Maria Roseli Monteiro Callado

Prevalência das manifestações clínicas iniciais da granulomatose de Wegener no Brasil: relato de seis casos e revisão da literatura

OBJECTIVES To describe the initial clinical manifestations of Wegeners Granulomatosis (WG) in Brazil. PATIENTS AND METHODS Retrospective analysis of six medical records of WG patients followed-up at the Rheumatology Department of Hospital Geral of Fortaleza (HGF), as well as a bibliographic survey of cases of WG in Brazil on LILACS, SciELO, and MEDLINE databases. RESULTS The study identified 49 patients, 15 (31%) males and 34 (69%) females. Systemic disease was observed in 35 patients (73%): 28 adults, 5 children, and 2 teenagers. Limited disease was observed in 13 adults and 1 child. The average age of onset in adults was 42.2 years (18 to 65 years). Acute clinical manifestations, with the onset of symptoms less than three months before the diagnosis, were observed in 41% (20/49) of the patients, and the insidious presentation in 59% (29/49) of the patients. The prevalence of the initial clinical manifestations in adults with systemic disease (n = 28) was 64% (18/28), upper airways, 36% (10/28), lungs, 18% (5/28), kidneys, 25% (7/28), eyes, 11% (3/28) skin, 25% (7/28), musculoskeletal, and 7% (2/28), neurological. In adults (n = 13) with limited disease, prevalent symptoms included: upper airway, 84% (10/13), eyes, 23% (3/13), and lungs, 15% (2/13). CONCLUSION The prevalence of the initial clinical manifestations of WG in Brazil was similar to that reported in the literature. The lack of specific symptoms may delay diagnosis cases with insidious presentation of the disease and increase the morbidity and mortality in acute disease.

Abatacept as an option therapy in difficult to treat psoriatic arthritis

Psoriatic arthritis (PA) is an inflammatory arthritis associated with cutaneous psoriasis. Treatment consists of non-steroidal anti-inflammatory drugs, corticosteroids at low doses and disease-modifying anti-rheumatic drugs. We relate a case of PA that after the fault of the handlings convecionais to sick we opted for an empiric treatment with Abatacept, based on the current knowledge on the physiopathology of PA and its low hepatotoxicity found in an animal model.

Interpretation of the presence of IgM and IgG antibodies in a rapid test for dengue: analysis of dengue antibody prevalence in Fortaleza City in the 20th year of the epidemic

INTRODUCTION The diagnosis of dengue and the differentiation between primary and secondary infections are important for monitoring the spread of the epidemic and identifying the risk of severe forms of the disease. The detection of immunoglobulin (Ig)M and IgG antibodies is the main technique for the laboratory diagnosis of dengue. The present study assessed the application of a rapid test for dengue concerning detection of new cases, reinfection recognition, and estimation of the epidemic attack rate. METHODS This was a retrospective, cross-sectional, descriptive study on dengue using the Fortaleza Health Municipal Department database. The results from 1,530 tested samples, from 2005-2006, were compared with data from epidemiological studies of dengue outbreaks in 1996, 2003, and 2010. RESULTS The rapid test confirmed 52% recent infections in the tested patients with clinical suspicion of dengue: 40% detected using IgM and 12% of new cases using IgG in the non-reactive IgM results. The positive IgM plus negative IgG (IgM+ plus IgG-) results showed that 38% of those patients had a recent primary dengue infection, while the positive IgG plus either positive or negative IgM (IgG+ plus IgM+/-) results indicated that 62% had dengue for at least a second time (recent secondary infections). This proportion of reinfections permitted us to estimate the attack rate as >62% of the population sample. CONCLUSIONS The rapid test for dengue has enhanced our ability to detect new infections and to characterize them into primary and secondary infections, permitting the estimation of the minimal attack rate for a population during an outbreak.

Uso do abatacepte em uma paciente com artrite psoriásica

Psoriatic arthritis (PA) is an inflammatory seronegative arthritis of unknown origin. Classically, PA has five clinical forms, and asymmetric oligoarthritis is the most common type. We describe the case of a patient with PA refractory to disease-modifying drugs, who developed drug-induced hepatitis after chemoprophylaxis with isoniazid, administered prior to the treatment with an anti-TNFα agent. Due to the risk of activating latent tuberculosis with the administration of anti-TNFα and hepatotoxicity onset caused by the TB treatment and based on the fact that the treatment of PA is similar to the treatment of rheumatoid arthritis, a decision was made to use the empirical treatment with abatacept. Approximately twenty days after the second infusion of the drug, the patient showed clinical improvement, resolution of the arthritis, almost complete disappearance of the skin lesions and improvement of anemia and inflammatory tests.

Antinuclear antibodies: two-step detection strategy

In order to evaluate the performance of the chemiluminescent immunoassay (CLIA) in antinuclear antibodies (ANA) testing, using indirect fluorescent antibody (IFA) on HEp-2 cells as a standard, 209 samples were studied from September to October/2010. The tests were conducted according to the procedures recommended by the manufacturers of the reagents. The interpretation of the IFA results was done according to the Brazilian standards. The charts of patients showing different results between the two techniques were analyzed. The CLIA efficiency was 89%, with a sensitivity of 65%, and a specificity of 94.7%. Nine (4.3%) false-positive and 14 (6.7%) false-negative results were detected. Of these, 13 (93%) represented no risk for the diagnosis and therapeutic management of the patients. The CLIA methodology reduced the need for the IFA manual technique by 77% (160/209). The ANA screening test proved to be a fast and acceptable methodology in the studied population. We established the following criteria for the introduction of an automated ANA screening: (1) Positive results must be confirmed by IFA to characterize the pattern and titer of the antibody. (2) Negative results are issued with a notice to request a new test by IFA when the clinical suspicion of autoimmune disease persists.

Anti-TNF therapy in renal amyloidosis in refractory rheumatoid arthritis: a new therapeutic perspective

Amyloidosis is a heterogeneous group of diseases characterized by extracellular deposits of a material composed of aggregates of amyloid--a poorly coupled protein--far from the site of synthesis, causing target organ dysfunction and clinical disease. Systemic amyloidosis A (AA), secondary to infections and chronic inflammation, especially rheumatoid arthritis (RA), is the most common form of amyloid deposition. Treatment of AA consists in the control or resolution of the baseline condition. The objective of the present study was to report a case of secondary renal amyloidosis in a patient with long-term refractory RA who presented sustained clinical improvement after the use of anti-TNFα (etanercept).

Utilidade da triagem dos anticorpos anti-dsDNA por quimioluminescência, seguida de confirmação por imunofluorescência indireta

OBJECTIVE: The purpose of this study was to evaluate the performance of a chemiluminescent immunoassay (CLIA) to detect anti-dsDNA antibodies, using the indirect immunofluorescence test (IIF) on Crithidia luciliae as a reference. METHODS: The automation system demonstrated 81% efficiency, 100% sensitivity and 82% specificity according to the intrinsic validation process performed using 179 consecutive samples from 169 patients in the beginning of 2011. These patients were subsequently divided into 3 groups according to the co-reactivity of anti-dsDNA results using the 2 methods (reactive, non-reactive and discrepant results). RESULTS: Upon data analysis, 77% (129/169) of the tests were requested by rheumatologists, and 57% (97/169) of the samples were from lupus patients. Both the reactive and non-reactive results of the CLIA were well defined and standardised, and automation reduced the manual labor required by 70% in a safe and high-quality manner. Furthermore, the high prevalence of patients with lupus and nephritis among the CLIA false-positive results corroborates the hypothesis that the actual index of CLIA false positivity is lower than that initially found in this study.

Usefulness of anti-dsDNA antibody screening with chemiluminescence followed by confirmation by indirect immunofluorescence

OBJECTIVE The purpose of this study was to evaluate the performance of a chemiluminescent immunoassay (CLIA) to detect anti-dsDNA antibodies, using the indirect immunofluorescence test (IIF) on Crithidia luciliae as a reference. METHODS The automation system demonstrated 81% efficiency, 100% sensitivity and 82% specificity according to the intrinsic validation process performed using 179 consecutive samples from 169 patients in the beginning of 2011. These patients were subsequently divided into 3 groups according to the co-reactivity of anti-dsDNA results using the 2 methods (reactive, non-reactive and discrepant results). RESULTS Upon data analysis, 77% (129/169) of the tests were requested by rheumatologists, and 57% (97/169) of the samples were from lupus patients. Both the reactive and non-reactive results of the CLIA were well defined and standardised, and automation reduced the manual labor required by 70% in a safe and high-quality manner. Furthermore, the high prevalence of patients with lupus and nephritis among the CLIA false-positive results corroborates the hypothesis that the actual index of CLIA false positivity is lower than that initially found in this study.

Retinite por citomegalovirus (CMV) após terapia imunossupressora para vasculite leucocitoclástica Cytomegalovirus (CMV) retinitis after immunossupressive therapy for leukocytoclastic vasculitis

Cytomegalovirus (CMV) retinitis is a rare disease which mainly affects patients with acquired immunodeficiency syndrome (AIDS). Nevertheless, other immunosuppressed patients, such as the organ transplant recipients, the ones using chemotherapy, patients with systemic lupus erythematosus (SLE) or in treatment with immunosuppressive drugs can also be attacked. The clinical characteristics are blurred vision, decrease of the visual acuity or visual field alterations, generally unilateral, with the possibility of retinal detachment. The visual loss is progressive, evolving in a variable rate until complete amaurosis of the attacked eye. The present case report describes a patient with severe leukocytoclastic vasculitis, submitted to corticosteroid therapy in immunosuppressive doses that evolved with glaucoma, panuveitis by CMV, loss of visual acuity and secondary bacterial infection.

Análise de prevalência e evolução das manifestações neuropsiquiátricas moderadas e graves em pacientes com lúpus eritematoso sistêmico internados no serviço de reumatologia do Hospital Geral de Fortaleza

OBJECTIVE: Evaluate the prevalence and therapy outcome of moderate and severe neuropsychiatric manifestations (NPM) in patients with systemic lupus erythematosus admitted at the Hospital Geral de Fortaleza. METHODS: During two years, 110 patients with consecutive hospitalizations suffering from systemic lupus erythematosus, according to the American College of Rheumatology criteria, were evaluated for moderate and severe NPM. The following parameters were studied in these patients: cause of admission, presence of auto-antibodies, cerebral spinal fluid, radiological imaging, retrospective study of medical records and treatment. RESULTS: The prevalence of NPM was 16.4% (18/110), being seventeen women and one man; the mean age was 29 years; during the hospitalization term, only 33% (6/18) of the patients had an NPM. The occurrence of the first NPM was in 11% (2/18) of the cases before diagnosis, in 33% (6/18) during diagnosis and in 56% (10/18) after diagnosis. The mortality rate was 11% (2/18). The most common NPMs were: seizures and headache (50%), psychosis (22%), cerebrovascular disease (17%), syncope and major depression (11%). Treatment outcome: 28% (5/18) of the patients responded to oral corticoids, 17% (3/18) had a pulse of methylprednisolone and 56% (10/18) were treated with cyclophosphamide. CONCLUSION: The prevalence of NPM in the patients of this study was on the lowest limit reported by the related literature. With no controlled clinical trials, the approach to these patients is based on case reports and the professional experience of the service.