Testicular vasculitis: a rare manifestation of rheumatoid arthritis

Testicular vasculitis is a very rare extra-articular manifestation of rheumatoid arthritis (RA). We describe the case of a 53-year-old man diagnosed with RA for eight years, who was poorly controlled and developed rheumatoid vasculitis, which manifested as leg ulcers and peripheral polyneuropathy. The patient also had acute neutrophilic meningitis and was treated with antibiotics and intravenous pulse therapy with methylprednisolone (500 mg daily) for three days, followed by oral cyclophosphamide (2 mg/kg daily) and prednisone. Overall improvement was observed, and the patient was discharged. But 15 days later, the meningitis recurred, and the patient was readmitted and treated again with antibiotics. Three days later, he developed pain and enlargement of his left testicle with gangrene. Unilateral orchiectomy was performed, revealing lymphocytic vasculitis. The patient died two days later due to aspiration pneumonia. This case illustrates a rare and severe manifestation of rheumatoid vasculitis.A vasculite testicular é uma manifestação extra-articular muito rara da artrite reumatoide (AR). Descrevemos o caso de um homem de 53 anos com diagnóstico de AR por oito anos, sem controle adequado da doença. O paciente desenvolveu vasculite reumatoide, manifestada por úlceras de membros inferiores e neuropatia periférica. Apresentou ainda meningite neutrofílica aguda, tendo sido tratado com antibióticos e posterior pulsoterapia endovenosa com metilprednisolona (500 mg/dia) por três dias, seguida de ciclofosfamida (2 mg/kg/ dia) e prednisona orais. O paciente apresentou melhora do quadro, mas 15 dias após a alta hospitalar, houve reativação da meningite bacteriana. O paciente foi reinternado e tratado novamente com antibióticos. Três dias depois da segunda admissão hospitalar, o paciente apresentou dor, aumento de volume do testículo esquerdo e posteriormente gangrena. Foi realizada orquiectomia unilateral e o exame anatomopatológico revelou vasculite linfocítica. O paciente faleceu dois dias após a cirurgia devido a pneumonia aspirativa. Esse caso ilustra a vasculite testicular como uma manifestação rara e grave da vasculite reumatoide.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Is painless synovitis different from painful synovitis? A controlled, ultrasound, radiographic, clinical trial

OBJECTIVE: This study compares the clinical, ultrasonography, radiography, and laboratory outcomes of painless and painful chronic synovitis in patients with established rheumatoid arthritis. METHODS: This cross-sectional study involved 60 patients with rheumatoid arthritis and synovitis in the metacarpophalangeal joints; 30 of the patients did not experience pain, and 30 had experienced pain for at least 6 months prior to the study. The radiocarpal, distal radioulnar, and metacarpophalangeal joints were evaluated using the ultrasound gray scale, power Doppler, and radiography. Past and present clinical and laboratory findings were also evaluated. RESULTS: There were no statistically significant differences between the groups for most of the outcomes. The group with pain scored worse on the disease activity indices (e.g., DAS 28 and SDAI), function questionnaires (HAQ and Cochin), and pinch strength test. A logistic regression analysis revealed that the use of an immunobiological agent was associated with a 3-fold greater chance of belonging to the group that experienced pain. The painless group had worse erosion scores in the second and fifth metacarpophalangeal with odd ratios (ORs) of 6.5 and 3.5, respectively. The painless group had more cartilage with grade 4 damage in the third metacarpophalangeal. CONCLUSIONS: The rheumatoid arthritis patients with both painless and painful synovitis exhibited similar disease histories and radiographic and ultrasound findings. However, the ultrasonography evaluation revealed worse scores in the second and fifth metacarpophalangeal of the synovitis patients who did not experience pain.Fundacao de Amparo a Pesquisa do Estado de Sao PauloUNIFESP communityHospital do Servidor Publico Estadual (IAMSPE)Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Disciplina de ReumatologiaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Diagnostico por ImagemUNIFESP, EPM, Disciplina de ReumatologiaUNIFESP, EPM, Depto. de Diagnostico por ImagemFAPESP - 2012/04867-6SciEL

Ultrassonografia de maos

Objetivos: Comparar o ultrassom articular (US) de maos de pacientes com lupus eritematoso sistemico (LES) e artrite reumatoide (AR) e avaliar a correlacao desse exame com variaveis clinicas, sorologicas, de atividade de doenca e funcionais nessas duas enfermidades. Material e metodos: 62 pacientes com LES e 60 pacientes com AR, tiveram bilateralmente suas articulacoes radiocarpicas, radioulnar distais, faces ventrais e dorsais da 1ª a 5ª metacarpofalangicas, face ventral da 1 a 5 interfalangicas proximais, avaliadas por US (sinovite, Power Doppler, erosao e cartilagem articular). Os seguintes instrumentos de avaliacao clinica foram utilizados: escala visual analogica para dor e edema articular (10 cm); forca de preensao palmar e pinca digital; indices de atividade de doenca (DAS 28 e SLEDAI); questionario funcional (HAQ); e notificacao de caracteristicas clinicas e sorologicas. A reprodutibilidade interobservador foi analisada em 10% da amostra. Considerou-se uma significancia estatistica de 5%. Resultados: Foram avaliados 2108 e 2040 recessos articulares nos grupos LES e AR respectivamente. O grupo AR possuiu ao US maior frequencia de erosao na grande maioria das articulacoes (p <0,001-0,008) e de sinovite e PD principalmente em punhos e 1MCF (p < 0,001-0,027). A cartilagem articular foi a variavel ao US com associacoes estatisticas menos consistentes. SLEDAI teve associacao apenas com PD em 2 MCF dorsal (p 0,027). O DAS 28 teve frequente associacao com captacao de PD na maioria dos recessos articulares estudados (p < 0,001-0,042). Valores mais elevados de HAQ se associaram principalmente ao PD nos pacientes com LES (p < 0,001-0,027). Menores valores de forca de pinca e de preensao se associaram a algumas variaveis ultrassonograficas, principalmente no grupo LES (p < 0,001-0,048). A associacao entre FR/anti-CCP e variaveis ultrassonograficas foram pouco frequentes, principalmente no grupo LES. O unico padrao de FAN associado ao US foi o Homogeneo (p 0,001-0,024). A variavel clinica que mais se associou as variaveis ultrassonograficas no grupo LES foi a omao em paoo (p 0,006-0,037). Quando se subdividiu o grupo LES segundo a presenca de erosao ao US, observou-se associacao do subgrupo erosivo (35,5% dos pacientes) com a presenca de comprometimento hematologico (p 0,016) e a artropatia de Jaccoud (p 0,035). A realizacao da curva ROC e da regressao logistica univariada demonstrou ser o US capaz de diferenciar AR do LES para as variaveis sinovite, PD (articulacoes radiocarpal e radioulnar distal) e erosao (radioulnar distal, 2ª e 5ª metacarpofalangicas). Observou-se boa a moderada reprodutibilidade interobservador (r 0,559-1). Conclusoes: Houve maior alteracao ultrassonografica no grupo AR quando comparado ao LES. O US no grupo LES teve associacao mais consistente com o escore de HAQ, forcas de pinca e preensao e presenca de omao em paoo. O subgrupo LES com erosao ao US teve maior frequencia de comprometimento hematologico e artropatia de Jaccoud. O US foi capaz de diferenciar AR do LES principalmente no punho.BV UNIFESP: Teses e dissertaçõe

Association of anti-glomerular basement membrane antibody disease with dermatomyositis and psoriasis: case report

CONTEXT: Anti-glomerular basement membrane (anti-GBM) antibody syndrome is characterized by deposition of anti-GBM antibodies on affected tissues, associated with glomerulonephritis and/or pulmonary involvement. This syndrome has been described in association with other autoimmune disorders, but as far as we know, it has not been described in association with dermatomyositis and psoriasis. CASE REPORT: A 51-year-old man with a history of dermatomyositis and vulgar psoriasis presented with a condition of sensitive-motor polyneuropathy of the hands and feet, weight loss of 4 kg, malaise and fever. On admission, he had been making chronic use of cyclosporin and antihypertensive drugs for three months because of mild arterial hypertension. Laboratory tests showed anemia and leukocytosis, elevated serum urea and creatinine and urine presenting proteinuria, hematuria, leukocyturia and granular casts. The 24-hour proteinuria was 2.3 g. Renal biopsy showed crescentic necrotizing glomerulonephritis with linear immunoglobulin G (IgG) deposits on the glomerular basement membrane by means of direct immunofluorescence, which were suggestive of anti-GBM antibodies. The patient was then treated initially with methylprednisolone and with monthly cyclophosphamide in the form of pulse therapy