Karen E. Hansen

Autoantibodies and common viral illnesses

OBJECTIVES To review the literature about common autoantibodies produced in association with viral infection. METHODS Medline review of the medical literature published in English. RESULTS Common viral infections are often associated with low-titer, polyspecific autoantibodies. However, high-titer antinuclear antibodies, double-stranded DNA antibodies, anticardiolipin antibodies, and other subtype antibodies may be found. Hepatitis C and B virus, human immunodeficiency virus, and parvovirus B19 appear to be associated with autoantibodies more commonly than other viruses. CONCLUSIONS Transient autoantibodies resulting from viral infections are not uncommon. Clinical and laboratory follow-up over time will help distinguish between connective tissue disease and self-limited illness.

Vitamin D and musculoskeletal health

Vitamin D is critical for calcium homeostasis. Following cutaneous synthesis or ingestion, vitamin D is metabolized to 25(OH)D and then to the active form 1,25(OH)2D. Low serum vitamin D levels are common in the general population and cause a decline in calcium absorption, leading to low serum levels of ionized calcium, which in turn trigger the release of parathyroid hormone, promoting skeletal resorption and, eventually, bone loss or osteomalacia. Vitamin D deficiency is generally defined as a serum 25(OH)D concentration <25–37 nmol/l (<10–15 ng/ml), but the definition of the milder state of vitamin D insufficiency is controversial. Three recent meta-analyses concluded that vitamin D must be administered in combination with calcium in order to substantially reduce the risk of nonvertebral fracture in adults over the age of 50 years. Fracture protection is optimal when patient adherence to medication exceeds 80% and vitamin D doses exceed 700 IU/day. In addition to disordered calcium homeostasis, low vitamin D levels might have effects on cell proliferation and differentiation and immune function. Randomized, double-blind, placebo-controlled trials are needed to clarify whether vitamin D supplementation is beneficial in cancer, autoimmune disease and infection. This Review focuses on the pathophysiology, clinical correlates, evaluation and treatment of hypovitaminosis D.

Uncertainties in the prevention and treatment of glucocorticoid‐induced osteoporosis

Much knowledge has accrued since the 2001 American College of Rheumatology (ACR) guidelines were published to assist clinicians in the prevention and treatment of glucocorticoid‐induced osteoporosis (GIO). Therefore, the ACR undertook a comprehensive effort to review the literature and update the GIO guidelines [Grossman JM, Gordon R, Ranganath VK, et al. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid‐induced osteoporosis. Arthritis Care Res (Hoboken). 2010;62:1515–1526]. Herein, we review the new guidelines for JBMR readers, highlighting the changes introduced by the 2010 publication. We discuss several patient scenarios for which the new treatment guidelines do not apply, or for which our committee interprets existing literature differently and suggests an alternative approach.

2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis

To develop recommendations for prevention and treatment of glucocorticoid‐induced osteoporosis (GIOP).

Interobserver Reproducibility of Criteria for Vertebral Body Exclusion

We studied reproducibility of the ISCD vertebral exclusion criteria among four interpreters. Surprisingly, agreement among interpreters was only moderate, because of differences in threshold for diagnosing focal structural defects and choice of which vertebra among a pair discordant for T‐score, area, or BMC to exclude. Our results suggest that reproducibility may be improved by specifically addressing the sources of interobserver disagreement.

Acute Kawasaki Disease: Not Just for Kids

Kawasaki Disease is a small-to-medium-vessel vasculitis that preferentially affects children. Kawasaki Disease can occur in adults, but the presentation may differ from that observed in children. Typical findings in both adults and children include fever, conjunctivitis, pharyngitis, and skin erythema progressing to a desquamating rash on the palms and soles. Adults more frequently present with cervical adenopathy (93% of adults vs. 15% of children), hepatitis (65% vs. 10%), and arthralgia (61% vs. 24–38%). In contrast, adults are less frequently affected by meningitis (10% vs. 34%), thrombocytosis (55% vs. 100%), and coronary artery aneurysms (5% vs. 18–25%). We report a case of acute Kawasaki Disease in a 24-year-old man who presented with rash, fever, and arthritis. He was successfully treated with high-dose aspirin and intravenous immunoglobulin (IVIG). Our case highlights the importance of considering Kawasaki Disease in adults presenting with symptoms commonly encountered in a general medical practice.

Vitamin D repletion does not alter urinary calcium excretion in healthy postmenopausal women

To evaluate, in a posthoc analysis of a previous study, whether vitamin D repletion in postmenopausal women with insufficient vitamin D increases urinary calcium excretion, as vitamin D therapy might contribute to hypercalciuria and calcium stones in susceptible individuals, and the effect of vitamin D on the risk of urolithiasis warrants attention.

Vitamin D and calcium levels in Ugandan adults with human immunodeficiency virus and tuberculosis

BACKGROUND Vitamin D increases cathelicidin production, and might alter mortality due to tuberculosis (TB) in human immunodeficiency virus (HIV) coinfection. However, due to abundant sun exposure, vita min D levels might be excellent among Ugandans with HIV and TB. METHODS We measured 25(OH)D and calcium levels in 50 HIV-negative, 50 HIV-infected and 50 TB-HIV coinfected Ugandan adults. RESULTS Mean ± standard deviation 25(OH)D levels were 26 ± 7 ng/ml in HIV-negative, 28 ± 11 ng/ml in HIV-infected and 24 ± 11 ng/ml in TB-HIV co-infected adults (P > 0.05 all comparisons). Vitamin D deficiency (< 12 ng/ml) was present in 10% of the HIV-infected subjects, 12% of the TB-HIV co-infected and none of the healthy controls (P = 0.03 for healthy vs. TB, P > 0.05 for other comparisons); 20% of the healthy controls, 22% of the HIV-positive and 38% of the TB-HIV co-infected subjects (P = 0.047 for healthy vs. TB, P > 0.05 for other comparisons) had suboptimal vitamin D levels (< 20 ng/ml). No participant had hypercalcemia. Serum 25(OH)D levels correlated positively with body mass index (r = 0.22, P = 0.03) and serum calcium levels (r = 0.18, P = 0.03). CONCLUSIONS Ugandan HIV-infected adults with and without TB commonly had suboptimal vitamin D levels. Clinical trials are needed to evaluate the effect of vitamin D on health outcomes in HIV-infected patients with low vitamin D levels.

Use of a questionnaire to assess vitamin D status in young adults

OBJECTIVE We hypothesized that young adults would commonly have vitamin D deficiency and that a questionnaire could help identify subjects with the condition. DESIGN Between January and May 2004, we administered a questionnaire to a convenience sample of young adults. We measured each participants serum level of 25-hydroxyvitamin D (25(OH)D) using a chemiluminescent assay and defined deficiency as serum 25(OH)D < 16 ng/ml. SETTING AND SUBJECTS We recruited young adults living in Madison, Wisconsin without pre-existing conditions affecting vitamin D and/or Ca metabolism. RESULTS One hundred and eighty-four adults (mean age 24 years, 53 % women, 90 % Caucasian) participated in the study. Nearly three in four adults (71 %) had 25(OH)D level <30 ng/ml and 26 % were vitamin D-deficient. In multivariate analysis, persons reporting a suntan (OR = 0.24, 95 % CI 0.09, 0.63, P = 0.004), tanning booth use (OR = 0.09, 95 % CI 0.02, 0.43, P = 0.002) and daily ingestion of two or more servings of milk (OR = 0.21, 95 % CI 0.09, 0.48, P < 0.001) were less likely to be deficient. These three questions provided a sensitivity and specificity of 79 % and 78 %, respectively, for the presence of deficiency. CONCLUSIONS The questionnaire is moderately useful to identify young adults likely to be vitamin D-deficient. Additional revisions of the questionnaire may improve its ability to predict vitamin D deficiency.

Disseminated histoplasmosis in systemic lupuserythematosus: Case report and review of the literature

OBJECTIVES To report a patient who developed both central nervous system systemic lupus erythematosus (SLE) and disseminated histoplasmosis and to review the literature regarding histoplasma infection in patients with SLE. METHODS MEDLINE review of the medical literature published in English. RESULTS Disseminated histoplasmosis occurs rarely in patients with SLE. The main risk factor is treatment with corticosteroids at doses of 20 mg/d or greater. Fever, dyspnea, pleurisy, and weight loss are typical presenting symptoms. The most commonly involved tissues are lung, liver, and bone marrow. In our patient, both SLE flare and disseminated histoplasmosis were present simultaneously. CONCLUSIONS Opportunistic infection is an important complication of SLE and may be difficult to diagnose. Symptoms of infection may mimic those of a lupus flare, or conversely, symptoms may be masked by the use of corticosteroids. Fever, unexplained tissue involvement, atypical clinical patterns, and poor response to immunosuppressive therapy should alert the clinician to aggressively pursue evaluation of possible infection in patients with SLE.