Divya Agarwal

Acute abdomen in SLE

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune connective tissue disease with protean manifestations. Most often it presents with mucocutaneous, musculoskeletal or renal involvement. In comparison, gastrointestinal (GI) manifestations of SLE are far less common. The case presented here highlights the differential diagnosis of GI manifestations of SLE that range from non‐life‐threatening to serious life‐threatening complications, including some of the complications of on‐going drug treatments. While some of them present as ‘acute abdomen’, others are more subacute or chronic, yet serious enough to be life‐threatening. The serious GI manifestations of SLE include mesenteric vasculitis causing perforation or hemorrhage with peritonitis, acute pancreatitis and intestinal pseudo‐obstruction. The patient in this paper had clinical features, imaging findings and laboratory parameters that helped the treating physician to narrow down the diagnostic possibilities and finally, in making the diagnosis of lupus‐pancreatitis. She was treated with intravenous ‘bolus’ (i.v.‐pulse) methylprednisolone for 3 days, i.v.‐pulse cyclophosphamide 750 mg (one dose) along with oral methylprednisolone and other supportive measures including blood transfusions. This led to prompt and complete recovery.

Low-dose and high-dose methotrexate are two different drugs in practical terms.

Methotrexate (MTX) was originally synthesised as an anti‐cancer drug. Soon it was also used in immunoinflammatory diseases, mainly in the field of rheumatology. However, the dose used in oncology is several‐fold higher as compared to the dose used in systemic immunoinflammatory rheumatological diseases. This led to the use of terms ‘low‐dose MTX’ (LD‐MTX) and ‘high‐dose MTX’ (HD‐MTX) respectively for its use in immunoinflammatory rheumatological diseases as against its use in oncology. Extensive studies have demonstrated that therapeutic action, clinical indications, adverse effects and mechanisms of action of LD‐MTX and HD‐MTX are quite different. It is somewhat akin to low‐dose aspirin versus high‐dose aspirin with entirely different spectra of therapeutic action and adverse effects. It is important to understand this difference. This would help in allaying unfounded fear of adverse effects of LD‐MTX that is often mistakenly considered the same as that of HD‐MTX used in oncology.

Crystalline to amorphous phase transition of tin oxide nanocrystals induced by SHI at low temperature

Tin oxide (SnO2) thin films were deposited using pulsed laser deposition (PLD) technique on Si substrates. The as-deposited films were irradiated using 100 MeV Ag ions at different fluences ranging from 3×1013 to 3×1014 ions/cm2 at an incidence angle of 75° with respect to surface normal at liquid nitrogen (LN2) temperature. The as-deposited and irradiated films have been characterized using X-ray diffraction (XRD) and atomic force microscopy (AFM) techniques to study the modifications in structural and surface morphological properties. Nanocrystalline film become completely amorphous and nanograins of tin oxide disappeared from the surface as indicated by XRD spectra and AFM micrographs respectively.

Multiple myeloma presenting with musculoskeletal manifestations: a case report

Multiple myeloma (MM) is a malignant plasma cell disorder. Musculoskeletal and skin manifestations of this disorder are rare. Here we report a case of a young male patient presenting with polyarthritis and skin rash resembling vasculitis. Detailed investigations revealed that he was suffering from multiple myeloma in which arthritis was a musculoskeletal complication of the disease.

Practising computer-aided objectified outcome-driven targeted treatment of rheumatoid arthritis in a resource constrained country: results from a single rheumatology clinic

Abstract Aims & Objectives The aim of the study was to test the feasibility of carrying out objectified assessment at each patient visit in a busy rheumatology clinic using a dedicated rheumatology software, adjusting the treatment accordingly to achieve predetermined outcome target of disease activity. The objective was to assess the results of targeted treatment to see if this method of RA treatment achieved better results than those by routine-care treatment that the patients received in the immediate past before coming to this clinic. Patients and Methods RA patients presenting from 1-7-07 to 30-6-09 were included. Specialized rheumatology software (Medic-Aid Rheumatology®) was used for data recording, disease assessment and prescription writing. Details of past-health care providers, the type of treatment taken, method used for measuring treatment outcome were recorded at the first clinic visit. A pre-planned treatment protocol was used, guided by the DAS28 or CDAI values. The treatment response was statistically compared with the disease activity status at the first visit. Results Study included 215 patients; 16% were having low disease activity or were in remission at the first presentation. Sixteen patients (7.4%) dropped out before adequate follow-up. The mean follow-up was for 37 (±12) weeks. Among 199 remaining patients, 83.4% had low disease activity or were in remission at the last follow-up visit. This difference was statistically highly significant. Conclusion Using dedicated rheumatology software, it was feasible to carry out objectified assessment of the disease activity and functional status in every RA patient in real-time at each follow-up visit in a routine OPD setting. Objectified computer-aided assessment and outcome-driven targeted treatment with standard DMARDs achieved low disease activity/remission in a vast majority of patients. This could be a practical and highly effective treatment strategy for patients with RA in a resource-constrained country like ours.

Vaccination as a triggering agent for the development of rheumatoid arthritis

Dear Editor, Rheumatoid arthritis (RA) is an autoimmune disease of unknown aetiology. Current thinking on its etiopathogenesis is related to a close interplay between a genetically determined hyper-reactive innate immune system, a genetically predisposed adaptive immune system and some environmental factor(s). The environmental triggers that have been implicated in its etiopathogenesis include smoking, viruses and bacterial products. One of the triggering agents occasionally implicated in RA has been vaccination. Recently we saw a 46-year-old man with a 6-week history of symmetric inflammatory polyarthritis of insidious onset. There was history of a stray-dog bite on the left leg (category III), 1 week prior to the development of symptoms. He was given post-exposure rabies prophylaxis with purified vero-cell culture rabies vaccine (ABHAYRAB ) on days 0, 3 and 7. He was concomitantly vaccinated with intramuscular tetanus toxoid 1.0 mL on day 0. There was a strong family history of autoimmune diseases, including scleroderma, RA and hypothyroidism. On musculoskeletal examination there were 16 tender and 14 swollen joints, that included a wrist, six metacarpophalangeal, eight proximal interphalangeal, mid-tarsal and metatarsophalangeal joints bilaterally. The calculated Disease Activity (DAS)-28 value was 5.51. Investigation results were as follows: erythrocyte sedimentation rate (ESR) 24 mm at 1 h; high sensitivity-C-reactive proteins 16.7 mg/L; platelets 219 · 10/lL; rheumatoid factor (RF) 26.3 IU/mL (low titre positive); anticyclic citrullinated peptide (CCP) 121.92 U/mL and human leucocyte antigen (HLA) B27 positive. Radiograph of both hands and feet were normal. He was prescribed methotrexate, hydroxychloroquine and low-dose methylprednisolone 16 mg once a week and 4 mg daily which was tapered off over the period of the next 2 months. At 2 months follow-up he showed marked improvement with no swollen or tender joints and a DAS-28 value of 2.22 (remission). On second follow-up after 10 months he continued in remission (DAS-28 1.53). This case could be classified as RA according to 1987 criteria as well as 2010 revised criteria of the American College of Rheumatology. The onset of the symptoms was within 1 week of two vaccinations, namely rabies and tetanus toxoid. The temporal relationship of the administration of vaccines and the onset of RA suggested the possibility of a causal association. Tetanus and hepatitis B vaccines have been often implicated in triggering the development of RA. The relationship between immunisation and development of arthritis has three possible explanations. First, this could be simply a chance occurrence with no causal relationship. Second, the vaccination could precipitate a specific form of ‘reactive’ arthritis that is distinct from RA and that is usually self-limiting. The third possible mechanism could be through immunological perturbations caused by the vaccination that may actually trigger the development of RA. The patient reported here could have the third possible mechanism for his disease. It is known that killed vaccines can induce the formation of auto-antibodies like RF and autoimmunity in humans. Of course, appearance of RF by itself does not always lead to the development of RA in the post-immunisation period. However, a person with a strong family history of RA may have increased chances of developing RA in the post-immunisation period. The implicated mechanism for vaccines as a trigger for autoimmunity could be an antigen of either a recombinant vaccine or a live attenuated viral vaccine which may resemble the host antigen and trigger auto-immunity through molecular mimicry. There is also an association between the presence of HLA B27 and/or HLA DR1 or DR4 and the development of RA. However, HLA B27 expression is not a pre-requisite for arthritis linked to vaccines, although its presence may predict more prolonged and severe episodes. There are also coincidental suggestions that administration of multiple International Journal of Rheumatic Diseases 2011; 14: e8–e9

Granular corneal dystrophy: an enigma resolved

PurposeTo report the intra-familial phenotypic variation of granular corneal dystrophy (GCD) across different age groups.MethodTwo cases of GCD belonging to the same family (mother and daughter) were assessed and clinical findings were noted.ResultAn 18-year-old female with complaint of glare, on examination showed brownish granules involving bowman’s layer and superficial corneal stroma suggesting a diagnosis of Bowman layer dystrophy. Screening of her mother revealed multiple diffuse white granular opacities with snowflake appearance involving the central cornea. The intervening cornea was clear and limbus was not involved. Focal illumination showed deep stromal involvement. All these findings were typical of GCD. Genetic analysis revealed mutation of TGF beta-1 located on 5q31 which was consistent with our clinical diagnosis of GCD.ConclusionVariable clinical presentation of GCD in different age groups can lead to diagnostic dilemma. Screening of family members can be helpful especially when dealing with early cases of GCD.

Formation and modifications of nanostructures of tin oxide by SHI irradiation

We deposited thin films of tin oxide (SnO2) by the thermal evaporation method on quartz and Si substrates. The as-deposited films were irradiated using 100 Mev Ag ions at different fluences ranging from 1×1012 to 1×1013 ions/cm2. Pristine and irradiated films were characterized for surface topographical study using atomic force microscopy. Pristine films on both types of substrates (Si and Quartz) are featureless. Irradiation at the lowest fluence (1×1012 ions/cm2) induces the nanostructures at the surface and higher fluence irradiations change the shape and size of these nanostructures. The value of roughness and growth exponent, as evaluated from power spectral density analysis, indicates that the formation of nanostructures is mainly due to the swift heavy ion-induced surface diffusion process. We have tried to explain the results in the framework of the thermal spike model.

100 MeV Ag Ion Irradiation Induced Structural and Optical Modifications in PLD Grown Tin Oxide Thin Films

Tin oxide thin films were deposited by pulsed laser deposition (PLD) technique on quartz and Si substrates. The as‐deposited films were irradiated using 100 MeV Ag ions at different fluencies. The as‐deposited and irradiated films have been characterized using XRD and UV‐Vis techniques to study the changes in structural and optical properties. Crystallinity has decreased and band gap has increased from 3.92 eV to 4.24 eV as indicated by XRD and UV‐Vis spectroscopy.

Routine laboratory testing for HLA-B*27 gene: Flowcytometry-based technique gives occasional false-negative results

drugs, TNF-α blockers in patients with early and longstanding disease and ineffectiveness of conventional DMARDs in ankylosing spondylitis. Prof. Naoyuki Kamatani spoke about genome-wide association study (GWAS), a powerful method to identify associations between genomic and phenotypic variations, which may also be used to identify targets of new drugs. The concurrent sessions were equally edifying. Personally, the sessions on RA, SLE (allogenic mesenchymal stem cell transplantation and lupus nephritis), autoimmune diseases (PSS and inflammatory myopathies) and gout were highly rated. The industry sponsored symposiums also maintained high standards. I was really elated by the number of oral presentations awarded at the symposium. It was encouraging to listen to a good number of young researchers present their work on the platform, which seldom happens in large events. A good number of didactic posters demonstrated the wealth of clinical research in the field of rheumatology. It was really energizing to have healthy discussions with a few of the young researchers in clinical rheumatology. In conclusion, the inaugural APLAR Symposium, by all counts, was a grand success, attaining its objectives, with a diverse and educative scientific programme, incorporating a good portion of topics within rheumatology.