Rheumatology (Bulgaria)

Efficacy of treatment with intravenous immunoglobulins and pulse therapies with methylprednisolone and cyclophosphamide in patients with active SLE

Valentina Simeonova Reshkova — 2024-12-29

Immunoglobulin preparations for intravenous administration (IVIG) contain highly purified native molecules of human IgG, freed from high-molecular aggregates and vasoactive substances stabilized with glucose, maltose, glycine, sorbitol, etc. Intravenous immunoglobulins can be used as adjunctive therapy in systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APLS) with recurrent miscarriages. The aim of the clinical observation is to establish the efficacy of the treatment of immunovenin in a scheme, in parallel with pulse therapies with methylprednisolone (MP) and cyclophosphamide (CYC) in patients with active SLE, compared with the application of pulse therapies with methylprednisolone and cyclophosphamide alone. When comparing the effect of treatment with immunovenin 400 mg/kg body weight every 3 months for a period of 12 to 18 months, in parallel with pulse therapies with methylprednisolone and cyclophosphamide 1 g monthly intravenously in disease activity, a significant difference in positive influence on organic brain syndrome, cranial nerve function, arthritis/arthralgias and proteinuria. In both groups, the concentration of anti dsDNA and ACLA decreased to the same extent. Treatment with immunovenin has a positive effect on influencing disease activity in SLE, added to treatment with pulse therapies with methylprednisolone and cyclophosphamide.

DETERMINATION OF SELF-ASSESSMENT OF OSTEOPOROSIS AND FRACTURE RISK AMONG WOMEN, WHO CONDUCTED OSTEODENSITOMETRY

Nikola Kirilov Kirilov — 2024-12-29

Osteoporosis (OP) is a metabolic bone disease that leads to a decrease in bone density and deterioration of the bone microarchitecture, increasing the risk of fractures. Its early detection, the calculation of fracture risk and the patient's self-assessment of the bone health status is a key moment for the prevention of osteoporotic fractures. The aim of this study was to investigate patients' self-assessment of OP and subsequent fracture risk. Among 324 women, before examining bone mineral density (BMD) with radiofrequency echographic multispectrometry (REMS), a survey was conducted with a self-report questionnaire for self-assessment of OP and fracture risk. It was found that 51.9% of women consider that the examination for OP is necessary, and 46.6% consider OP as a threatening disease. Unfortunately, only 8.3% knew they could self-assess their fracture risk and 0.6% had ever had their 10-year fracture risk assessed using the "FRAX" model. Interestingly, the older the women were, the less often they consider OP as a threatening disease. 77.5% of the women studied had a decreased bone density, measured with REMS. This demonstrates poor education and self-awareness of the patients regarding OP, as well as the lack of an objective assessment of the risks associated with it, and the need to conduct osteodensitometry.

Sarcopenia and Spondyloarthritis activity and functional assessment

Samar AbdAlhamed Tabra — 2024-12-29

Background: Sarcopenia is progressive loss of muscle mass and strength; this may cause increased morbidity and mortality. Rheumatic diseases as spondyloarthropathies have greater risks of developing sarcopenia.

Objectives: Assessment of sarcopenia in Egyptian patients with psoriatic arthritis (PSA) and axial spondyloarthritis (axSPA) and investigate the relation between sarcopenia and different factors.

Methods: This study included 56 PSA (Group I), 58 axSPA patients (Group II), and 60 healthy controls (Group III). Demographic data were collected, disease activity was assessed using Disease Activity Index for Psoriatic Arthritis (DAPSA) score for PSA patients and ASDAS-CRP (Ankylosing Spondylitis Disease Activity Score) for axSPA patients. Functional assessment was done using Bath ankylosing spondylitis functional index (BASFI) for axSPA patients and Health Assessment Questionnaire (HAQ) for PSA patients. Sarcopenia was assessed by measuring Muscle mass, muscle strength and physical performance.

Results: There was no significant difference between study groups regarding age, and BMI. None of the studied patients had definite sarcopenia, twelve PSA patients (21.43%), and fifteen axSPA patients (25.86%) had probable sarcopenia. While seven PSA, and five axSPA patients had pre-sarcopenia.

We found significant differences between PSA and controls regarding muscle quantity, muscle strength, and muscle performance. While we found significant differences between axSPA and controls regarding muscle strength, and muscle performance. the risk of probable sarcopenia in axSPA patients increased with increasing age and ASDAS-CRP and in PSA patients it increased with increasing age, DAPSA and HAQ.

Conclusions: probable sarcopenia was significantly increased in PsA and axSPA. Our analysis suggests that age, and disease activity were associated with the development of sarcopenia in PSA and axSPA.

Common mistakes in capillaroscopy

Jaklin Doncheva-Dilova — 2024-12-29

Nail fold capillaroscopy (NFC) is a non-invasive examination and the "gold standard" in rheumatology practice to evaluate the microcirculation and distinguish primary from secondary Raynaud's phenomenon (RP). Alternatives to videocapillaroscopy are USB microscopy, dermatoscopy and ophthalmoscopy. Before the capillaroscopy examination, a detailed general history (including concomitant diseases) and occupational history (including a history of recent trauma to the fingers or onychophagia), a history regarding the patient's hobbies, practicing sports and physical activity, history of taking medications (beta-blockers, vasodilators, anticoagulants, antihypertensives), as well as the use of other vasoactive substances (tobacco, caffeine, cannabis, cocaine, amphetamines) should be taken. A detailed history regarding discoloration of the fingers is necessary to confirm the diagnosis of Raynaud's phenomenon (RP). Capillaroscopic examination should be carried out under certain conditions (not during an attack of RP, after acclimatization, in a certain position of the patient, without consumption of coffee and smoking before the examination, without manicure procedures in the last 15-30 days, examination of all 8 fingers, excluding those with recent trauma and/or infection). Correctly following all these steps will avoid technical errors that can change the interpretation of the result. It is necessary for the examiner to have a good knowledge of the normal capillaroscopic pattern, the variations of the norm in adults, the differences that might be found between children and adults, as well as the different pathological findings and specific patterns ("scleroderma" and "scleroderma-like" type) in diseases occurring with secondary RP. While in rheumatology practice there are defined criteria for "scleroderma" and "scleroderma-like" capillaroscopic finding, the changes in some paraneoplastic, socially significant (AH and DM), occupational (VD) and infectious diseases (Covid-19) occurring with microangiopathy, which can lead to misinterpretation of the finding. The “scleroderma-like” pattern also differs in different rheumatic diseases and the findings can also be misleading. The results of the study must be carefully interpreted with a view to the correct assessment of the patients' condition.

INTEGRATING EXERCISE AND REHABILITATION IN RHEUMATOLOGY: ADVANCING THERAPEUTIC STRATEGIES FOR OPTIMAL PATIENT OUTCOMES

Alexander Krasimirov Angelov — 2024-12-29

This review examines the integration of exercise and rehabilitation into rheumatologic care, highlighting their synergistic effects alongside pharmacological treatment. Exercise modalities such as aerobic, resistance, and flexibility training enhance physical function, alleviate pain, and reduce systemic inflammation, primarily through the activity of exercise-induced myokines which support immune regulation and tissue repair. Despite demonstrated benefits, adoption is hindered by barriers, including limited adherence, healthcare access, and absence of standardized guidelines. This review suggests personalized exercise protocols, interdisciplinary collaboration, and telehealth innovations to promote accessibility and adherence. Expanding exercise and rehabilitation as standard practices in rheumatology may optimize patient outcomes and long-term disease management, with future research needed to refine protocols and validate rehabilitation strategies.

“Treat-to-Target” in Systemic Lupus Erythematosus: Novel Definitions of Remission and Low Disease Activity

Daliya Tsvetanova Pencheva — 2024-12-29

Abstract: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with alternating periods of activity and remission, where an accurate assessment of disease activity remains crucial for optimal treatment. For this purpose, various instruments and composite measures have been developed to enable objective evaluation and effective patient monitoring. In recent years, the SLE Disease Activity Score (SLE-DAS), validated in 2019, has emerged as a reliable and precise method. It combines 17 clinical and laboratory parameters, offering a more accurate assessment of disease activity. Furthermore, SLE-DAS defines clear criteria for remission and low disease activity, supporting the “treat-to-target” approach. Despite the significance of SLE-DAS, other scales such as the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and its modified versions, Systemic Lupus Activity Measure (SLAM), SLAQ (Systemic Lupus Activity Questionnaire), and the British Isles Lupus Assessment Group (BILAG) Index—continue to be used in clinical practice. Of these, SLEDAI-2K remains the most frequently employed tool in daily rheumatological practice. Despite the variety of tools available, SLE-DAS stands out for its precision, practicality, and wide applicability, both in routine clinical practice and clinical trials, emphasizing its broad utility in managing SLE.

Factor V Leiden mutation in patients with polyarthralgia – case reports and review of literature

Dobromir Tanev — 2024-12-29

Patients with rheumatological diseases might be at increased risk of venous thromboembolism (VTE) because of inflammation, autoimmune disturbances, prolonged immobilization, and corticosteroid (CS) use. Therefore, more efforts are needed to identify additional prothrombotic factors and provide preventive strategies.

Herein, we presented two cases of young men with polyarthralgia who have undergone unprovoked VTE. The first patient underwent VTE after several intra-articular CS applications, while the other had no concomitant risk factors. The hereditary thrombophilia testing revealed a heterozygous Factor V Leiden (FVL) state in the first patient and homozygous FVL carrier status in the second patient.

Both cases suggest a possible benefit of thrombophilia testing in men under the age of 50 years with polyarthralgia, unprovoked VTE, and impending CS therapy. Estimating the complex thrombotic risk in rheumatological patients before CS use is crucial for preventing thromboses.