Ana Paula Monteiro Gomides

Sensorineural dysacusis in patients with systemic lupus erythematosus.

The objective of this study was to establish the frequency of involvement of the auditory apparatus in 45 female patients with systemic lupus erythematosus (SLE) submitted to general clinical and laboratory assessments, and tone and vocal audiometry accompanied by a questionnaire evaluating auditory symptoms. The control group consisted of 45 healthy women, matched by age. Auditory symptoms were present in 25 (55.5%) patients, with a diagnosis of sensorineural hearing loss in seven (15.6%) patients. A significant correlation with hypoacusis (P < 0.001), ear fullness (P = 0.012) and tinnitus (P = 0.017) was observed in patients with hearing loss. None of the clinical or laboratory parameters showed an association with sensorineural hearing loss. In the control group, three women (6.7%) presented audiometric alterations, including two with altered tympanometry results and one with mild sensorineural hearing loss. In conclusion, an adequate investigation of auditory symptoms is important during the follow-up of patients with SLE, since manifestations of the auditory apparatus and sensorineural hearing loss can affect a significant proportion of patients. Lupus (2007) 16, 987—990.

Perda auditiva neurossensorial em pacientes com granulomatose de Wegener: relato de três casos e revisão de literatura

Wegeners granulomatosis is a primary systemic vasculitis that affects small and medium-sized vessels. The classical manifestations occur in the upper and lower respiratory tract and in the kidneys, but other organs may be involved. The auditory system can be frequently affect in its various portions (outer, middle and/or inner ear), showing different manifestations. Neurosensory hearing loss might be a consequence of changes in the inner ear and should be recognized early. Rapid and effective treatment may prevent irreversible damage. We report herein three cases of Wegeners granulomatosis and sensory hypoacusis, which responded differently to treatment.

Sarcoidose na infância com manifestações raras: vasculite, acometimento do sistema nervoso central, ósseo e genital

Sarcoidosis is a systemic granulomatous disease with rare occurrence in children. Vasculitis associated to sarcoidosis is uncommon and can affect small, medium or large-sized vessels. Symptomatic involvement of the central nervous and peripheral system occurs in 5% to 10% of the patients and osseous in 3% to 13%. Sarcoidosis of the genitourinary tract is extremely rare. We describe a case of a 12-year-old child with a diagnosis of sarcoidosis associated with vasculitis and with involvement of the central nervous system, osseous and genital. This case illustrates the wide spectrum of rare clinical manifestations in sarcoidosis.

Paquimeningite hipertrófica e parotidite: manifestações raras da granulomatose de Wegener

The wegeners granulomatosis is a systemic angiitis of small and medium caliber vessels. Normally, it is characterized by the formation of granulomas with necrosis in the respiratory system and necrosing glomerulonephritis. even though it is more common in the upper respiratory system, in the lung and in the kidney, a great range of manifestation in other different organs and tissues can be described. we report the case of a patient who, in parallel with the typical symptoms of this disease, developed some rare alteration such as the parotiditis and the hypertrophic pachymeningitis. in face of serious situations, severe disease, atypical or non responsive to conventional treatments, it is necessary a more detailed study of the case and the use of new therapeutic drugs.

Intestinal parasites infection: protective effect in rheumatoid arthritis?☆

Rheumatoid arthritis (RA) is a systemic autoimmune inflammatory disease, with a progressive course, characterized by chronic synovitis that may evolve with deformities and functional disability, and whose early treatment minimizes joint damage. Its etiopathogenesis is not fully elucidated but comprises immunologic responses mediated by T helper cells (Th1). An apparent minor severity of RA in patients from regions with lower income could be associated with a higher prevalence of gut parasites, especially helminths. Strictly, a shift in the immune response toward the predominance of T helper cells (Th2), due to the chronic exposure to helminths, could modulate negatively the inflammation in RA patients, resulting in lower severity/joint injury. The interaction between the immunological responses of parasitic helminths in rheumatoid arthritis patients is the purpose of this paper.

2017 recommendations of the Brazilian Society of Rheumatology for the pharmacological treatment of rheumatoid arthritis

The objective of this document is to provide a comprehensive update of the recommendations of Brazilian Society of Rheumatology on drug treatment of rheumatoid arthritis (RA), based on a systematic literature review and on the opinion of a panel of rheumatologists. Four general principles and eleven recommendations were approved. General principles: RA treatment should (1) preferably consist of a multidisciplinary approach coordinated by a rheumatologist, (2) include counseling on lifestyle habits, strict control of comorbidities, and updates of the vaccination record, (3) be based on decisions shared by the patient and the physician after clarification about the disease and the available therapeutic options; (4) the goal is sustained clinical remission or, when this is not feasible, low disease activity. Recommendations: (1) the first line of treatment should be a csDMARD, started as soon as the diagnosis of RA is established; (2) methotrexate (MTX) is the first-choice csDMARD; (3) the combination of two or more csDMARDs, including MTX, may be used as the first line of treatment; (4) after failure of first-line therapy with MTX, the therapeutic strategies include combining MTX with another csDMARD (leflunomide), with two csDMARDs (hydroxychloroquine and sulfasalazine), or switching MTX for another csDMARD (leflunomide or sulfasalazine) alone; (5) after failure of two schemes with csDMARDs, a bDMARD may be preferably used or, alternatively a tsDMARD, preferably combined, in both cases, with a csDMARD; (6) the different bDMARDs in combination with MTX have similar efficacy, and therefore, the therapeutic choice should take into account the peculiarities of each drug in terms of safety and cost; (7) the combination of a bDMARD and MTX is preferred over the use of a bDMARD alone; (8) in case of failure of an initial treatment scheme with a bDMARD, a scheme with another bDMARD can be used; in cases of failure with a TNFi, a second bDMARD of the same class or with another mechanism of action is effective and safe; (9) tofacitinib can be used to treat RA after failure of bDMARD; (10) corticosteroids, preferably at low doses for the shortest possible time, should be considered during periods of disease activity, and the risk-benefit ratio should also be considered; (11) reducing or spacing out bDMARD doses is possible in patients in sustained remission.

AB0417 Biological drugs in the treatment of rheumatoid arthritis: real life data in a brazilian multicentric study

Background Rheumatoid arthritis (RA) is a chronic disease, characterised by inflammatory involvement of the synovial joints. The ”treat to target” concept is well established in the rheumatologic community, however, in many patients, especially in developing countries, its implementation is not feasible. Considering the high costs of treatment com of RA and the limited national epidemiological data available on this disease, we sought to describe the profile of use of biological drugs in Brazilian patients with RA to help the decision-making process by public health managers. Objectives To describe the frequency and time of use of biological drugs in Brazilian patients with rheumatoid arthritis. Methods The REAL – RA in real life in Brazil – is a multicenter prospective cohort study, with twelve-month follow-up period. To be included in this study, consecutive patients from 11 tertiary rheumatology centres had to meet the 1987 ACR or the 2010 ACR/European League Against Rheumatism (EULAR) criteria. Data were collected during routine clinical care and previous medical records were used as secondary sources. The present study present data taken from the participants’ initial assessment. This research was approved by the Ethics Committees of each centre. Results A total of 1125 patients were analysed. 89% were women with a mean age of 56.6 years. The main clinic data were: DAS 28 (median)=3.52, HAQ (median)=0.87 and CDAI (median)=9. 1022 (90.84%) used synthetic DMARDs and 406 (36.09%) biologic therapy. The frequency of use of the biologic therapy was: abatacept (73 patients/6.49%), etanercept (66/5.87%), tocilizumab (60/5.33%), adalimumab (54/4.8%), infliximab (50/4.44%), rituximab (49/4.36%), golimumab (37/3.29%), certolizumab (17, 1.51%). The time of use of the biological drugs is presented in table 1.Abstract AB0417 – Table 1 Time (in years) of use of biological drugs in patients with rheumatoid arthritis DRUG MEAN MAXIMUM ABATACEPT 1.95 8 ADALIMUMAB 1.70 12 CERTOLIZUMAB 0.63 2.0 ETANERCEPT 1.49 9.0 GOLIMUMAB 0.65 2.0 INFLIXIMAB 1.56 9.0 RITUXIMAB 1.27 6.0 TOCILIZUMABE 2.0 6.0 Conclusions The therapeutic profile of this cohort of Brazilian RA patients shows some interesting results. The relatively high number of patients on biologics, compared to other studies, may be related to fact that the centres involved were reference centres, probably dealing with more difficult cases. References [1] Azevedo AB, Ferraz MB, Ciconelli RM. Indirect Costs of Rheumatoid Arthritis in Brazil. Value in Health2008;11(5):869–877. [2] Boonen A, Severens JL. The burden of illness of rheumatoid arthritis. Clin Rheumatol2011;30(Suppl 1):S3–S8. Disclosure of Interest None declared

Work disability in fibromyalgia and other soft tissue disorders: analysis of preventive benefits in Brazil from 2006 to 2015

BackgroundFibromyalgia is a common chronic disease characterized by persistent diffuse pain, fatigue, sleep disorders and functional symptoms.The disease can have negative consequences in personal and social life, in addition to significant public health expenses caused by treatment and work leave.The purpose of this article is to evaluate the number of social security benefits granted due to incapacity for work in Brazil in patients with ICD M79 and variants in the period 2006–2015.There has been no previous study with data referring to work withdrawals caused by fibromyalgia in Brazil.MethodsData for this study were obtained through an official Social Security platform. The disability and retirement benefits were analyzed.ResultsA total of 95,882 social security disability benefits were granted to ICD M79 and variants in the period from 2006 to 2015.Regarding gender, 69,420 benefits (72.3%) were granted to women and 26,562 (27.7%) to men. Regarding the types of benefits, we found 93,556 (97.5%) temporary withdrawals from work and 2426 (2.5%) permanent withdrawals. When comparing the initial and final years, we observed a significant reduction in the number of awards: 15,562 in 2006 to 6163 in 2015.ConclusionFibromyalgia was an important cause of withdrawal due to incapacity for work in Brazil, with consequent public health expenditure.These data may serve as a basis for new studies and can alert professionals of the need for adequate management of fibromyalgia to reduce work withdrawal and its consequences.

Gut Parasites in Rheumatoid Arthritis: Imminent Threat or Protective Effect?

Parasitic infections are among the oldest and most common infections in humans. Host defense alterations caused by autoimmune diseases or immunosuppressive drugs can cause modifications of the symptoms: indolent parasites can be reactivated, asymptomatic patients may experience new symptoms, or mild or moderate symptoms can become serious and, rarely, may lead to death. In recent years, new drugs have been used in the treatment of rheumatoid arthritis (RA), causing a greater level of immunosuppression and, therefore, more concerns regarding the risk of serious parasitic diseases. Of note, experimental studies have demonstrated that the immunomodulation induced by infection with helminths can minimize the occurrence and severity of rheumatoid arthritis. Products derived from helminths (such as glycoprotein ES-62) can exert favorable effects in RA patients via their anti-inflammatory actions. Greater knowledge of these substances may serve as a basis for the development of new treatments for RA. The full impact of parasitic diseases on patients with rheumatoid arthritis remains controversial, and further studies are warrented.

Contribuição dos métodos de imagem na avalição do envolvimento pulmonar na dermatomiosite

A dermatomiosite (DM) e uma desordem generalizada caracterizada por miopatia inflamatoria e comprometimento cutâneo tipico. A miopatia e representada por fraqueza da musculatura proximal das regioes escapular e pelvica, caracteristicamente simetrica, indolor, de inicio e progressao lentos. No entanto, o grau de inflamacao pode variar desde clinicamente inaparente (como na dermatomiosite sem miosite) ate casos graves, de inicio agudo, com acometimento da musculatura intercostal, levando a insuficiencia respiratoria. O comprometimento cutâneo tipico apresenta papulas de Gottron (patognomonicas), sinal de Gottron, heliotropo, entre outros menos tipicos, como eritema linear sobre a superficie extensora das maos, vasculite periungueal, hipertrofia das cuticulas, sinal do V ou do xale e as chamadas maos de mecânicos (associadas a sindrome antisintetase)(1,2). Outros orgaos internos podem estar envolvidos, dentre eles o pulmao. Ha quatro formas de doenca pulmonar: alveolite difusa, com tosse e dispneia rapidamente progressiva, encontrada nos pacientes com sindrome anti-sintetase; uma forma mais lentamente progressiva, em que a miopatia mascara a gravidade do envolvimento pulmonar (a mais frequente); pneumonia de aspiracao e uma forma assintomatica na qual ha apenas os achados radiograficos e/ou funcionais correspondentes a doenca intersticial(3). Esta ultima ocorre em 5% a 30% dos pacientes na dependencia dos metodos utilizados na investigacao(4). O pneumomediastino e uma complicacao rara(5) e esta relacionado a pior prognostico(6). Sua etiopatogenese ainda nao foi esclarecida, mas os seguintes mecanismos foram levantados na literatura: vasculopatia pulmonar levando a necrose e ruptura da arvore traqueobronquica, corticoterapia provocando uma fragilidade tissular, bem como aumentando o risco de infeccoes e fibrose pulmonar com ruptura de cistos e bolhas subpleurais(7-11).