Vineeta Shobha

Pulmonary Hemorrhage in Henoch-Schönlein Purpura: Case Report and Systematic Review of the English Literature

BACKGROUND Diffuse alveolar hemorrhage (DAH) is a rare complication of Henoch-Schönlein purpura (HSP) and data on its prevalence, management, and outcomes are scant. OBJECTIVES To enable evidence-based management of DAH in HSP. METHODS A case report and a systematic review were conducted of all reported cases of DAH complicating HSP in the English literature. RESULTS DAH predominantly affects older male children and adults with HSP. The occurrence of DAH in HSP is rare and the reported prevalence ranged from 0.8% to 5%. DAH occurred variably after the diagnosis of HSP, ranging from 2 days to 18 years. Hemoptysis (75%), drop in hemoglobin (74%), and chest infiltrates (94%) were the most common clinical findings. Lung biopsy showed leukocytoclastic vasculitis with alveolar hemorrhage (69.2%) or only alveolar hemorrhage (31.8%) with variable IgA staining by immunofluorescence. DAH was frequently severe and 50% of the patients required mechanical ventilation. Cyclophosphamide and pulse methylprednisolone for DAH was associated with better outcomes, particularly in patients who were already receiving steroids at the time of DAH. Steroids and immunosuppressants were administered for a median duration of 9 and 4.5 months, respectively. Systemic recurrences (27.7%) and recurrences of DAH (8.3%) were frequent. DAH was associated with high mortality (27.6%) and morbidity (persistent urinary abnormalities, 12%; chronic renal failure, 9%; complications of therapy, 27%). CONCLUSIONS DAH is a life-threatening complication in HSP. Current protocols use pulse methylprednisolone and cyclophosphamide for 6 months.

Temporal arteritis: A case series from south India and an update of the Indian scenario

Objective: To study the clinical, pathological and prognostic profile of patients with temporal arteritis in India. Materials and Methods: The study was conducted in a tertiary care center from south India from 2005 to 2010 in the departments of neurology and medicine. The details of all patients that satisfied the ACR 1990 criteria for diagnosis of temporal arteritis were reviewed. The clinical presentation, laboratory parameters and biopsy findings of the patients were analyzed and compared with other studies from India done over the last decade. Results: A total of 15 patients were diagnosed with temporal arteritis. The male:female ratio was 1.5:1. The mean age of onset was 67.58 years. Mean time for detection after onset of symptoms was 2.56 months. Typical manifestations included headache (100%), temporal artery tenderness (100%), jaw claudication (20%), polymyalgia rheumatica (53%) and visual manifestations (20%). The erythrocyte sedimentation rate was elevated in all patients. Biopsy was done in 13 patients, with 11 of them being positive. All patients responded to steroids well, with most patients being symptom-free within the first 48 h of treatment. Conclusions: Temporal arteritis seems to be underdiagnosed in India, with all patients previously misdiagnosed, and with a mean time from symptom onset to diagnosis of 2.5 months. The clinical presentation of temporal arteritis in India appears to be similar to that of the West, with no gender preference and a slightly younger age group.

Domains and determinants of quality of life in schizophrenia and systemic lupus erythematosus.

Background: The World Health Organization Quality of Life-Bref (WHOQOL-Bref) scale was designed to measure quality of life (QOL) in both medical and psychiatric illnesses. There have been a few studies to date that compare aspects of QOL in medical and psychiatric illnesses. Aim: The aim of the study was to compare QOL in patients with systemic lupus erythematosus (SLE), a chronic medical illness and schizophrenia, a chronic psychiatric disorder. Materials and Methods: In a prospective design, 50 patients with SLE and 50 patients with schizophrenia were assessed on measures of QOL by using the WHOQOL-Bref scale, demographic factors, disease severity, and psychiatric comorbidity. Results: There was a significant difference between the SLE group and the schizophrenia group on the social domain of the WHOQOL-Bref scale but not on other domains. Patients with SLE had lower scores, except on social domain. Disease severity correlated with scores on the physical domain and environmental domain in both illnesses. The presence of psychiatric comorbidity was associated with significantly lower QOL scores in SLE. The presence of insight was associated with nonsignificantly lower QOL scores in schizophrenia. There was a significant association between QOL scores and both income and religious belief system in SLE, while age and duration of illness correlated with QOL scores in schizophrenia. Conclusion: Although the QOLs in schizophrenia and SLE were comparable on all domains except the social domain, the factors that mediate QOL in both these illnesses are different.

Comorbidities and related factors in rheumatoid arthritis patients of south India- Karnataka Rheumatoid Arthritis Comorbidity (KRAC) study

The aim was to study the prevalence of comorbidities in rheumatoid arthritis (RA) patients in everyday clinical practice and their association with disease-specific and demographic factors. The multi-center study recruited 3,247 (at 14 centers, and 265) were excluded due to incomplete data. The number of subjects considered for the analysis was 2982. The mean (±standard deviation) age was 48.98±12.64 years and the male-to-female ratio was 1:5. The data was collected based on a pre-structured pro forma by trained clinical research associates through interview and verification of charts and reports available in the patient records. The following comorbidities were studied: cardiovascular disease, hypertension, diabetes mellitus, hypercholesterolemia, thyroid disease, psychiatric diseases like depression, and pulmonary disease. Hypertension (20.7%), diabetes mellitus (14.4%) and thyroid disease (18.3%) were the most prevalent comorbidities. Hypercholesterolemia (5.3%), pulmonary diseases (2.1%), cardiovascular diseases (0.2%) and depression (0.03%) were prevalent in ≤5% of the study population. The overall presence of comorbidity increased with age and reduced with the duration of illness prior (DOIP). The age, gender, and DOIP differed significantly between groups with and without hypercholesterolemia. Females had a statistically increased prevalence of thyroid disease. The prevalence of comorbidities in RA patients from south India is around 40% and the incidence of comorbidity increased with age. As per the literature evidence, the prevalence in the current study subjects was higher when compared to prevalence of similar diseases occurring in the general south Indian population.

Factors influencing remission in rheumatoid arthritis patients: results from Karnataka rheumatoid arthritis comorbidity (KRAC) study.

To study the prevalence of remission in rheumatoid arthritis (RA) patients and the influence of different factors like literacy, socioeconomic status, presence of comorbidity and treatment strategy in achieving remission.

Efficacy and safety of golimumab in Indian patients with rheumatoid arthritis: Subgroup data from GO-MORE study.

To conduct a subgroup analysis of GO‐MORE trial Part 1, comparing efficacy and safety of add‐on subcutaneous golimumab therapy in rheumatoid arthritis (RA) patients enrolled from and outside India.

Common anti-infective prophylaxis and vaccinations in autoimmune inflammatory rheumatic diseases

Abstract An exhilarating era for autoimmune inflammatory rheumatic diseases (AIRD) has arrived; new therapeutics are emerging that not only control symptoms, but also may allow a chance for remission. However, enthusiasm must be tempered with judicious caution as gaps in our knowledge remain regarding long-term safety data especially with respect to new onset infections and reactivation of latent infections such as tuberculosis (TB). Chronic vigilance and appropriate anti-infective measures such as trimethoprim/sulphamethaxozole and TB chemoprophylaxis should be instituted whenever indicated to minimise risk. Vaccination is an appropriate choice to prevent substantial number of these infections. In this context, pneumococcal and influenza vaccines are the best evaluated and are recommended by standard vaccination guidelines by most of experts. Some studies have found mildly impaired immune responses to vaccines among patients receiving long-term immunosuppressive therapy and tumour necrosis factor (TNF) antagonists, but post vaccination antibody titres are frequently adequate to provide shield for the majority of immunised individuals. The accumulated data on the safety and effectiveness of vaccines warrant immunisation with the majority of vaccines for patients with AIRD with the exception of live vaccines. In India, however there is a concern about futility of influenza vaccine, as it is feared that the serotypes targeted in this vaccine may not be the prevailing in our geographic area. Vaccination status assessment as soon as diagnosis of any of AIRDs is established and updating to appropriate vaccination status should compulsorily be implemented in daily clinical practice by rheumatologists.

Unravelling thyroid dysfunction in rheumatoid arthritis: History matters.

Autoimmune thyroid disease (AITD) frequently coexists with other systemic autoimmune conditions such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Due to the overlapping and nonspecific nature of symptoms, it is difficult to clinically uncover thyroidal illnesses in RA patients. This study was conducted to estimate the prevalence of thyroid dysfunction including the presence of anti‐thyroid peroxidase (antiTPO) autoantibodies in patients with RA and to analyze symptomatology of thyroid dysfunction in patients diagnosed with RA.

Supplementing Vitamin D: Dangers of too much of a good thing

The practice of checking and supplementing vitamin D even in situations where it is not warranted has become common practice among physicians. While many do not develop ill effects, some patients may suffer from consequent toxicity. This occurs mostly in patients who are vitamin D sufficient or those who have underlying disorders. We report a case of vitamin D supplementation in an elderly lady which resulted in hypercalcemia and pathological calcification.