Nashwa El-Shaarawy

Correlations of Urinary Biomarkers, TNF-Like Weak Inducer of Apoptosis (TWEAK), Osteoprotegerin (OPG), Monocyte Chemoattractant Protein-1 (MCP-1), and IL-8 with Lupus Nephritis

ObjectiveThis case-controlled study was designed to correlate urinary biomarkers, TNF-like weak inducer of apoptosis (TWEAK), osteoprotegerin (OPG), monocyte chemoattractant protein-1 (MCP-1), and interleukin-8 (IL-8) levels, with renal involvement in a cohort of systemic lupus erythematosus (SLE) patients to examine their diagnostic performance.Patients and MethodsIn 73 SLE patients, and in 23 healthy volunteers, urinary levels of TWEAK, OPG, MCP-1, and IL-8 levels were measured. Disease activity was assessed by total SLE disease activity index, and renal activity by renal activity index (rSLEDAI), and both were correlated with urinary biomarkers. Sensitivity, specificity, and predictive values of individual biomarkers to predict lupus nephritis were also calculated.ResultsSignificantly higher levels of urinary biomarkers were observed in SLE patients with lupus nephritis (LN) compared with those without LN (TWEAK, p < 0.001; MCP-1, p < 0.001; OPG, p < 0.001; IL-8, p < 0.032). Other significantly higher levels were observed in SLE patients with LN compared with control subjects (TWEAK, MCP-1, OPG, and IL-8 p < 0.001). Positive correlations were observed between rSLEDAI and TWEAK (r = 0.612 and p < 0.001), MCP-1 (r = 0.635 and p < 0.001), and OPG (r = 0.505 and p < 0.001).ConclusionsUrinary levels of TWEAK, OPG, and MCP-1 positively correlate with renal involvement as assessed by rSLEDAI with reasonable sensitivity, specificity, and predictive values to detect lupus nephritis while IL-8 was not significantly associated with global or rSLEDAI.

Transient osteoporosis of the hip, complete resolution after treatment with Alendronate as observed by MRI Description of 8 cases and review of the literature

Transient osteoporosis of the hip (TOH), also referred to as transient bone marrow edema syndrome, is most common in middle-aged men and often after trivial trauma or sport-related injuries. Diagnosis is usually made by eliminating other possible causes of hip pain. Magnetic resonance imaging (MRI) plays an important role in diagnosis and demonstrates a typical pattern of bone marrow edema (BME) in the form of diffuse low signal on T1-weighted images and high signal on T2 fat-suppressed or short T1 inversion recovery images. No consensus exists about the management of TOH, as it may progress to avascular necrosis. We describe eight cases of TOH treated with alendronate resulting in improvement of pain and function and complete resolution of BME on MRI. The literature is reviewed regarding TOH and the relationship with bone marrow edema syndrome, avascular necrosis of the hip, and regional migratory osteoporosis. To our knowledge, this is the first report describing the improvement of this condition after of alendronate with documented radiological improvement on follow-up MRI.

Knee Enthesitis and Synovitis on Magnetic Resonance Imaging in Patients with Psoriasis without Arthritic Symptoms

Objective. This case-control study was designed to evaluate magnetic resonance imaging (MRI) findings of knee joints in patients with psoriasis without clinical peripheral or axial joint involvement, and to correlate MRI findings with disease and demographic variables. Methods. In total 48 patients with psoriasis and no clinical evidence of synovitis or enthesitis in any peripheral or axial joints were enrolled. A random sample of 20 healthy subjects without knee or other joint complaints and matched for age and sex served as controls. All patients and controls underwent enhanced MRI studies of both knee joints, and MRI findings were compared. Results. Among 48 patients (96 knees), a total of 90 entheseal lesions were detected, with no enthesitis in 2 cases (6.3%). Signs of continuing inflammation bilaterally were frequently found: soft tissue edema (STE; n = 52), bone marrow edema (BME; n = 20), perientheseal BME (n = 3), cartilaginous erosions (n = 42), and bone erosions (n = 27). In controls, 2 (10%) subjects had BME and another 5 (25%) showed cartilaginous erosions. None showed evidence of enthesitis. Significant correlations were observed between the number of entheseal lesions of both knees vs STE (present vs absent; r = 0.314, p = 0.030) and STE (number of lesions; r = 0.351, p = 0.014). Enthesitis (unilateral vs bilateral) was significantly and positively correlated with STE (r = 0.304, p = 0.036), cartilaginous erosions (r = 0.304, p = 0.036), and villous projections (r = 0.347, p = 0.016). Conclusion. Subclinical synovitis and enthesitis are frequently found in the knee joint of patients with psoriasis. These may be an early sign of psoriatic arthritis.

Arterial vasculopathy in systemic sclerosis: Computerized tomography (CT) angiographic features of macrovascular and microvascular upper limbs arteries

OBJECTIVE To describe the CT angiographic findings of arterial vasculopathy in the major vessels as well as medium and micro vascular affection of the whole upper limbs arterial tree in patients with systemic sclerosis (SSc) with and without digital ulceration. METHODS Twenty-two cases with systemic sclerosis (12 limited and 10 diffuse) were recruited for the study. All patients fulfilled the American Rheumatism Association (ACR) criteria for the classification of SSc. For all patients routine laboratory investigations were performed including complete lipid profile. Computed tomography angiography (CTA) studies for the whole upper limb arterial tree were performed for both upper limbs in all cases. RESULTS CTA studies showed involvement of subclavian arteries in 3 cases and axillary artery was involved in five cases. Brachial artery was affected in 5 cases. In the forearm the radial artery was affected in 4 cases with bilateral involvement in two cases (6 vessels), while ulnar artery was affected in five cases. Unilateral non visualization of the superficial palmar arch was observed in two cases with limited disease, while thinning out of the vessel wall with poor distal run off in 18 cases. A higher number of arterial vasculopathy was significantly associated with systolic pulmonary artery pressure (P=0.001). CONCLUSIONS Macrovascular arterial vasculopathy of upper limbs may occur in SSc irrespective of the disease pattern. Major arteries can be affected in association with other medium sized arteries of the forearms and microvascular arterial branches of the hands.

Lichen Planus in Association with Adult-onset Still’s Disease Successfully Treated with Mycophenolate Mofetil

To the Editor: A 55-year-old woman presented with acute onset of spiking fever, symmetric polyarthritis with intense myalgia, and sore throat. Onset was associated with diffusely itchy purple papules involving the trunk, anterior chest wall, and upper and lower limbs. Initial laboratory investigation showed elevated erythrocyte sedimentation rate (90 mm/h), elevated C-reactive protein (17.8 mg/dl), negative rheumatoid factor (RF), negative anti-citrullinated protein antibody, and negative antinuclear antibody (ANA). Complete blood count showed leukocytosis with white blood cell count 14.7 × 103/μl, anemia with hemoglobin 9.6 g/dl, thrombocytosis with platelet count 802 × 103/μl, and 2-fold increase in serum ferritin levels (350 ng/ml, normal values up to 150 ng/ml). Other laboratory investigations showed elevated liver enzymes [aspartate transaminase 69 IU/l, alanine transaminase 125 IU/l, and elevated creatine phosphokinase (CPK) levels 320 IU/l, normal 40–120 IU/l] with negative virology screening for viral hepatitis. Skin biopsy showed focal thinning of the epidermis with focal destruction of basal layers and focal dermal mononuclear infiltrate, features consistent with the diagnosis of lichen planus … Address correspondence to Dr. Emad; E-mail: yasseremad68{at}yahoo.com

Axial involvement with facet joint arthropathy and bony ankylosis in a case of camptodactyly, arthropathy, coxa vara, pericarditis (CACP) syndrome

Familial arthropathy associated with congenital camptodactyly has been previously recognized as a definite clinical entity in the literature. The clinical spectrum of this disease seems to be variable. The typical features of congenital camptodactyly, arthropathy, coxa vara and pericarditis (CACP syndrome) appear to be a more frequent presentation in children from the Middle East and North Africa. Musculoskeletal presentation of this rare familial form of arthropathy is unique and heterogeneous. In all previous reports, non-inflammatory pattern of arthropathy involving the peripheral joints with typical coxa vara deformity were described, and in a few cases spine abnormalities, including kyphosis, lordosis, or scoliosis. We describe the first case of axial involvement in a typical case of CACP syndrome with facet joint arthropathy and ankylosis at L5/S1 levels.

Magnetic resonance imaging features of hip disorders in an Egyptian pediatric population

Hip disorders in a pediatric population are a diagnostic challenge. The aim of the study is to assess the role of magnetic resonance imaging (MRI) in the evaluation of non-traumatic hip disorders in a series of Egyptian patients and to review the literature on the most common hip conditions. Seventy two consecutive patients [40 males (55.6%) and 32 females (44.4)] with acute onset of hip complaints unrelated to trauma or falls were recruited. All patients underwent an initial full clinical assessment and blood tests as well as contrast enhanced MRI of both hips. The most common diagnosis in this group of Egyptian patients was transient synovitis in 29 (40.3%) cases, followed by seronegative enthesopathy and arthropathy syndrome in 8 (11.1%), septic arthritis in 10 (13.9%), tuberculous arthritis in 4 (5.6%), sickle-cell disease in 7 (9.7%), complicated with septic arthritis in 3 (4.2%), transient bone marrow edema (BME) in 3 (4.2%), osteomyelitis in 2 (2.8%), osteosarcoma in 2 (2.8%), sciatic nerve injury in 1 (1.4%), leukemia with BME in 1 (1.4%), coxa vara of both hips and L5/S1 facet joint ankylosis in 1 (1.4%), and a benign bone cyst in 1 (1.4%). MRI studies showed hip effusion in a total of 51 patients (70.8%), joint space narrowing in 9 (12.5%), and BME in 15(20.8%). MRI is a sensitive tool for assessing hip disorders in a pediatric population and can play an important role in both diagnosis and management of different hip disorders, irrespective of the underlying pathology.

Giant Intraosseous Synovial Cyst with Intraarticular Communication with the Ankle Joint in Longstanding Rheumatoid Arthritis

The term “intraosseous synovial cyst” is used to designate the epiphyseal cyst-like lesions seen in a variety of clinical settings. Extraarticular synovial cysts in rheumatoid arthritis (RA) have rarely been documented in case reports. The same is true for giant intraosseous synovial cysts with intraarticular communication. We describe an adult case of RA with uncontrolled disease, involving a giant intraosseous synovial cyst in the lower end of the …

Antibodies to extractable nuclear antigens (ENAS) in systemic lupus erythematosus patients: correlations with clinical manifestations and disease activity

The aim was to explore possible correlations of antibodies to extractable nuclear antigens (ENA) with clinical manifestations and disease activity indices in systemic lupus erythematosus (SLE) patients. A total of 70 consecutive SLE patients (64 females) were included. Disease activity was assessed by SLE activity index (SLEDAI), and British Isles Lupus Assessment Group (BILAG). Anti-Ro/SSA correlated positively with, headache (r=0.24, p=0.04), blurring of vision (r=0.25, p=0.03) and SLEDAI (r=0.25, p=0.04) and negatively with C3 (r=-0.35, p=0.003). Anti-Ro/SSA correlated with anti La/SSB antibodies (r=0.69, p<0.001), but not with anti-DNA, anti-RNP and anti-Sm antibodies. Anti-La/SSB antibodies correlated with headache (r=0.26, p=0.03), SLEDAI (r=0.25, p=0.03) and negatively with C3 (r=-0.34, p=0.004). Anti-La/SSB did not correlate with anti-RNP or anti-Sm antibodies. Anti-Sm antibodies correlated with disease duration (r=0.34, p=0.003), 24 hours urinary proteins (r=0.31, p=0.008), SLEDAI (r=0.31, p=0.009), BILAG renal score (r=0.29, p=0.02) and negatively with age at onset (r=-0.27, p=0.02), WBCs (r=-0.29, p=0.014) and C4 (r=-0.25, p=0.049). In multivariate analyses, anti-Ro/SSA antibodies remained associated with headache, blurring of vision and C3 and anti-La/SSB antibodies remained associated with C3 and with headache. Anti-Sm antibodies were independently associated with disease duration and total SLEDAI scores, while anti-RNP antibodies remained significantly associated with BILAG mucocutaneous scores only. Antibodies to ENAs are associated with clinical aspects of SLE and may play a role in the assessment of disease activity. Insight into these ENAs may lead to new approaches to diagnostic testing, accurate evaluation of disease activity and lead to target approach for SLE.