Ana Beatriz Santos Bacchiega

Giant cell arteritis: a multicenter observational study in Brazil

OBJECTIVE: To describe demographic features, disease manifestations and therapy in patients with giant cell arteritis from referral centers in Brazil. METHODS: A retrospective cohort study was performed on 45 giant cell arteritis patients from three university hospitals in Brazil. Diagnoses were based on the American College of Rheumatology classification criteria for giant cell arteritis or temporal artery biopsy findings. RESULTS: Most patients were Caucasian, and females were slightly more predominant. The frequencies of disease manifestations were as follows: temporal headache in 82.2%, neuro-ophthalmologic manifestations in 68.9%, jaw claudication in 48.9%, systemic symptoms in 44.4%, polymyalgia rheumatica in 35.6% and extra-cranial vessel involvement in 17.8% of cases. Aortic aneurysms were observed in 6.6% of patients. A comparison between patients with biopsy-proven giant cell arteritis and those without temporal artery biopsies did not yield significant differences in disease manifestations. All patients were treated with oral prednisone, and intravenous methylprednisolone was administered to nearly half of the patients. Methotrexate was the most commonly used immunosuppressive agent, and low-dose aspirin was prescribed to the majority of patients. Relapses occurred in 28.9% of patients, and aspirin had a protective effect against relapses. Females had higher prevalences of polymyalgia rheumatica, systemic manifestations and jaw claudication, while permanent visual loss was more prevalent in men. CONCLUSIONS: Most of the clinical features of Brazilian giant cell arteritis patients were similar to those found in other studies, except for the high prevalence of neuro-ophthalmic manifestations and permanent blindness in the Brazilian patients. Aspirin had a protective effect on relapses.

Interleukin 6 Inhibition and Coronary Artery Disease in a High‐Risk Population: A Prospective Community‐Based Clinical Study

Background Atherosclerosis is a chronic inflammatory disease, with interleukin 6 (IL‐6) as a major player in inflammation cascade. IL‐6 blockade may reduce cardiovascular risk, but current treatments to block IL‐6 also induce dyslipidemia, a finding with an uncertain prognosis. Methods and Results We aimed to determine the endothelial function responses to the IL‐6–blocking agent tocilizumab, anti–tumor necrosis factor α, and synthetic disease‐modifying antirheumatic drug therapies in patients with rheumatoid arthritis in a 16‐week prospective study. Sixty consecutive patients with rheumatoid arthritis were enrolled. Tocilizumab and anti–tumor necrosis factor α therapy were started in 18 patients each while 24 patients were treated with synthetic disease‐modifying antirheumatic drugs. Forty patients completed the 16‐week follow‐up period. The main outcome was flow‐mediated dilation percentage variation before and after therapy. In the tocilizumab group, flow‐mediated dilation percentage variation increased statistically significantly from a pre‐treatment mean of (3.43% [95% CI, 1.28–5.58] to 5.96% [95% CI, 3.95–7.97]; P=0.03). Corresponding changes were 4.78% (95% CI, 2.13–7.42) to 6.75% (95% CI, 4.10–9.39) (P=0.09) and 2.87% (95% CI, −2.17 to 7.91) to 4.84% (95% CI, 2.61–7.07) (P=0.21) in the anti–tumor necrosis factor α and the synthetic disease‐modifying antirheumatic drug groups, respectively (both not statistically significant). Total cholesterol increased significantly in the tocilizumab group from 197.5 (95% CI, 177.59–217.36) to 232.3 (201.62–263.09) (P=0.003) and in the synthetic disease‐modifying antirheumatic drug group from 185.8 (95% CI, 169.76–201.81) to 202.8 (95% CI, 176.81–228.76) (P=0.04), but not in the anti–tumor necrosis factor α group. High‐density lipoprotein did not change significantly in any group. Conclusions Endothelial function is improved by tocilizumab in a high‐risk population, even as it increases total cholesterol and low‐density lipoprotein levels.

Ocular involvement in patients with spondyloarthritis

Ocular inflammatory diseases can present as isolated conditions but also as part of systemic inflammatory diseases. Anterior uveitis is closely related to SpA and shares the common genetic background of HLA-B27. Other ocular manifestations, such as episcleritis and scleritis, may also occur, although less frequently. Therefore, ocular involvement has been included as one of the important clinical features of SpA in the recently published classification criteria for axial and peripheral disease. However, there are a wide variety of aetiologies for ocular diseases and this must be considered in assessment of SpA.

Recommendations of the Brazilian Society of Rheumatology for the induction therapy of ANCA-associated vasculitis

The purpose of these recommendations is to guide the appropriate induction treatment of antineutrophil cytoplasmic antibody-associated vasculitis (AAV) patients with active disease. The recommendations proposed by the Vasculopathies Committee of the Brazilian Society Rheumatology for induction therapy of AAV, including granulomatosis with polyangiitis, microscopic polyangiitis and renal-limited vasculitis, were based on systematic literature review and expert opinion. Literature review was performed using Medline (PubMed), EMBASE and Cochrane database to retrieve articles until October 2016. PRISMA guidelines were used for the systematic review and articles were assessed according to the Oxford levels of evidence. Sixteen recommendations were made regarding different aspects of induction therapy for AAV. The purpose of these recommendations is to serve as a guide for therapeutic decisions by health care professionals in the management of AAV patients presenting active disease.

Ankylosing Spondylitis with Bulbar Syndrome and Atlantoaxial Synovitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease. Neurological manifestations can occur because of atlantoaxial subluxation in about 14% of patients1. A 43-year-old man diagnosed with AS according to the 1984 modified New York criteria presented with bulbar symptoms, such as severe dysphagia and dysphonia. Physical examination revealed the left hemitongue paralysis without any other focal neurological finding. He presented stiffness in the cervical, thoracic, and lumbar spine. Magnetic resonance imaging (MRI) …

Sacroiliitis in Behçet syndrome.

33-year-old woman presented with inflammatory low back pain for 1 year, recurrent painful oral aphthous, and genital ulcers for 6 months with remaining tissue scarring, extensive pseudofolliculitis on the upper and lower limbs, fever, weight loss, and bilateral anterior uveitis. Seven months later, the pa- tient presented bilateral panuveitis. She had no abdominal pain, diarrhea, anemia, or other symptoms that suggested inflam- matory intestinal disease. Human leukocyte antigen B27 and antinuclear antibody tests were negative. The patient was diag- nosed with Behcet disease according to the International Study Group criteria. 1 Most symptoms were resolved with corticoste- roid eye drops, oral corticosteroids, colchicine, and methotrexate, but the low back pain alleviated only with nonsteroidal anti- inflammatory drugs. After 4 years of follow-up, there is no back pain or skin or eye disease on this treatment. Radiography has not been performed again. Radiography of the sacroiliac joints did not show abnor- malities. After gadolinium administration, coronal T1-weighted magnetic resonance imaging of the sacroiliac joints demonstrated left joint space enhancement indicative of synovitis (Figure, arrows). Edema of the sacral surface of the adjacent sacroiliac joint (Figure, open arrow) and sclerosis of the iliac surface (Figure, asterisk) were also observed, indicating sacroiliitis. Behcet disease, a systemic vasculitis of unknown etiology, is characterized by relapsing episodes of oral and genital ulcers, skin lesions, and ophthalmological disease. It can also affect the vascular, gastrointestinal, and neurological systems. 1Y4 Rheu- matic manifestations have been described in 45% of patients with Behcet syndrome, ranking second after skin and mucosal mani- festations. Inflammatory arthralgia is the most common mani- festation (81% of cases), and sacroiliitis is uncommon (7.5% of cases). 1Y5 Some authors have described a high prevalence of sacroiliitis in patients with Behcet disease, but others have found no association between these conditions. 5 The main reason for these differing results could be a high degree of interobserver variation in interpreting radiographs of the sacroiliac joints. In our case, sacroiliitis was demonstrated by magnetic resonance imaging, the most sensitive method for the detection and early diagnosis of this condition. Joint involvement can be an early manifestation of Behcet syndrome, potentially causing significant