Osteonecrosis of carpal bones in systemic sclerosis

Background. Systemic sclerosis (SSc) is a rare chronic disease, with unknown aetiology and complex pathogenesis. The hand is often implied in the main clinical findings, being affected primarily by the vascular component (Raynaud phenomenon, digital ulcers). One of the possible complications of the hand vasculopathy is osteonecrosis (ON) of the carpal bones. In these cases, the lunate is the most frequently affected, followed by the scaphoid. In the ON process, not only the vascular supply is important, but the nearby mechanical factors and anatomic variants of the wrist. Our objective was to reveal the most important aspects regarding the ON of the carpal bones in patients with SSc. Methods. A systematic literature review was performed through July 31, 2021 on Pubmed and Cochrane databases. The eligible articles were read in full text and were included in this paper, in the absence of exclusion criteria and after consensus between two reviewers. Results. Ten articles met the inclusion criteria, their main results being described in this review. In all studies, ON of the lunate and the scaphoid is associated with advanced SSc and severe Raynaud phenomenon. Conclusions. In conclusion, carpal ON is a rare complication of SSc, especially of the diffuse type. There is limited data on this condition, its prevalence being difficult to estimate due to the lack of symptoms.

Rehabilitation therapy in patients with psoriatic arthritis after SARS-CoV-2 infection

Objectives. We want to present the evolution of a lot of patients, previously diagnosed with psoriatic arthritis, who last spring went through a difficult period due to infection with the new coronavirus. After healing from COVID-19, the patients had returned to the hospital after a period of 4-6 months, to follow a rehabilitation treatment, the majority of the accusations being those related to psoriatic arthritis, with close follow-up of these patients in connection with the treatment applied. Material and methods. The patients were evaluated at hospitalization (biological inflammatory markers like CRP and ESR), pain scale, DAPSA score, PASI and the quality of life score (DLQI and QOL scale), after which they followed different rehabilitation treatments for a period of 21 days. After 3 months of completing this treatment they were re-evaluated. Patients diagnosed with psoriatic arthritis who do not have documentation to suggest SARS-CoV-2 infection (antibodies/ previous RT-PCR positive tests) were not included in the study. Outcomes. There were some significant differences in terms of the initial score at hospitalization and that performed after rehabilitation treatment. Most of the indices performed had lower values at reassessment (pain scale score, DAPSA, PASI, DLQI and even lower values of CRP and ESR), thus resulting in an important step in terms of the beneficial effects of rehabilitation therapy, both for patients with psoriatic arthritis and for post-COVID-19 recovery. The most important change was observed in the score for quality of life. Conclusions. The inclusion of rehabilitation therapy in patients with psoriatic arthritis should be a step that each patient should take. Its effects are long-term, with periods of pain decreasing in frequency and intensity, thus changing the quality of life of these patients. The mental, social and emotional impact of COVID-19 on people who have gone through the disease can be changed in a good way, also following a rehabilitation therapy.

Enthesitis in psoriatic arthritis

Enthesitis is a distinctive feature of psoriatic arthritis. New imaging techniques help to better understand the pathophysiology of entheses, being one of the essential factors of the subclinical and prodromal stages of psoriatic arthritis. This paper aims to review the main clinical scores, imaging scores, confounding factors that might influence the interpretation of results and the impact of medication on enthesitis in psoriatic arthritis.

Active rheumatoid arthritis with multiple pulmonary nodules failure to multiple remissive therapy: Which is the solution?

We describe the case of a 63-year-old nonsmoker woman, with a long history of active seropositive rheumatoid arthritis, failure to multiple disease-modifying antirheumatic drugs due to both loss of efficacy and adverse drug reaction. She was exposed to silicon dust some years ago and has many pulmonary nodules, revealed by imaging studies as multiple cavitary lung nodules. Her initial pathological samples were negative for any infections and treatment against tuberculosis and anti-fungal therapy did not improve the appearance of the nodules. After an extensive reevaluation of pulmonary nodules, the Baricitinib treatment was started.

Systemic sclerosis – metamorphosis of a life

Systemic sclerosis is a complex autoimmune disorder marked by heterogeneous clinical manifestations and variable disease course. We present the case of a patient with diffuse cutaneous systemic sclerosis with anti-PM/Scl antibodies and associated calcinosis cutis. Currently, there is no uniformly effective therapy for calcinosis, but in the present case study combined therapy (calcium channel blocker, colchicine, bisphosphonate and minocycline) showed a good outcome with significant clinical improvement. Calcinosis in patients with systemic sclerosis is relatively common and it represents a challenge that requires appropriate management.

Features of late-onset systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease, characterized by multiorgan involvement, most commonly targeting the skin, joints and kidneys. Late-onset disease occurs in patients over the age of 50 and represents a diagnostic challenge, as it is less frequently encountered and it may exhibit a more unusual clinical and paraclinical picture. The aim of this paper is to highlight two cases of SLE diagnosed in female patients of considerably advanced ages, 81 and 72 years respectively, in order to enhance physician awareness with regard to this distinct disease subtype.

Clinically suspect arthralgia – are we going towards a new shift in the therapeutic paradigm of rheumatoid arthritis?

Background. There is a time sensitive window of opportunity in rheumatoid arthritis (RA) in which therapeutic intervention is more effective, the disease being more susceptible to the immunomodulatory effects of the remissive medication. The goal is to prevent osteo-articular damage, which causes severe functional deficit, and to raise the chance to lead the disease in remission. Evolution towards RA represents a multi-step process. In other medical fields prevention has the same important role as treatment, so could we in the future switch again the therapeutic paradigm in RA, from early treatment to prevention of RA, by treating patients with high risk of developing disease? Initiating treatment in the pre-RA phases could potentially lead to a better immune modulation or even preventing disease development by acting on less mature pathogenic processes. Treating in the initial symptomatic phase of the disease could potentially be more effective in reducing disease persistence and the development of structural lesions. The clinically suspect arthralgia (CSA) definition offers a support of clinical parameters for future longitudinal studies, where together with para clinical parameters, laboratory studies and imagistic studies, could lead to the development of imminent RA classification criteria. Currently there are more ongoing studies that have the primary objective to prove this concept with different subpopulations and treatments, but most of them have inclusion criteria based on the presence of autoantibodies. The publication of this trials results in the next decade will help to better understand the efficacy of therapeutic intervention with the scope of preventing chronic arthritis and what subset of patients at risk to treat. There are no recommendations for management of CSA, but current practice is symptomatic treatment with nonsteroidal anti-inflammatory drugs, pain relievers and of course monitoring.

Rehabilitation therapy in patients with psoriatic arthritis after SARS-CoV-2 infection

Objectives. We want to present the evolution of a lot of patients, previously diagnosed with psoriatic arthritis, who last spring went through a difficult period due to infection with the new coronavirus. After healing from COVID-19, the patients had returned to the hospital after a period of 4-6 months, to follow a rehabilitation treatment, the majority of the accusations being those related to psoriatic arthritis, with close follow-up of these patients in connection with the treatment applied. Material and methods. The patients were evaluated at hospitalization (biological inflammatory markers like CRP and ESR), pain scale, DAPSA score, PASI and the quality of life score (DLQI and QOL scale), after which they followed different rehabilitation treatments for a period of 21 days. After 3 months of completing this treatment they were re-evaluated. Patients diagnosed with psoriatic arthritis who do not have documentation to suggest SARS-CoV-2 infection (antibodies/ previous RT-PCR positive tests) were not included in the study. Outcomes. There were some significant differences in terms of the initial score at hospitalization and that performed after rehabilitation treatment. Most of the indices performed had lower values at reassessment (pain scale score, DAPSA, PASI, DLQI and even lower values of CRP and ESR), thus resulting in an important step in terms of the beneficial effects of rehabilitation therapy, both for patients with psoriatic arthritis and for post-COVID-19 recovery. The most important change was observed in the score for quality of life. Conclusions. The inclusion of rehabilitation therapy in patients with psoriatic arthritis should be a step that each patient should take. Its effects are long-term, with periods of pain decreasing in frequency and intensity, thus changing the quality of life of these patients. The mental, social and emotional impact of COVID-19 on people who have gone through the disease can be changed in a good way, also following a rehabilitation therapy.

Pregnancy, systemic lupus erythematosus and a short communication on labor complications as new onset of the disease

Systemic lupus erythematosus (SLE) occur frequently in women of fertile age. In the pathogenesis of SLE, estrogen plays an important role, hormonal changes such as pregnancy and the postpartum increase the risk of disease flares. Also, pregnancy in SLE patients carries a higher fetal risk compared with healthy women. Pregnancy outcome may be optimized by careful planning of the pregnancy and close follow-up of the mother and of the fetus. SLE is associated with high maternal and fetal risk especially when non-diagnosed before planning a pregnancy. Herein we present two cases of SLE manifested by preeclampsia and acute renal insufficiency during labor and postpartum period, with a difficult diagnosis after a few months of a worsening clinical situation.

Scleroderma renal crisis as the sole presenting feature of systemic sclerosis in a postpartum woman

Systemic sclerosis is a chronic autoimmune disorder characterized by multiorgan involvement, most notably of the skin through fibrosis and vasculopathy. One of its most feared complications requiring rapid intervention is scleroderma renal crisis, as it can be fatal in the absence of prompt treatment. A 34-year old woman presents with a history of acute renal failure and malignant hypertension occurring one month postpartum and no other scleroderma feature in the following 5 years. Eventually, skin, heart and lung involvement is observed, positive anti-ARN III polymerase antibodies and suggestive capillaroscopic findings. Immunosuppressive therapy with mycophenolate mofetil is initiated and later switched to off-label Rituximab, with significant improvement of disease manifestations. Regular patient monitoring for novel symptom occurrence and appropriate treatment adjustment is essential for optimal management of scleroderma.