Roopa Rawat

Preventing tuberculosis flare in patients with inflammatory rheumatic diseases receiving tumor necrosis factor-α inhibitors in India - an audit report.

Objective. To test the efficacies of a strategy for preventing tuberculosis (TB) in Indian patients with inflammatory rheumatic diseases (IRD) treated with tumor necrosis factor-α (TNF-α) inhibitor. Methods. The screening strategy included tuberculosis skin test (TST), QuantiFERON-TB Gold (QTG) test, standard chest radiograph, and contrast enhanced-computerized tomography of the chest (CT). Results. Among 53 patients screened, 17 (32%) had ≥ 1 test positive, with 5 (9.4%) patients having TB infection (clinical, CT, biopsy). The remaining 12 patients showed latent TB; 1 additional patient with negative screening tests was diagnosed with latent TB retrospectively for he developed TB disease within a few weeks of receiving infliximab. The remaining 35 patients tested negative with all tests. The combination of 4 screening tests gave a sensitivity of 0.83, specificity of 0.74, positive predictive value (PPV) 0.29, and negative predictive value (NPV) 0.97. Only 22 patients could afford treatment with TNF-α inhibitors; 19 of them were negative in the screening tests. Three patients who were positive on TST and/or QTG received prophylactic treatment with TNF-α inhibitor. Since implementation of the screening strategy, only 1 of 22 (4.5%) patients given TNF-α inhibitor developed probable TB disease. Conclusion. With the use of these 4 TB screening tests in India, where TB is highly prevalent, TB could be excluded with a high degree of certainty (NPV 0.97). However, as even this combination of tests has only moderate sensitivity and specificity and poor PPV for detecting TB, vigilance may be advisable even if only one of the tests is positive.

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.

Comparison of patients with ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) from a single rheumatology clinic in New Delhi.

Comparison of ankylosing spondylitis (AS) with non‐radiographic axial spondyloarthritis (nr‐axSpA) classified with the recent ASsessment of spondyloArthritis International Society (ASAS) criteria.

Recommended Screening Strategy for Preventing Tuberculosis Flare in Patients with Inflammatory Rheumatic Diseases Receiving Tumor Necrosis Factor-α Inhibitors in India — Followup Report

To the Editor: We published a strategy for screening of latent tuberculosis infection (LTBI) for prevention of TB flare among patients with inflammatory rheumatic diseases (IRD) receiving tumor necrosis factor-α (TNF-α) inhibitors1. Flare of LTBI has been a serious problem among patients receiving monoclonal antibody-based TNF-α inhibitors in high-burden TB regions of the world, including India. We present results on an additional 33 patients … Address correspondence to Dr. A.N. Malaviya, Flat 2015, Sector B-2, Vasant Kunj, New Delhi, 110070, India; E-mail: anand_malaviya{at}yahoo.com

Is radiographic axial SpA a distinct subset with more severe axial involvement? Comment on the article by Deodhar et al.

To the Editor: We read with great interest the recent article by Deodhar and colleagues (1) in which they discussed several key concerns of the Food and Drug Administration (FDA) regarding the concept of nonradiographic axial spondyloarthritis (axSpA) as put forth by the Assessment of SpondyloArthritis international Society (ASAS) classification criteria (2). The authors conceded that the ASAS classification criteria for nonradiographic axSpA may have some degree of nonspecificity due to the inclusion of certain nonspecific “SpA features” (namely, inflammatory back pain, family history, and enthesitis). They suggested that adding objective parameters, e.g., increased levels of acute-phase reactants (among others) for classifying nonradiographic axSpA could make the ASAS classification criteria more specific. This may dispel some of the concerns of the FDA by making this subgroup of patients eligible for appropriate treatment, including treatment with biologic agents. We extracted data from our clinic’s rheumatologyspecific electronic medical record system (3), as part of a small project for defining characteristic features of axSpA in India. Patients were classified according to the ASAS criteria (2), and a large number of variables were studied. For 290 patients with axSpA, standard radiographs of the sacroiliac joints were available for assessing sacroiliitis. Based on the modified New York criteria for evaluating sacroiliitis (4), 188 patients were categorized as having radiographic sacroiliitis (group 1). In the remaining 102 patients, sacroiliitis was not observed on standard radiographs (group 2). Statistical comparisons showed significant differences between the groups but only in the following variables: disease duration (longer in group 1; P 0.013); onset with axial and sacroiliac joint symptoms, e.g., buttocks pain (more prevalent in group 1; P 0.0001); male:female ratio (higher in group 1; P 0.0052); disease course with predominantly axial involvement (more prevalent in group 1; P 0.0358); Bath Ankylosing Spondylitis Metrology Index (BASMI) (higher in group 1; P 0.0009); and syndesmophytes (exclusively in group 1) (Malaviya et al: unpublished observations). We concluded that despite being classifiable as having axSpA (according to the ASAS criteria), patients with radiographic SpA could be a distinct subset in whom axial involvement is more severe. In light of the suggestion made by Deodhar and colleagues, we reanalyzed our 102 patients with nonradiographic axSpA. Among these patients, 45 had high C-reactive protein (CRP) levels ( 8 mg/liter). This subgroup of patients with nonradiographic axSpA was then compared with 187 of the patients with radiographic axSpA. Among the significant differences between group 1 and group 2 (as described above), several became nonsignificant when group 1 was compared with the subgroup of patients with nonradiographic axSpA who had a high CRP level, as follows: male:female ratio (P 0.0525), disease duration (P 0.8615), onset with axial and sacroiliac joint symptoms (buttocks pain) (P 0.7940), and BASMI (P 0.3474). However, a predominantly axial pattern was still significantly more common among patients with radiographic SpA compared with patients with nonradiographic axSpA and high CRP levels (P 0.0467). Moreover, syndesmophytes were observed in 8.6% of patients with radiographic axSpA, while none of the patients with nonradiographic axSpA, even those with a high CRP level, showed syndesmophytes or bamboo spine. Our analysis on patients with radiographic axSpA strengthens, to some extent, the suggestion by Deodhar et al that including “high CRP levels” among “SpA features” in the ASAS criteria for nonradiographic axSpA may make the criteria more specific and acceptable. However, a predominance of the axial pattern of involvement and spinal damage (syndesmophytes, bamboo spine) in radiographic axSpA may suggest that these could be 2 distinct subsets of axSpA with different natural histories. Only long-term studies on the natural history of axSpA may be able to resolve the issue.

Herpes Zoster Vaccination Compliance: The Role of Specialist Rheumatology Nurses

To the Editor: We read the paper by Sheth, et al 1 with great interest. The authors have brought out an important aspect of patients with autoimmune immune rheumatic diseases (AIRD) with the example of rheumatoid arthritis (RA) being at an increased risk of herpes zoster (HZ) infection. This is because of the disease activity itself, the immunosuppressive disease-modifying therapies, and other comorbidities2. In fact, such patients show a greater than 2-fold increased risk of serious infection and up to a 4-fold increase while receiving longterm glucocorticoids. Infection is one of the leading causes of morbidity and … Address correspondence to Dr. R.D. Thakran, Indian Spinal Injuries Centre, Sec-C, Vasant Kunj, New Delhi, 110070 India. E-mail: ravita_33{at}yahoo.com

The Nonradiographic Axial Spondyloarthritis, the Radiographic Axial Spondyloarthritis, and Ankylosing Spondylitis: The Tangled Skein of Rheumatology

Since 1984 the diagnosis of ankylosing spondylitis (AS) has been based upon the modified New York (mNY) criteria with mandatory presence of radiographic sacroiliitis, without which the diagnosis is not tenable. However, it may take years or decades for radiographic sacroiliitis to develop delaying the diagnosis for long periods. It did not matter in the past because no effective treatment was available. However, with the availability of a highly effective treatment, namely, tumour necrosis factor-α inhibitors (TNFi), the issue of early diagnosis of AS acquired an urgency. The Assessment of SpondyloArthritis International Society (ASAS) classification criteria published in 2009 was a significant step towards this goal. These criteria described an early stage of the disease where sacroiliitis was demonstrable only on MRI but not on standard radiograph. Therefore, this stage of the disease was labelled “nonradiographic axial SpA” (nr-axSpA). But questions have been raised if, in search of early diagnosis, specificity was compromised. The Federal Drug Administration (FDA, USA) withheld approval for the use of TNFi in patients with nr-axSpA because of issues related to the specificity of these criteria. This review attempts to clarify some of these aspects of the nr-axSpA-AS relationship and also tries to answer the question whether ASAS classifiable radiographic axial spondyloarthritis (r-axSpA) term can be interchangeably used with the term AS.

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.

Dr. Malaviya, et al reply

To the Editor: We are grateful to Dr. Abud-Mendoza, et al for their observations on our report1. We fully agree that tuberculin skin test (TST) alone may not be an ideal method for screening of latent tuberculosis infection (LTBI), especially in high-burden TB regions. It was for this reason that we used 3 different LTBI screening methods: (1) a higher than usual dose of tuberculin (10 TU) for the Mantoux test; (2) added Quanti-FERON-TB … Address correspondence to Dr. Malaviya; E-mail: anand_malaviya{at}yahoo.com.