Cristina Costa Duarte Lanna

A cross-sectional study of 130 Brazilian patients with Crohn's disease and ulcerative colitis: analysis of articular and ophthalmologic manifestations.

This is a cross-sectional study that analyzed the pattern and frequency of articular and ophthalmologic manifestations in patients with Crohn’s disease (CD) and ulcerative colitis (UC), with or without signs of active bowel inflammation. One hundred and thirty consecutive patients with CD (n = 71) and UC (n = 59) were examined. Simple X-rays of lumbar spine, sacroiliac joints, and calcaneal bone were performed and human leukocyte antigen (HLA)-B27 was typed. Joint manifestations occurred in 41 (31.5%) patients, 27 (38%) with CD and 14 (23.7%) with UC. Peripheral involvement occurred in 22 patients, axial involvement in five, and mixed involvement in 14. The most frequently involved joints were knees (56.1%), ankles (29.3%), and hips (29.3%), while the predominant pattern was oligoarticular (84.6%) and asymmetrical (65.6%). Enthesitis was identified in seven (5.4%) patients and inflammatory lumbar pain in 13 (10%). Eight of these patients fulfilled the diagnostic criteria for ankylosing spondylitis (6.2%). Radiographic sacroiliitis occurred in 12 patients (9.2%). Ocular abnormalities were present in six patients (6.2%), and HLA-B27 was positive in five (5.8%). In conclusion, the articular manifestations in the present study were predominantly oligoarticular and asymmetric, with a low frequency of ophthalmologic involvement and positive HLA-B27.

Consenso da Sociedade Brasileira de Reumatologia para o diagnóstico, manejo e tratamento da nefrite lúpica

OBJECTIVE To develop recommendations for the diagnosis, management and treatment of lupus nephritis in Brazil. METHOD Extensive literature review with a selection of papers based on the strength of scientific evidence and opinion of the Commission on Systemic Lupus Erythematosus members, Brazilian Society of Rheumatology. RESULTS AND CONCLUSIONS 1) Renal biopsy should be performed whenever possible and if this procedure is indicated; and, when the procedure is not possible, the treatment should be guided with the inference of histologic class. 2) Ideally, measures and precautions should be implemented before starting treatment, with emphasis on attention to the risk of infection. 3) Risks and benefits of treatment should be shared with the patient and his/her family. 4) The use of hydroxychloroquine (preferably) or chloroquine diphosphate is recommended for all patients (unless contraindicated) during induction and maintenance phases. 5) The evaluation of the effectiveness of treatment should be made with objective criteria of response (complete remission/partial remission/refractoriness). 6) ACE inhibitors and/or ARBs are recommended as antiproteinuric agents for all patients (unless contraindicated). 7) The identification of clinical and/or laboratory signs suggestive of proliferative or membranous glomerulonephritis should indicate an immediate implementation of specific therapy, including steroids and an immunosuppressive agent, even though histological confirmation is not possible. 8) Immunosuppressives must be used during at least 36 months, but these medications can be kept for longer periods. Its discontinuation should only be done when the patient achieve and maintain a sustained and complete remission. 9) Lupus nephritis should be considered as refractory when a full or partial remission is not achieved after 12 months of an appropriate treatment, when a new renal biopsy should be considered to assist in identifying the cause of refractoriness and in the therapeutic decision.

Subclinical rheumatic valvitis: a long-term follow-up.

In order prospectively to investigate the frequency and evolution of subclinical valvitis, we selected 40 consecutive patients suffering their initial attack of rheumatic fever, seen in our clinic from 1992 to 1994, and followed-up until 2001, with a mean period of follow-up of 8.1 years, and a standard deviation of 0.6 year. We also assembled a matched control group of 37 healthy children and adolescents. We discovered a murmur of mitral regurgitation in 28 (70.0%) of the patients. In 3 (7.5%) of these patients, there was also a murmur of aortic regurgitation. In the group of 28 symptomatic patients, Doppler echocardiography showed mitral regurgitation in all, and aortic regurgitation in 17. In the group of 12 patients without clinical evidence of cardiac involvement, Doppler echocardiography identified mitral regurgitation in 2, isolated in one and associated with aortic regurgitation in the other. Thus, the frequency of subclinical valvitis was 16.7%. In patients with subclinical valvitis only the aortic regurgitation regressed during the period of follow-up. In the group of 28 symptomatic patients, mitral regurgitation disappeared in 6 (21.4%), aortic regurgitation in 7 of the 17 having this feature (41.2%), while 2 patients (7.1%) developed mitral stenosis. The sensitivity and specificity of cardiac auscultation were, respectively, 93.3%, with 95% confidence intervals between 72.3% and 97.4%, and 100%, with 95% confidence intervals between 65.5% and 100%, for the diagnosis of mitral regurgitation, and 16.7%, with 95% confidence intervals between 4.4% and 42.3%, and 100%, with 95% confidence intervals between 81.5% and 100%, for that of aortic regurgitation. We conclude that the Doppler echocardiogram is an important means of diagnosing and assessing the evolution of subclinical rheumatic valvar lesions, which are not always transient. We suggest that Doppler echocardiography should be performed in all patients with acute rheumatic fever. Subclinical valvitis should be considered as mild carditis, provided that strict criterions are observed in the differential diagnosis from physiological regurgitation, and Doppler echocardiographic findings are analyzed in the context of the other manifestations of the disease.

Nutritional status and food intake in patients with systemic lupus erythematosus

OBJECTIVE Systemic inflammation, therapy with corticosteroids, and reduced physical activity may increase the predisposition to accumulate body fat in patients with systemic lupus erythematosus (SLE). The aim of this study was to assess the nutritional status and food intake of patients with SLE. METHODS One hundred seventy women with SLE were evaluated consecutively in a cross-sectional study. Nutritional status was assessed by subjective global assessment and body mass index. Food intake was assessed by a 24-h recall and a semiquantitative food frequency questionnaire. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), considering P < 0.05 as significant. RESULTS The mean ± SD age of the patients was 39.14 ± 9.98 y, and the duration of the disease was 9.94 ± 6.18 y. Approximately 91.8% patients were classified as being well nourished; 6.5% were classified as suspected or moderately malnourished, and 1.8% were classified as severely malnourished. In terms of body mass index, malnutrition was found in 1.2% of the patients, normal weight in 35.9%, overweight in 35.3%, and obesity in 27.7%. Most patients reported food consumption below the estimated needs for energy. Calcium was the nutrient with the most inadequate intake. Low consumption of fruits, vegetables, and dairy products and a high consumption of oils and fats were reported. CONCLUSION The results showed that patients with SLE have inadequate nutritional status and food intake.

Assessment of nutritional status and physical activity in systemic lupus erythematosus patients

INTRODUCTION Patients with systemic lupus erythematosus (SLE) may present nutritional changes triggered by disease or treatment, and these conditions may interfere with prognosis. OBJECTIVE Assess the nutritional status, physical activity and associated factors in patients with SLE under treatment at the Service of Rheumatology of Hospital das Clínicas/Universidade Federal de Minas Gerais. METHODS A cross-sectional study evaluating the nutritional status, clinical laboratory findings, sociodemographic, and treatment characteristics of 170 SLE female patients. RESULTS Patients aged between 18 and 60 years were included. The mean (SD) age of patients and duration of SLE was 39.1 (10.0) and 9.9 (6.2) years, respectively. Two (1.2%) patients were classified as grade I underweight, 59 (34.7%) eutrophic, 61 (35.9%) as overweight, 37 (21.8%) as grade I obesity, seven (4,1%) as grade II obesity, and four (2,4%) as grade III obesity. Overweight and obesity were significantly associated with older age, lower education, higher SLE damage index, higher serum concentration of complement, higher incidence of hypertension and diabetes mellitus, presence of ovarian failure, and less frequent use of antimalarials Regarding physical activity, 39 patients (22.9%) were classified as inactive, 100 (58.8%) insufficiently active, and 31 (18.2%) active. Of the latter, 13 (43.3%) were in the eutrophic group. CONCLUSION Excess weight was high in this population and associated with some traditional risk factors for cardiovascular disease and SLE poor prognosis. Therefore, encouraging weight control must be part of the main goals in treating SLE patients.

Freqüência de doença cardiovascular aterosclerótica e de seus fatores de risco em pacientes com lúpus eritematoso sistêmico

INTRODUCTION: the pathogenesis of coronary disease in systemic lupus erythematosus patients is not completely understood. Risk factors associated with lupus or its treatment may be associated with traditional risk factors for coronary disease. Such risk factors are more common in patients with lupus. OBJECTIVE: to determine the frequency of cardiovascular disease and traditional risk factors in patients with systemic lupus erythematosus at Rheumatology Division of Hospital das Clinicas of Minas Gerais Federal University. METHODS: 172 patients with systemic lupus erythematosus were evaluated. Cardiovascular events, traditional risk factors and clinical-laboratorial findings were investigated in this cross-sectional research. RESULTS: the mean age (SD) of the patients was 38.5 years (11.2 years). 95.9% were female and 64.5% were non white. Cardiovascular disease was identified in 8 patients (4.7%), with 11 different diagnoses. Three patients had coronary insufficiency, three had stroke and five had peripheral arterial disease. Systemic arterial hypertension was the most frequent risk factor (48.8%), followed by dyslipidemia in 70 patients (40.7%) and hypertriglyceridemia in 51 patients (29.7%). LDL-c > 100 mg/dl was found in 77 patients (44.8%). Among 165 female patients, 67 (40.6%) had menopause, 43.3% of them with early menopause. CONCLUSION: the present study describes the frequency of risk factors for coronary artery disease in a Brazilian sample of lupus patients. The impact of recognition and management of those risk factors in prevention of cardiovascular events should be object of others studies.

Ácidos graxos poli-insaturados ômega-3 e lúpus eritematoso sistêmico: o que sabemos?

Various studies have demonstrated the impact of omega-3 fatty acids on the concentration of C reactive protein (CRP), pro-inflammatory eicosanoids, cytokines, chemokines and other inflammatory mediators. Therefore, the supplementation of these types of lipids may represent additional option treatment for chronic systemic diseases, such as Systemic Lupus Erythematous and other rheumatic diseases. The role of these lipids has not been well established, yet. However, it seems there is a direct relationship between its intake and the decrease of the disease clinical manifestations as well as of the inflammatory status of the patients. Thus, the aim of this manuscript is to present a thorough review on the effects of omega-3 fatty acids in patients with SLE. Bibliographic data set as the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) were searched using as key words: systemic lupus erythematous (SLE), polyunsaturated fatty acids omega-3, eicosapentanoic acid (EPA), docosahexanoic acid (DHA), antioxidants and diet. Manuscripts published up to September 2013 were included. There were 43 articles related to the topic, however only 15 pertained human studies, with three review articles and 12 clinical studies.

Prevalence of serological markers for celiac disease (IgA and IgG class antigliadin antibodies and IgA class antiendomysium antibodies) in patients with autoimmune rheumatologic diseases in Belo Horizonte, MG, Brazil

CONTEXT Patients with autoimmune rheumatologic conditions and celiac disease tend to have a variety of autoantibodies, many of which have no clear pathogenic role. The literature contains frequent reports of celiac disease being more prevalent in patients with rheumatologic diseases, although this remains controversial. OBJECTIVES To investigate the prevalence of positive serum tests for celiac disease, particularly IgA and IgG antigliadin (AGA) antibodies and IgA antiendomysium antibodies (EmA) in patients with autoimmune rheumatologic diseases. A second aim was to correlate positive serum tests with prednisone and immunosuppressant medication. METHODS A total of 190 adults and pediatric patients with a variety of autoimmune rheumatologic diseases (systemic lupus erythematosus, rheumatoid arthritis, juvenile rheumatoid arthritis and spondyloarthrophathies) were evaluated and tested for IgA and IgG antigliadin-antibodies and IgA antiendomysium antibodies. Patients with positive serum tests underwent endoscopic duodenal biopsies for pathology studies. RESULTS There were four positive sera (2.1%) for AGA IgA, all of which tested negative for AGA IgG and EmA. Three sera (1.6%) tested positive for AGA IgG; all were negative for AGA IgA and EmA. The EmA test at a 1:2.5 serum dilution tested positive in 94 patients (49.5%); at a 1:5 serum dilution it was positive in 41 patients (21.6%). Eleven subjects tested positive for EmA at 1:40 dilution; and all of these tested negative for IgA tissue antitransglutaminase (tTG) antibodies. Nine of the 11 EmA-positive patients and all 7 patients with positive antigliadin antibodies tests underwent duodenal endoscopic biopsies, and no significant changes were demonstrated in their duodenal mucosa. A positive EmA was associated with elevated optical density AGA IgA readings; however, there was no relationship between positive EmA and AGA IgG optical density readings. Prednisone and immunosuppressant use were unrelated to AGA IgA optical density readings or AGA IgG readings. These drugs were associated with fewer positive EmA tests. CONCLUSIONS Positive AGAA, AGAG or EmA results are probably nonspecific for the presence of celiac disease among autoimmune rheumatologic disease patients. The intake of prednisone and immunosuprressant drugs seems to reduce the prevalence of IgA EmA, but it does not interfere with antigliadin antibodies tests.Further studies are required to estimate more accurately the prevalence of this disease in rheumatologic patients.

Thyroid abnormalities in systemic lupus erythematosus: a study in 100 Brazilian patients

INTRODUCTION: the association of thyroid abnormalities with systemic lupus erythematosus (SLE) is not well established. OBJECTIVE: to study the prevalence of thyroid dysfunction in hundred lupus patients and evaluate a possible association between thyroid dysfunction and SLE disease activity. METHODS: a total of one hundred patients with SLE underwent assessment for clinical and laboratorial thyroid abnormalities. Clinical activity was assessed using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). RESULTS: seventeen patients (17%) had abnormal thyroid function by laboratory testing, which included ten patients (10%) with subclinical hypothyroidism, two patients (2%) with subclinical hyperthyroidism, four patients (4%) with primary hypothyroidism and one patient with serum thyroxine below the normal range. Regarding antithyroid antibodies, six patients were positive, as follows: four (4%) for antiperoxidase, one (1%) for antithyroglobulin and one (1%) for both antibodies. SLE disease activity was not significantly different between groups, regardless of the presence of thyroid dysfunction. CONCLUSION: these results show that thyroid abnormalities are frequently found in SLE patients. However, it does not appear to be an association between thyroid abnormalities and SLE clinical disease activity.

Increased expression of 2′5′oligoadenylate synthetase and double-stranded RNA dependent protein kinase messenger RNAs on affected skin of systemic sclerosis patients

Scleroderma or systemic sclerosis (SSc) is an autoimmune disorder of unknown aetiology characterized by excessive collagen synthesis and subsequent deposition on the skin and various internal organs. Interferons (IFNs) are well-known immunomodulators and inhibitors of collagen production. However, IFN therapy has been implicated in the development or exacerbation of several autoimmune diseases, including SSc. We analyzed the expression of several interferon-stimulated genes (ISGs) in affected skin of SSc patients (skin tissue and cultured skin fibroblasts). A set of ISGs (PKR, 2′5′OAS, M×A, and 6–16) was analyzed by real-time PCR using RNA extracted from cultured skin fibroblasts and skin tissue of normal individuals and SSc patients. Both normal and SSc affected skin cultured fibroblasts were sensitive to the IFN treatment and presented similar levels of all ISGs tested. However, PKR and 2′5′OAS mRNA expression levels were significantly higher in the affected skin tissue of SSc patients when compared to normal controls. These data suggest that the IFN system plays a role in the pathogenesis of SSc.