Turkish Journal of Rheumatology - 2011; 26(4) - Current Issue

Editorial

Deniz Evcik — 2011-12-01

Management of Rheumatoid Arthritis: Consensus Recommendations From the Turkish League Against Rheumatism

2011-12-01

Objectives: Taking new developments in the management of rheumatoid arthritis (RA) and the economic conditions of our country into account, the Turkish League Against Rheumatism (TLAR) aimed to develop national treatment recommendations for the management of RA; thus, they consulted with national experts for their opinions. Materials and methods: Eight rheumatologists and 15 physiatrists experienced in the field contributed to the development of the TLAR recommendations for the management of RA. The expert committee planned to develope “Recommendations for the Management of RA in Turkey” based on EULAR 2010 recommendations for the management of RA with synthetic and biological disease-modifying antirheumatic drugs (DMARDs) in light of expert opinions. Following the meeting, a systematic literature review was performed by searching the Medline and Cochrane, Embase, and Turkish Medical Index databases between 2009 and 2010 for pharmacological treatment recommendations and between 2007 and 2010 for non-pharmacological treatment recommendations. This was done in addition to the studies included in the EULAR 2010 recommendations. All articles were examined, their contents were summarized, their levels of evidence were determined, and the Delphi process was initiated. Results: Sixteen general recommendations were listed along with five main principles and one non-pharmacological treatment method. A consensus was reached for all recommendations, and their strength levels were voted upon. Conclusion: Recommendations were formed for the management of RA in Turkey. These national recommendations are intended to guide physical medicine and rehabilitation specialists (physiatrists), rheumatologists, and family physicians and should be regularly updated.

Relationship of the Vitamin D Receptor and Collagen Iα1 Gene Polymorphisms with Low Bone Mineral Density and Vertebral Fractures in Postmenopausal Turkish Women

2011-12-01

Objectives: This study aims to investigate (i) the frequencies of the vitamin D receptor (VDR) gene and collagen Iα1 (COL Iα1) gene polymorphisms and (ii) whether there is a relation between the Bsm1 polymorphisms in the VDR gene, and the Sp1 polymorphisms in the COL Iα1 gene and low bone mineral density (BMD), and vertebral fractures in postmenopausal Turkish women. Patients and methods: A hundred postmenopausal Turkish women (mean age 63.4�8.7 years; range 48 to 86 years) who were admitted to our polyclinic for the diagnosis or treatment of osteoporosis were included in this study. The study population was divided into three groups according to the T score value based on BMD measurements. Patients with a T score of >-1.0 formed the control group (n=30). In addition, patients with a T score of <-1.0−>-2.5 formed the osteopenic group (n=30), and those with a T score of <-2.5 formed the osteoporotic group (n=40). The Bsm1 (B/b) polymorphism in the VDR gene and the Sp1 (S/s) polymorphism in the COL Iα1 gene were detected by two parallel polymerase chain reactions and subsequent hybridization. Bone mineral density of the lumbar spine and femur were measured by dual-energy X-ray absorptiometry. Results: The genotype frequencies of the Bsm I (B/b) polymorphism in the VDR gene and the Sp1 (S/s) polymorphism in the COL Iα1 gene were not statistically different among the three study groups. Additionally, no significant difference was found between the patients with vertebral fracture and the patients without fracture in terms of the BB, Bb, and bb genotypes of the VDR gene or in terms of the SS, Ss, and ss genotypes of the COL Iα1 gene. Conclusion: Our findings showed that the Bsm1 polymorphism of the VDR gene and the Sp1 polymorphism of the COL Iα1 gene were not associated with low BMD or vertebral fractures in postmenopausal Turkish women.

An Investigation Into the Relationship Between Taq1 and Apa1 Polymorphisms of the Vitamin D Receptor Gene and the Development of Osteoarthritis

2011-12-01

Objectives: This study aims to determine whether Vitamin D receptor (VDR) gene TaqI and ApaI polymorphisms are involved in the development of osteoarthritis in the Turkish population. Patients and methods: In this study, genomic DNA was isolated from 140 subjects (95 patients with osteoarthritis and 45 healthy controls). The DNA was amplified with specific primers by polymerase chain reaction and the restriction fragment length polymorphism (RFLP) technique was used to analyze the VDR gene TaqI and ApaI polymorphism genotypes. Polymerase chain reaction-RFLP products were assessed with and ultraviolet transilluminator by being exposed to agarose gel electrophoresis. Results: In terms of the genotype distributions and the allele frequencies of VDR gene TaqI and ApaI polymorphisms, there was no statistically significant difference (p>0.05) between the osteoarthritis patients and the controls. In addition, there was also no statistically significant difference between the genotypes and clinical characteristics of the patients or controls. Conclusion: In conclusion, the results of the present study suggest that VDR gene TaqI and ApaI polymorphisms are not involved in the development of osteoarthritis in the studied Turkish population.

Juvenile Lupus Erythematosus: Fourteen Years of Experience

Funda BA�TU�, Hakan POYRAZO�LU, Z�beyde G�ND�Z, Sebahat T�LPAR, Ruhan D��NSEL — 2011-12-01

Objectives: This study aims to describe the main clinical and laboratory features as well as the morbidity and mortality of juvenile systemic lupus erythematosus (JSLE) in Turkish children. Patients and methods: Thirty children (27 girls, 3 boys; mean age at diagnosis 12.3 years; range 3 to 16 years) with JSLE were evaluated retrospectively. All patients met the 1982 American College of Rheumatology revised criteria for the diagnosis of SLE and had shown clinical manifestations of the disease before the age of 16. Results: The mean period of follow-up was 2.9 years (range 2 months-10 years) and the mean duration of symptoms before diagnosis was 3.3 months (range 2 days-2 years). The frequencies of the clinical and laboratory features of the patients were as follows: erythematous malar rash was seen in 17 (56%), discoid rash in one, photosensitivity in 16 (53.3%), oral ulcers in eight (26.7%), musculoskeletal involvement in 26 (87%), serositis in 13 (43%), hematological abnormalities in 21 (70%), renal involvement in 17 (56%), antinuclearantibody positivity in 27 (93%), pulmonary involvement in eight (27%), cardiovascular disease in seven (23%), and central nervous system involvement in seven patients (23%). During the follow-up four patients (13%) died, three of renal failure and one from sepsis. During the study two patients were in remission without treatment and 22 patients were in remission with treatment. Two patients were lost to follow-up. Conclusion: Juvenile systemic lupus erythemathosus is a serious multisystem organ disease. Although JSLE has a high remission rate with early diagnosis and treatment, it still has a significant mortality rate.

Relationship Between the Bone Formation Rate and Functional Status in Symptomatic Knee Osteoarthritis

Demet TEKD�� DEM�RC�O�LU, Nurdan PAKER, Derya SOY BU�DAYCI — 2011-12-01

Objectives: This study aims to investigate the relationship between serum levels of bone-specific alkaline phosphatase and functional status in patients with symptomatic knee osteoarthritis (OA). Patients and methods: Seventy patients (57 females, 13 males; mean age 57.5�9.3 years; range 48 to 67 years) diagnosed with knee OA based on the American College of Rheumatology (ACR) criteria and 30 age- and gender-matched healthy controls (mean age 56.4�7.5 years) were enrolled in the study. Patients were evaluated using clinical, laboratory and radiographic methods. Bone-specific alkaline phosphatase and 24-hour urinary calcium and phosphorus levels were tested to assess bone metabolism. The Lequesne index was used for the severity of disease and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used for the functional status. Results: The mean bone-specific alkaline phosphatase value was 13.69�4.76 mg/dl in the patient group. No statistically significant difference was found between the patient group and the control group in terms of bone-specific alkaline phosphatase values (p=0.584). The bone formation rate was high in 28.5% of the patients. A significantly positive correlation was found between the bone-specific alkaline phosphatase and the WOMAC stiffness scores (p=0.07, r=0.340). No significant correlation was found between the bone-specific alkaline phosphatase and the pain, physical function, and the total scores of the WOMAC and Lequesne index (p=0.590, r=0.090, p=0.489, r=0.107, p=0.413, r=0.139, p=0.285, r=0.70 respectively). Conclusion: In this study, an increase was shown in the bone formation rate in approximately 1/4 of the patients with symptomatic knee osteoarthritis. A significant positive correlation was found between bone formation rate and knee stiffness. However, no relationship was observed between the bone formation rate and pain, physical function, when they were compared with severity of the disease.

Eosinophilic Gastroenteritis Associated with Rheumatoid Arthritis

2011-12-01

Objectives: In this article we evaluated the relationship between rheumatoid arthritis and eosinophilic gastroenteritis. Patients and methods: A 71-year-old female patient with a diagnosis of rheumatoid artritis was admitted to our clinic with gastrointestinal symptoms and peripheral eosinophilia. We examined the patient via gastrointestinal endoscopy, ultrasonography, computed tomography, stool analysis, and biochemical analysis. Results: Gastrointestinal endoscopy revealed esophageal dysmotility, pangastritis, and duedonal erythema. Histopathologic examinations revealed subacute and chronic inflammation with dense eosinophilic infiltration. Stool analyses were negative for fat, parasites, and other pathogens. The results for ultrasonograpy and computed tomographies were normal. Conclusion: This brief report showed us the importance of conducting further analysis when a patient with rheumatoid arthritis presents with peripheral eosinophilia and gastrointestinal discomfort. It also represents the possible coexistence of rheumatoid arthritis and eosinophilic gastroenteritis without an apparent etiology.

Multiple Cavitary Nodules Accompanied by Pulmonary Nocardiosis in a Patient with Systemic Lupus Erythematosus

Zehra �a�la KARAKO�, �ule NAMLI, S�leyman Tevfik ECDER, Recep TEK�N — 2011-12-01

Pulmonary nocardiosis is a chronic suppurative infection that may occur in immunosuppressed patients. It can be self-limited, or it can have an acute, subacute, or chronic course. Radiological diagnosis of pulmonary nocardiosis is difficult because of the very low prevalence of the disease even in immunocompromised patients and is also problematic because the radiographic findings are diverse with no characteristic findings. Multiple nodules and cavitations are more commonly described in acquired immune deficiency syndrome (AIDS) patients but are uncommon in non-AIDS patients. Also, the association of nocardia infection with systemic lupus erythematosus has been described occasionally. In this article, we report a rare case of pulmonary nocardiosis with multiple cavitary lesions and acute respiratory failure in a HIV-negative patient with systemic lupus erythematosus who was receiving corticosteroid treatment.

Lupus Myositis with Normal Creatinine Kinase Levels Following Adalimumab Use in a Rheumatoid Arthritis Patient

Hani ALMOALLIM,, Ahlam ALMASARI, Hadeel KHADAWARDI — 2011-12-01

We report a rare case of histopathologically confirmed lupus myositis that developed in a 32-year-old female with seropositive rheumatoid arthritis that had been treated with adalimumab for one year. She had demonstrated excellent response to her arthritis initially but then developed profound muscle weakness with a conversion of her antinuclear antibody and anti-double stranded DNA from negative to strongly positive. Her creatinine kinase levels remained normal. She responded well to high-dose steroid therapy and rituximab.

Bisphosphonate-Related Osteonecrosis of the Jaw Bones in a Patient with Ankylosing Spondylitis Receiving Anti-Tumor Necrosis Factor Treatment

Banu ��LETEN, Simin HEPG�LER, Selen BAYRAKTARO�LU, G�khan KESER — 2011-12-01

Bisphosphonate-related osteonecrosis of the jaw bones is a rare, but well-recognized pathology, occurring mainly in patients receiving parenteral and high doses of bisphosphonates for the treatment of skeletal metastasis and/or hypercalcemia associated with cancer. However, to a lesser extent, this complication may also occur in patients receiving oral bisphosphonates for the treatment of osteoporosis. In this article, we present a 58-yearold female patient with ankylosing spondylitis (AS) who developed mandible osteonecrosis following long-term oral alendronate treatment for osteoporosis. Dental tooth extraction possibly triggered the occurrence of mandible osteonecrosis in this patient. This patient is notable for receiving concomitant anti-tumor necrosis factor (anti-TNF) treatment. To our knowledge, occurrence of bisphosphonate-related jaw osteonecrosis in a patient with AS receiving concomitant anti-TNF treatment has not been reported previously in the literature.