Vinay Sagar

A case series and review of Poncet's disease, and the utility of current diagnostic criteria.

Poncets disease is a well recognized form of reactive arthritis in the presence of extra‐articular tuberculosis. There are very limited case reports even from countries where tuberculosis is common and there are no accepted diagnostic criteria for Poncets disease. In the present study we are describing clinical features of Poncets disease from a tuberculosis‐endemic region along with a proposal of a new diagnostic criteria.

Giant cell arteritis in India: Report from a tertiary care center along with total published experience from India

OBJECTIVES Giant cell arteritis (GCA) is a granulomatous large vessel vasculitis with very scarce data from India. The purpose of this study was to present a comprehensive data of all published Indian cases along with our experience from North India. MATERIALS AND METHODS This was a retrospective study of all patients diagnosed to be having GCA according to the American College of Rheumatology criteria at a large tertiary care hospital. The demographic data, clinical, investigations, treatment details, and outcomes were noted. Details of all case series and case reports published from India were pooled along with our experience in order to generate a cumulative data of all cases from India. This was then compared with several large published case series from South America, Europe, and Asia. RESULTS A total of 72 patients (17 patients in the present series and another 55 patients from other Indian case series and case reports) were identified. The findings of our study are similar to the studies published from other parts of the world, except for the onset of the disease a decade earlier, a male predilection, a lower temporal artery biopsy positivity, and a higher incidence of ophthalmic complications. CONCLUSIONS Indian patients with GCA have an earlier age of onset, male preponderance, and higher ophthalmic complications.

Randomized Controlled Trial Comparing 2 Different Starting Doses of Methotrexate in Rheumatoid Arthritis

PURPOSE Methotrexate (MTX) remains the gold standard disease-modifying antirheumatic drug for the treatment of rheumatoid arthritis (RA). Few studies have compared different starting doses of MTX in RA. We hypothesized that starting with a higher MTX dose may be more effective but associated with more adverse effects. We compared a starting dose of 7.5 versus 15 mg per week of MTX followed by similar fast escalation. METHODS This was an open-label (blinded assessor), parallel-group, randomized controlled trial that included RA patients aged 18 to 65 years, not on MTX, and having active disease (Disease Activity Score for 28 joints using 3 variables [DAS28(3)] ≥5.1). Patients were randomized to receive MTX at a starting dose of 7.5 mg (group 1) or 15 mg (group 2) per week. The dose of MTX was escalated by 2.5 mg every 2 weeks to a maximum of 25 mg. Patients were seen every 4 weeks, and dose escalation was continued if DAS28(3) was >2.6 and there were no laboratory abnormalities (transaminitis [>2 × upper limit of normal] or cytopenia). The primary endpoint was change in disease activity at 12 weeks (assessed by using the DAS28[3]). Secondary endpoints were patient withdrawals and episodes ofcytopenia or transaminitis. Adverse effects were ascertained by using a questionnaire. Both intention-to-treat and per-protocol analyses were performed. FINDINGS We enrolled 100 patients (female:male ratio, 78:22) with a mean (SD) age of 43.6 (10.8) years and a disease duration of 4.7 (4.8) years. At baseline, patients had a mean DAS28(3) of 6.2 (0.7) and a Health Assessment Questionnaire score of 1.3 (0.6). Group 1 (7.5 mg) and group 2 (15 mg) included 47 and 53 patients, respectively, with no significant differences in baseline characteristics. At 12 weeks, the mean dose of MTX reached was 17.3 (4.6) mg in group 1 and 23.6 (3.0) mg in group 2 (P < 0.001). The 2 groups had a similar number of patient withdrawals. The mean change in DAS28(3) at 12 weeks in group 1 (-0.47 [0.86]) and group 2 (-0.55 [0.79]) was not significantly different (P = 0.60). The change in the Health Assessment Questionnaire score was also similar in the groups. The frequency of episodes of transaminitis (6 and 7; P = 0.8) and cytopenia (1 and 2; P = 0.9) did not differ significantly between groups 1 and 2, respectively. Results remained the same according to the per-protocol analysis. Among adverse effects, nausea was more common in group 2 compared with group 1 (relative risk, 1.6 [95% CI, 1.1-2.2]). IMPLICATIONS There were no significant differences in efficacy between the 2 starting doses of MTX. The fast escalation of dose in both groups may have blunted any advantage of starting at a higher dose. Nausea occurred more commonly in patients started on 15 mg of MTX. We suggest longer trials to confirm our findings. ClinicalTrials.gov identifier: NCT01404429.

An unusual cause of recurrent pneumonia in adults

Selective IgM deficiency is a rare primary immunodeficiency defined as isolated low levels of IgM. It presents with recurrent infections and has been described as first presenting in adulthood with recurrent respiratory tract infections. Unlike its better known counterpart of IgA deficiency, this particular immunodeficiency is often overlooked. We present a case of selective IgM deficiency who presented with recurrent respiratory infections.

Nocardia pyomyositis in a patient with granulomatosis with polyangiitis

Dear Editor, Pyomyositis is an infection of the skeletal muscles without involvement of adjoining structures like skin, soft tissue or bone. Staphylococcus aureus is the most common etiological agent reported in all the case series and case reports. Infection with other microorganisms is uncommon, and with Nocardia is very rare, with no reports in the English literature. We are reporting one such case of Nocardia pyomyositis in a patient on immunosuppression for granulomatosis with polyangiitis (GPA). A 63-year-old man with GPA, presented with fever and left thigh pain for 3 days. He was diagnosed as having GPA 3.5 years previously, when he presented with sinusitis, nasal crusting, nasal bleeding, pulmonary nodules, microscopic hematuria, renal dysfunction (serum creatinine 1.5 mg/dL), ventricular failure, antineutrophil cytoplasmic antibodies and anti-PR3 positivity. Cyclophosphamide pulses according to the European Vasculitis Study Group regime were given initially, and he was presently on prednisolone (5 mg/day) and azathioprine (100 mg/day). He had moderate grade (up to 38.3°C) fever for 3 days, associated with severe pain in the left thigh resulting in inability to walk. There was marked local tenderness of the hamstring muscles. Further clinical examination was normal. There was mild anemia (hemoglobin 91 g/L [reference value 120–180 gm/L), total leucocyte count 6000/lL (4–11 9 10/lL), platelet count 344 9 10/lL (150– 400 9 10/lL). Serum electrolytes, renal functions and liver functions were normal. Urine routine examination was also normal. Initial ultrasound of the thigh done 2 days prior to admission was normal. MRI of the thigh region demonstrated abnormal T2 hyperintensity in muscles of the posterior and adductor compartment of the left thigh, extending to the obturator muscles, associated with collections, the largest measuring 6.5 9 4.5 cm in the muscular and intermuscular compartments of the upper thigh (Fig. 1). There were no hip joint effusions. One hundred and sixty-five microliters of frank pus was aspirated under ultrasound guidance. Pus culture grew Gram-positive branching filamentous bacilli of Nocardia species. Intravenous trimethoprim-sulfamethoxazole was given at a dose of 10 mg/kg of trimethoprim, along with amikacin 15 mg/kg, for 21 days. Repeated aspirations of the collections were required during admission, eventually resulting in clinical improvement and radiological resolution over 3 weeks. Oral trimethoprim-sulfamethoxazole was started with a plan to continue it for at least 1 year. Pyomyositis is a purulent disease condition involving skeletal muscles. Various risk factors include human immunodeficiency infection, patients on

Inflammatory optic disc edema due to Sarcoidosis mimicking malignant hypertension

A common ocular manifestation of sarcoidosis is anterior uveitis. Posterior uveitis is uncommon and optic disc edema is rare. We report one such case in which the initial presentation was mimicking malignant hypertension as the patient had a recent record of high blood pressure. However, the painful progressive vision loss due to optic disc edema, along with anterior uveitis, and histological proof of non‐caseating granulomas on transbronchial lung biopsy clinched the diagnosis of ocular sarcoidosis. There was complete resolution of signs and symptoms with institution of steroids. There was also probable cardiac involvement. This case highlights the fact that all disc edemas in a diabetic and hypertensive patients is not just due to malignant hypertension, even if there is a recent history of elevated blood pressure.