with sarcoidosis. Successful regression of cutaneous inflammation was achieved using a course of oral steroids, hydroxychloroquine and methotrexate. The incidence of scar sarcoidosis is rare and therefore not well-understood. However, inflammatory alterations in preexisting scars may be important indicators of disease onset. J Enam Med Col 2020; 10(2): 122-125

Case of rare association of peripheral neuropathy with mixed connective tissue disorder

Chronic inflammatory demyelinating polyneuropathy (CIDP) is probably the best-recognised progressive immune-mediated peripheral neuropathy. It presents with symmetrical, motor predominant peripheral neuropathy that produces both distal and proximal weakness. Here we report a case of a 38-year-old man who presented with chronic additive large and small joint inflammatory polyarthritis, associated with morning stiffness, anasarca associated with frothy urine and progressive episodic, relapsing and remitting, sensorimotor lower motor neuron type quadriparesis without any bladder and bowel involvement. He was diagnosed as a case of CIDP, and the aetiology was found out to be mixed connective tissue disorder, which is a rare association with CIDP. The patient responded dramatically to glucocorticoid.

Impending radiographic erosive progression over the following year in a cohort of consecutive patients with inflammatory polyarthritis: prediction by serum biomarkers

Background/PurposeTo evaluate biomarkers as predictors of impending erosion progression.MethodsVariables were measured at baseline and annually up to 5 years in patients with recent-onset polyarthritis treated to zero swollen joints. Erosive status was defined as ≥5 Units in Sharp/van der Heijde Erosion Score; Rapid Erosive Progression (REP) was defined as an increase ≥5 Units in Erosion Scores between consecutive visits. Generalised estimating equations (GEEs) evaluated the effect on REP of positive anticyclic citrullinated peptides (ACPAs) and/or rheumatoid factor (RF), C-reactive protein ˃8.0 mg/L (High-CRP) and 14-3-3η protein ≥0.50 ng/mL (High-14-3-3η), alone and in combinations.ResultsOut of 2155 evaluations in 749 consecutive patients, REP occurred after 186 (8.6%) visits, including 13 (2.2%) in patients recruited since 2010. Only 18/537 (3.4%; 6/411 (1.5%) in non-erosive vs 12/126 (9.5%) in patients already erosive) visits without any positive biomarker were followed by REP; at least one biomarker was positive prior to REP in 168/186 (90.3%) visits. Being positive for all four biomarkers conferred a positive predictive value (PPV) of 30.0% (RR 21.8) in patients non-erosive at the visit versus 35.5% (RR 3.07) in those already erosive. High-14-3-3η increased REP only in visits with High-CRP (eg, RR 2.5 to 3.9 when ACPA also positive) and in patients with non-erosive status (eg, RR from 4.3 to 9.4 when also High-CRP).ConclusionsAdding High-14-3-3η to positive antibodies and CRP improves prediction of impending REP. Although REP is becoming rarer, signatures of biomarkers might help to adapt treatment strategies in at-risk individuals, even those already erosive.