Psychiatric Morbidity, Stressors, Impact, and Burden in Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is a chronic painful disorder conceivably with adverse psychological sequelae that might influence the outcome of the disease and its treatment. This study was designed to detect the presence of psychiatric disorders and associated abnormal psychosocial situations among children and adolescents with JIA and to evaluate their impact on and burden for their caregivers. Forty subjects with JIA suffering for at least one year were included in the study. Forty age- and sex-matched healthy subjects were included as controls. Clinical psychiatric assessment was carried out blindly, and psychiatric disorders and stressors on abnormal psychosocial situation were assigned on the basis of ICD-10 clinical diagnoses of multiaxial classification of child and adolescent psychiatric disorders. Chronicity, distress, social impairment, and burden for others were rated with the impact supplement of the strengths and difficulties questionnaire (SDQ). Of the 40 cases of JIA, 24 were boys and 16 were girls aged 10-18 years, with a mean age of 13.25 years. The frequency of psychiatric disorders was 35% in the JIA and 12.5% in the controlgroup (p <0.001). The long duration of illness was associated with a higher proportion of cases with psychiatric disorders. In the JIA group, the diagnoses in decreasing order were depressive disorder (15%), somatoform disorder (12.5%), adjustment disorder (5%), and mixed anxiety and depressive disorder (2.5%). Significantly higher stressors, perceived difficulties, distress, social impairment, and burden for caregivers were reported in the JIA group with psychiatric morbidity. The presence of psychiatric disorders was associated with substantial impairment of learning, peer relationship, and leisure activities. Early psychiatric intervention might increase the likelihood of satisfactory outcome of treatment in JIA

Eosinophilic Fasciitis: What Matters in Management in a Developing Country—A Case Report with Two and a Half-year Follow-up

Eosinophilic fasciitis is an uncommon disorder of unknown aetiology and poorly-understood pathogenesis. Since 1974, over 250 cases of eosinophilic fasciitis have been reported worldwide. The first case of eosinophilic fasciitis from Bangladesh is reported here. The challenges of diagnosis, treatment, and follow-up, including family and social support, are discussed

Disseminated Histoplasmosis without Pulmonary Involvement in an Immunocompetent Host - A Case Report

Histoplasmosis is a dimorphic fungal infection caused by histoplasma capsulatum. It is the most prevalentendemic mycosis in the United States, but now it is a disease of world wide occurrence. Most infections areasymptomatic or self-limited, some individuals develop acute pulmonary infections or severe and progressivedisseminated infection. Progressive disseminated histoplasmosis occurs in about one in 2000 patients with acuteinfection. Besides lung it may affect skin, lymph nodes, GIT, CNS, adrenals, liver and spleen. The patient ofdisseminated histoplasmosis usually presents with fever, anorexia, weight loss, myalgia and manifestationsaccording to organ involved. Here we described a 45 year-male who presented to us with fever, weight loss,generalized lymphadenopathy, growths in the oral cavity and chylous ascites. The particular interest of this paperis to present a case of disseminated histoplasmosis in an immunocompetent host without pulmonary involvement,and to demonstrate the differences between this entity and other similarly presented diseases like disseminatedtuberculosis, lymphoma and metastatic malignancy.Key words: histoplasmosis; disseminated histoplasmosis; histoplasma capsulatum; immunocompetent host; Bangladesh.DOI: 10.3329/bsmmuj.v3i1.5515BSMMU J 2010; 3(1): 44-4

Eosinophilic Fasciitis: What Matters in Management in a Developing Country \u2014 A Case Report with Two and a Half-year Follow-up

Eosinophilic fasciitis is an uncommon disorder of unknown aetiology and poorly-understood pathogenesis. Since 1974, over 250 cases of eosinophilic fasciitis have been reported worldwide. The first case of eosinophilic fasciitis from Bangladesh is reported here. The challenges of diagnosis, treatment, and follow-up, including family and social support, are discussed

Digital Gangrene:An Unusual Manifestation of Non-Hodgkin Lymphoma

BACKGROUND: Non-Hodgkin lymphomas (NHLs) comprise a group of haematologic malignancies with different histologic subtypes. The clinical picture varies from indolent to aggressive presentation and nodal (lymphadenopathy) to extranodal (central nervous system, gastrointestinal, cutaneous plaque, or ulcer) involvement. Digital gangrene is seldom reported. Here, we describe a patient with pain and blackening of all fingers and toes as presenting symptoms of NHL. Case Presentation. A 32-year-old male weaver had been smoking three to five cannabis-containing cigarettes daily for about ten years and methamphetamine four to five tablets daily for five years. He had no history of Raynaud's phenomenon, fever, cough, weight loss, skin rash, joint pain, and atherogenic or thrombogenic risk factors. We found normal blood pressure and absent peripheral pulses in arms and legs, dry gangrene of all fingers and toes, generalized lymphadenopathy, and hepatomegaly with ascites. The chest X-ray was normal, as were blood sugar, lipid profile, and hepatic and renal function. Rheumatoid factor, antinuclear and antiphospholipid antibodies, C-ANCA and P-ANCA, hepatitis B and C, and HIV were negative. CT abdomen revealed hepatosplenomegaly with multiple intra-abdominal lymphadenopathies. The peripheral angiogram showed 90-99% stenosis of radial and dorsalis pedis arteries with normal proximal vessels. Diagnosis of non-Hodgkin lymphoma was confirmed by histopathology of cervical lymph node (diffuse type), immunohistochemically subtyped as peripheral T cell lymphoma (not otherwise specified). The digital ischemia worsened despite cessation of cannabis and methamphetamine and starting CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) treatment, making amputation necessary. CONCLUSION: We present, to our knowledge, the first report of peripheral T cell lymphoma, NOS presenting with gangrene in all digits complicated by methamphetamine and cannabis abuse. This uncommon vascular manifestation of non-Hodgkin lymphoma may cause a diagnostic dilemma and delayed initiation of treatment

The prevalence and clinical characteristics of nonradiographic axial spondyloarthritis among patients with inflammatory back pain in rheumatology practices: a multinational, multicenter study

BACKGROUND: Patients with ankylosing spondylitis (AS), who by definition have radiographic sacroiliitis, typically experience symptoms for a decade or more before being diagnosed. Yet, even patients without radiographic sacroiliitis (i.e., nonradiographic axial spondyloarthritis [nr-axSpA]) report a significant disease burden. The primary objective of this study was to estimate the prevalence and clinical characteristics of nr-axSpA among patients with inflammatory back pain (IBP) in rheumatology clinics in a number of countries across the world. A secondary objective was to estimate the prevalence of IBP among patients with chronic low back pain (CLBP). METHODS: Data were collected from 51 rheumatology outpatient clinics in 19 countries in Latin America, Africa, Europe, and Asia. As consecutive patients with CLBP (N = 2517) were seen by physicians at the sites, their clinical histories were evaluated to determine whether they met the new Assessment of SpondyloArthritis international Society criteria for IBP. For those who did, their available clinical history (e.g., family history, C-reactive protein [CRP] levels) was documented in a case report form to establish whether they met criteria for nr-axSpA, AS, or other IBP. Patients diagnosed with nr-axSpA or AS completed patient-reported outcome measures to assess disease activity and functional limitations. RESULTS: A total of 2517 patients with CLBP were identified across all sites. Of these, 974 (38.70 %) fulfilled the criteria for IBP. Among IBP patients, 29.10 % met criteria for nr-axSpA, and 53.72 % met criteria for AS. The prevalence of nr-axSpA varied significantly by region (p < 0.05), with the highest prevalence reported in Asia (36.46 %) and the lowest reported in Africa (16.02 %). Patients with nr-axSpA reported mean ± SD Ankylosing Spondylitis Disease Activity Scores based on erythrocyte sedimentation rate and CRP of 2.62 ± 1.17 and 2.52 ± 1.21, respectively, indicating high levels of disease activity (patients with AS reported corresponding scores of 2.97 ± 1.13 and 2.93 ± 1.18). Similarly, the overall Bath Ankylosing Spondylitis Disease Activity Index score of 4.03 ± 2.23 for patients with nr-axSpA (4.56 ± 2.17 for patients with AS) suggested suboptimal disease control. CONCLUSIONS: These results suggest that, in the centers that participated in the study, 29 % of patients with IBP met the criteria for nr-axSpA and 39 % of patients with CLBP had IBP. The disease burden in nr-axSpA is substantial and similar to that of AS, with both groups of patients experiencing inadequate disease control. These findings suggest the need for early detection of nr-axSpA and initiation of available treatment options to slow disease progression and improve patient well-being

Disseminated Histoplasmosis Without Pulmonary Involvement in An

Histoplasmosis is a dimorphic fungal infection caused by histoplasma capsulatum. It is the most prevalent endemic mycosis in the United States, but now it is a disease of world wide occurrence. Most infections are asymptomatic or self-limited, some individuals develop acute pulmonary infections or severe and progressive disseminated infection. Progressive disseminated histoplasmosis occurs in about one in 2000 patients with acute infection.Besides lung it may affect skin, lymph nodes, GIT, CNS, adrenals, liver and spleen. The patient of disseminated histoplasmosis usually presents with fever, anorexia, weight loss, myalgia and manifestations according to organ involved. Here we described a 45 year-male who presented to us with fever, weight loss, generalized lymphadenopathy, growths in the oral cavity and chylous ascites. The particular interest of this paper is to present a case of disseminated histoplasmosis in an immunocompetent host without pulmonary involvement, and to demonstrate the differences between this entity and other similarly presented diseases like disseminated tuberculosis, lymphoma and metastatic malignancy

Tofacitinib for the treatment of inflammatory bowel disease‑associated arthritis: two case reports

Background Musculoskeletal manifestations are common extraintestinal manifestations of inflammatory bowel disease. Tofacitinib is a Janus kinase inhibitor approved for treating rheumatoid arthritis and ulcerative colitis. There are limited data on the efficacy of tofacitinib in managing inflammatory bowel disease-associated arthritis. Here we report two patients with ulcerative colitis- and Crohn’s disease-associated arthritis successfully responding to tofacitinib. Cases A 34-year-old Bangladeshi woman presented with lower limb polyarthritis for 7 years. Six months after the onset of polyarthritis, she developed abdominal pain with rectal bleeding. Colonoscopy and rectal biopsy findings confirmed ulcerative colitis. Ulcerative colitis associated arthritis was diagnosed. Treatment with sulfasalazine, etanercept, adalimumab, infliximab, and methotrexate gave no long-lasting remission. Methotrexate with mesalazine gave a partial response, and tofacitinib 5 mg twice per day was added. Her articular and abdominal symptoms improved within a month, and remission persisted till 24 months of follow-up, except a short-lasting mild flare at the seventh month. A 52-year-old Bangladeshi man had Crohn’s disease for 5 years. He presented with a swollen left knee and pain in other joints. Laboratory showed positive HLA-B27. He was intolerant to sulfasalazine and experienced poor response to methotrexate. Due to his inability to afford anti-tumor necrosis factor, tofacitinib was initiated. His arthritis improved within a month, and he remained in remission up to the sixth month. Conclusions In a woman with ulcerative colitis associated arthritis, refractory to biologic therapy, both arthritis and colitis improved with tofacitinib. A patient with Crohn’s disease-associated arthritis went into remission with tofacitinib. Tofacitinib may be effective in inflammatory bowel disease-associated arthritis

Psychiatric Morbidity, Stressors, Impact, and Burden in Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is a chronic painful disorder conceivably with adverse psychological sequelae that might influence the outcome of the disease and its treatment. This study was designed to detect the presence of psychiatric disorders and associated abnormal psychosocial situations among children and adolescents with JIA and to evaluate their impact on and burden for their caregivers. Forty subjects with JIA suffering for at least one year were included in the study. Forty age- and sex-matched healthy subjects were included as controls. Clinical psychiatric assessment was carried out blindly, and psychiatric disorders and stressors on abnormal psychosocial situation were assigned on the basis of ICD-10 clinical diagnoses of multiaxial classification of child and adolescent psychiatric disorders. Chronicity, distress, social impairment, and burden for others were rated with the impact supplement of the strengths and difficulties questionnaire (SDQ). Of the 40 cases of JIA, 24 were boys and 16 were girls aged 10-18 years, with a mean age of 13.25 years. The frequency of psychiatric disorders was 35% in the JIA and 12.5% in the controlgroup (p <0.001). The long duration of illness was associated with a higher proportion of cases with psychiatric disorders. In the JIA group, the diagnoses in decreasing order were depressive disorder (15%), somatoform disorder (12.5%), adjustment disorder (5%), and mixed anxiety and depressive disorder (2.5%). Significantly higher stressors, perceived difficulties, distress, social impairment, and burden for caregivers were reported in the JIA group with psychiatric morbidity. The presence of psychiatric disorders was associated with substantial impairment of learning, peer relationship, and leisure activities. Early psychiatric intervention might increase the likelihood of satisfactory outcome of treatment in JIA