Maria Cecília da Fonseca Salgado

Recomendações sobre diagnóstico e tratamento da esclerose sistêmica

Descricao do metodo de elaboracao das evidencias Os integrantes da Comissao de Esclerose Sistemica da Sociedade Brasileira de Reumatologia (bienio 2010-2012) participaram do Curso de Elaboracao de Evidencias da Associacao Medica Brasileira, em Sao Paulo, durante o primeiro semestre de 2011. As questoes foram propostas e discutidas pela internet, no segundo semestre de 2011. As 15 questoes clinicas consideradas relevantes foram estruturadas por meio da estrategia do P.I.C.O. (Paciente; Intervencao ou Indicador; Comparacao; Outcome). As estrategias de busca avaliaram as bases de dados MEDLINE, EMBASE, Scielo/Lilacs, Cochrane Library ate setembro de 2012 (Apendice). Os artigos selecionados na primeira estrategia de busca foram submetidos a avaliacao critica das evidencias, utilizando-se o escore de Jadad. Foram considerados tambem estudos observacionais e series de casos na ausencia de ensaios clinicos randomizados. Foi realizada insercao de estudos relevantes obtidos por busca manual. Posteriormente, foram elaboradas as respostas as perguntas das Recomendacoes, em que cada referencia bibliografica selecionada apresentava o correspondente grau de recomendacao e forca de evidencia cientifica. Para as Recomendacoes finais, as referencias bibliograficas foram atualizadas ate dezembro de 2012, redigidas em texto unico pelo coordenador, e submetidas aos coautores em quatro turnos, para elaboracao do texto final. Grau de recomendacao e forca de evidencia A: Estudos experimentais e observacionais de melhor consistencia. B: Estudos experimentais e observacionais de menor consistencia. C: Relatos de casos (estudos nao controlados). D: Opiniao desprovida de avaliacao critica, baseada em consensos, estudos fisiologicos ou modelos animais. Objetivo Estabelecer as recomendacoes para o manejo e para o tratamento da esclerose sistemica.

Recommendations for the management and treatment of systemic sclerosis.

Description of the method to elaborate the evidence The members of the Comissao de Esclerose Sistemica da Sociedade Brasileira de Reumatologia (Systemic Sclerosis Commission of the Brazilian Society of Rheumatology, SBR) 2010- 2012 took part in the Evidence Preparation Course given by the Associacao Medica Brasileira (Brazilian Medical Association, AMB) in Sao Paulo in the first semester of 2011. The questions were formulated and discussed via internet in the second semester of 2011. The 15 clinical questions considered to be relevant were structured using the P.I.C.O. method (patient; intervention or indicator; comparison; outcome). The literature search was conducted by searching the databases MEDLINE, EMBASE, SciElo/Lilacs, and the Cochrane Library through February, 2012 (Appendix). Critical assessment of the evidence in the selected articles was performed using the Jadad score. The observational studies and case series were considered for analysis when randomised clinical trials could not be located. A manual search located the relevant studies that were included in the analysis. The answers to the questions included in the Recommendations were refined and elaborated, and all of the selected references exhibited the corresponding grade of recommendation and the strength of scientific evidence. The references were updated through December, 2012, entered into a single file by the coordinator, and sent to the co-authors in four successive rounds for preparation of the final version. Grades of recommendation and strength of evidence A. Most consistent experimental and observational studies. B. Less consistent experimental and observational studies. C. Case reports (uncontrolled studies). D. Opinion that is not substantiated by critical evaluation, based on consensus, physiological studies or animal models. Objective To establish recommendations for the management and treatment of systemic sclerosis.

Carpal tunnel syndrome after chikungunya infection

Chikungunya virus (CHIKV) is an arbovirus of the Togaviridae family, genus Alphavirus. It has attracted increasing attention in the last decade for its global spread and large number of epidemics. Infection with CHIKV causes debilitating inflammatory rheumatism. Carpal tunnel syndrome (CTS) is a focal neuropathy frequently associated with compression of the median nerve in the wrist and rheumatic disorders. A case of CHIKV infection with severe arthritis and CTS in a 41-year-old Brazilian woman is reported. The patient had a history of fever (38.5–40 8C), followed by severe pain and swelling in her right knee, with difficulty performing a flexion movement. The pain intensity increased within 24 h and spread to the knee, wrist, fingers, and feet. One week later, stiffness and constant tingling began in the left hand, which was relieved with movement. The cramp was more frequent at night and was associated with a cold sensation in the tips of the left fingers. At that time, the patient complained of pain in the shoulder joints, with greater intensity on the left side, and stiffness in the neck. She had no history of other comorbidities. Forty-five days after the onset of symptoms, there was a bilateral decreased tactile sensitivity at the thenar eminence, as well as an inability of both thumb opponency and bending of the last two phalanges of the left index finger (Figure 1). Routine blood analysis was normal. RT-PCR was negative for Zika virus (ZIKV) and CHIKV in serum and urine, and for dengue

A short neuropsychological evaluation of patients with primary Sjogren's syndrome

OBJECTIVE To investigate cognitive deficits in patients with primary Sjögrens syndrome (PSS). METHOD Eighteen patients with PSS, aged between 25 and 61 years, were subjected to a short neuropsychological battery and compared with 18 patients with multiple sclerosis and 18 healthy controls. RESULTS The analysis of variance (ANOVA) revealed that the clinical groups had significantly worse performance than the control group on the Rey Auditory Verbal Learning Test 3; (F(2,53) =3.500, p=0.038) and 7 (F(2,53) =5.068, p=0.010). The clinical groups had elevated levels of depression on the Beck Depression Inventory (BDI); (p=0.003). The analysis of the data from the Trail Making Test B-A revealed a significant difference between the clinical and control groups (p=0.023). The analysis of covariance with BDI score as a covariate, did not change the outcome. CONCLUSION Our study revealed cognitive deficits in patients with PSS detectable by a short neuropsychological battery.

Acute gouty arthritis as a manifestation of immune reconstitution inflammatory syndrome after initiation of antiretroviral therapy

Immune reconstitution inflammatory syndrome (IRIS) in HIV-infected subjects initiating antiretroviral therapy most commonly involves new or worsening manifestations of previously subclinical or overt infectious diseases. Reports of non-infectious IRIS are much less common but represent important diagnostic and treatment challenges. We report on a 34-year-old HIV-infected male patient with no history of gout who developed acute gouty arthritis in a single joint one month after initiating highly active antiretroviral therapy.

First report of persistent dengue-1-associated autoimmune neurological disturbance: neuromyelitis optica spectrum disorder

Dengue virus (DENV) causes immune-mediated diseases. Neurological involvement represents a severe condition that is rarely observed in DENV-1 infection. Neuromyelitis optica (NMO)/NMO spectrum disorders (NMOSD) are idiopathic immune-mediated demyelinating syndromes of the central nervous system. We report a 17-year-old female with oligosymptomatic DENV-1 viremia, diagnosed as NMOSD. Magnetic resonance imaging showed spinal cord and brainstem lesions. Antibody for aquaporin 4 was negative. DENV-1 RNA infection was detected by serial RT-PCR and confirmed by phylogenetic analysis in serum. Although there are some reports of NMO post-dengue infection, there are not any published accounts of NMOSD with coexistent and persistent DENV-1 infection.

Cerebrospinal Fluid Immunoglobulins as Potential Biomarkers of Chikungunya Encephalitis

Chikungunya virus causes fever and severe polyarthritis or arthralgia and is associated with neurologic manifestations that are sometimes challenging to diagnose. We demonstrate intrathecal synthesis of chikungunya antibodies in a patient with a history of acute infection complicated by encephalitis. The specificity of the intracerebral immune response supports early chikungunya-associated encephalitis diagnosis.