Research Articles (Rheumatology)

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    A massive pericardial effusion in South Africa is not always due to tuberculosis
    (South African Heart Association, 2020) Ntshalintshali, Sipho; Mhlana, Nontembiso; Moosajee, Farzana; Abousriwiel, Riyad; George, Kiran; Du Toit, Riette
    South Africa (SA) has a high incidence of tuberculosis. Medical conditions mimicking tuberculosis often result in erroneous treatment with antitubercular therapy (ATT) before a definitive diagnosis is made. We report on 2 cases presenting with massive pericardial effusions secondary to Still’s disease (sJIA) and Adult onset Still’s disease (AOSD). Both cases were treated with ATT, with an alternative diagnosis only considered upon poor response to therapy and the development of ATT associated side effects. Our objective is to remind clinicians of other potential differential diagnoses in the clinical scenario of massive effusive pericarditis in a tuberculosis endemic region.
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    Points to consider in cardiovascular disease risk management among patients with rheumatoid arthritis living in South Africa, an unequal middle income country
    (BMC (part of Springer Nature), 2020-06-16) Solomon, Ahmed; Stanwix, Anne E.; Castaneda, Santos; Llorca, Javier; Gonzalez-Juanatey, Carlos; Hodkinson, Bridget; Romela, Benitha; Ally, Mahmood M. T. M.; Maharaj, Ajesh B.; Van Duuren, Elsa M.; Ziki, Joyce J.; Seboka, Mpoti; Mohapi, Makgotso; Jansen Van Rensburg, Barend J.; Tarr, Gareth S.; Makan, Kavita; Balton, Charlene; Gogakis, Aphrodite; González-Gay, Miguel A.; Dessein, Patrick H.
    Background: It is plausible that optimal cardiovascular disease (CVD) risk management differs in patients with rheumatoid arthritis (RA) from low or middle income compared to high income populations. This study aimed at producing evidence-based points to consider for CVD prevention in South African RA patients. Methods: Five rheumatologists, one cardiologist and one epidemiologist with experience in CVD risk management in RA patients, as well as two patient representatives, two health professionals and one radiologist, one rheumatology fellow and 11 rheumatologists that treat RA patients regularly contributed. Systematic literature searches were performed and the level of evidence was determined according to standard guidelines. Results: Eighteen points to consider were formulated. These were grouped into 6 categories that comprised overall CVD risk assessment and management (n = 4), and specific interventions aimed at reducing CVD risk including RA control with disease modifying anti-rheumatic drugs, glucocorticoids and non-steroidal anti-inflammatory drugs (n = 3), lipid lowering agents (n = 8), antihypertensive drugs (n = 1), low dose aspirin (n = 1) and lifestyle modification (n = 1). Each point to consider differs partially or completely from recommendations previously reported for CVD risk management in RA patients from high income populations. Currently recommended CVD risk calculators do not reliably identify South African black RA patients with very high-risk atherosclerosis as represented by carotid artery plaque presence on ultrasound. Conclusions: Our findings indicate that optimal cardiovascular risk management likely differs substantially in RA patients from low or middle income compared to high income populations. There is an urgent need for future multicentre longitudinal studies on CVD risk in black African patients with RA.
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    Speckle tracking echocardiography in acute lupus myocarditis : comparison to conventional echocardiography
    (BioScientifica, 2017) Du Toit, Riette; Herbst, Phillip G.; Van Rensburg, Annari; Snyman, Hendrik W.; Reuter, Helmuth; Doubell, Anton F.
    Aims: Lupus myocarditis occurs in 5–10% of patients with systemic lupus erythematosus (SLE). No single feature is diagnostic of lupus myocarditis. Speckle tracking echocardiography (STE) can detect subclinical left ventricular dysfunction in SLE patients, with limited research on its utility in clinical lupus myocarditis. We report on STE in comparison to conventional echocardiography in patients with clinical lupus myocarditis. Methods and results: A retrospective study was done at a tertiary referral hospital in South Africa. SLE patients with lupus myocarditis were included and compared to healthy controls. Echocardiographic images were reanalyzed, including global longitudinal strain through STE. A poor echocardiographic outcome was defined as final left ventricular ejection fraction (LVEF) <40%. 28 SLE patients fulfilled the criteria. Global longitudinal strain correlated with global (LVEF: r = −0.808; P = 0.001) and regional (wall motion score: r = 0.715; P < 0.001) function. In patients presenting with a LVEF ≥50%, global longitudinal strain (P = 0.023), wall motion score (P = 0.005) and diastolic function (P = 0.004) were significantly impaired vs controls. Following treatment, LVEF (35–47% (P = 0.023)) and wall motion score (1.88–1.5 (P = 0.017)) improved but not global longitudinal strain. Initial LVEF (34%; P = 0.046) and global longitudinal strain (−9.5%; P = 0.095) were lower in patients with a final LVEF <40%. Conclusions: This is the first known report on STE in a series of patients with clinical lupus myocarditis. Global longitudinal strain correlated with regional and global left ventricular function. Global longitudinal strain, wall motion score and diastolic parameters may be more sensitive markers of lupus myocarditis in patients presenting with a preserved LVEF ≥50%. A poor initial LVEF and global longitudinal strain were associated with a persistent LVEF <40%. Echocardiography is a non-invasive tool with diagnostic and prognostic value in lupus myocarditis.
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    Meeting the challenges in the diagnosis of inflammatory myopathies
    (Health & Medical Publishing Group, 2015) Manie, Mouroed
    Inflammatory myopathy (IM) is a rubric term to describe a heterogeneous group of muscle diseases typified by dermatomyositis and polymyositis. The current classifications are unsatisfactory, but IM associated with other connective tissue diseases (CTDs), such as systemic lupus erythematosus, underlying malignancy and HIV, should also be included. Although uncommon, IM should always be considered in a patient who presents with proximal weakness of gradual onset and has raised serum muscle enzymes. The diagnosis may be obvious if the patient has diagnostic skin signs such as heliotropic rash (peri-orbital discoloration) and Gottron’s lesions (typically on the extensor surfaces of the fingers). In the absence of obvious skin manifestations, other features of a CTD such as Raynaud’s phenomenon, abnormal capilloroscopy and the presence of serum antinuclear factor antibody should be searched for. Conditions that mimic IM include other causes of myopathy such as endocrine disorders, adverse effects of medication, metabolic myopathies and muscle dystrophies. Atypical features suggesting an alternative diagnosis are acute onset, severe pain, assymmetrical involvement, distal weakness and wasting. Appropriate investigations include a chest radiograph indicating interstitial lung disease or malignancy. Electromyography and muscle biopsy are useful in cases where other diagnoses are suspected.
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    Chloroquine-induced retinal toxicity
    (Health & Medical Publishing Group, 2005) Whitelaw, D.; Jessop, S.
    [No abstract available]