Journal of Clinical Rheumatology and Immunology

The increasing prevalence of hand osteoarthritis (OA) in Hong Kong’s aging population and its economic burden necessitate more effective management strategies. This study examines the efficacy of the Hand OsteoArthritis Self-management and Integrated Scheme (OASIS-H) compared to routine clinical care for patients with symptomatic hand OA. In this open-label, randomized controlled trial, symptomatic OA hand patients are included and randomized into early intervention and routine clinical care groups. The early intervention group undergoes an 8-week integrated hand OA management program, consisting of modified self-management education sessions, exercise, education, and occupational therapy intervention. At 6 months, routine clinical care patients will cross over to receive the same program as the early intervention group. The primary endpoint is the change in finger pain on visual analogue scale (VAS) at 6 months from baseline. The study aims to determine if the integrated program is more efficacious than routine care in reducing pain and improving function in hand OA patients.

Background: The objective of this study was to evaluate demographic characteristics, clinical presentation, laboratory findings, treatments, and their impact on the outcome of systemic lupus erythematosus (SLE)-related diffuse alveolar hemorrhage (DAH) in our local setting.

Methods: A total of seven patients were selected from our hospital’s local SLE database between 2013 and 2024 based on the inclusion criteria. Various variables were captured and analyzed using the Mann-Whitney $U$ test or Fisher’s exact test for comparison where appropriate.

Results: All seven patients were female, with a median age of 26 years, and the median duration of SLE before DAH was 3 months. More than half were presented with all three symptoms: fever (57%), dyspnea (71.4%), and hemoptysis (85.7%). Kidney involvement was present in all cases. All patients received methylprednisolone as initial treatment with 71.4% subsequently received plasmapheresis, 57% received cyclophosphamide, 28.6% received intravenous immunoglobulin, and 14.3% received rituximab. Five out of the seven patients required invasive mechanical ventilation. The mortality rate was 57%. Two out of three survivors received a combination of multiple immunosuppressive agents. Non-survivors had significantly higher acute physiology and chronic health evaluation II (APACHE II) scores ($p$ = 0.034), while other variables were not statistically linked to mortality. In spite of that, all patients with nosocomial infection did not survive.

Conclusion: Our observational study showed that a higher APACHE-II score was associated with a higher mortality rate. The efficacy of these treatment modalities cannot be conclusively determined due to the small sample size of this study. However, a combination of multiple immunosuppressive agents appeared to be associated with better outcomes in some patients.

Objective: To compare the accuracy and reliability of detecting the intensity of spinal inflammation on short tau inversion recovery (STIR) with the apparent diffusion coefficient (ADC) values of the active magnetic resonance imaging (MRI) lesions in axial spondyloarthritis (axSpA).

Materials and methods: Fifty active lesions in the STIR sequence of spinal MRI were identified. With reference to sites of active lesions in STIR, the corresponding region of interest (ROI) on the ADC map was drawn to determine the maximum ADC (ADC${}_{\mathrm{\text{max}}}$), mean ADC (ADC${}_{\mathrm{\text{mean}}}$), normalized maximum (nADC${}_{\mathrm{\text{max}}}$), and mean (nADC${}_{\mathrm{\text{mean}}}$). Four independent readers scored the identified active lesions as “intense” or “non-intense” according to the Spondyloarthritis Research Consortium of Canada (SPARCC) MRI index. They were compared to various ADC parameters for assessment of accuracy and reliability. Regression analyses were used to adjust potential factors that could affect ADC.

Results: Significant differences were found in ADC ${}_{\mathrm{\text{max}}}$ between “intense” and “non-intense” lesions scored by three of the four readers (1,405.7 ± 271.4 vs. 1,165.8 ± 223.8, $p$ = 0.01; 1,420.7 ± 272.1 vs. 1,209.0 ± 248.5, $p$ = 0.01; 1,438.0 ± 307.2 vs. 1,213.6 ± 231.0, $p$ = 0.01). Only one reader could differentiate a difference in “intense” and “non-intense” lesions with respect to ADC${}_{\mathrm{\text{mean}}}$ (899.2 ± 248.3 vs. 711.0 ± 222.6, $p$ = 0.01) and nADC${}_{\mathrm{\text{mean}}}$ (4.4 ± 2.1 vs. 3.4 ± 1.4, $p$ = 0.05). Inter-reader agreements were slight to moderate (kappa = 0.07–0.45). Reliability substantially improved when only the lowest and highest 25th percentiles of ADC values were included (kappa = 0.17–0.75). Regression analyses showed that the “intense” lesions were associated with higher ADC values after adjustment for confounders.

Conclusion: Reading of STIR MRI is limited by the lack of ability in differentiating subtle differences of spinal inflammation. ADC could be an alternative method.

Antiphospholipid syndrome (APS) and polyarteritis nodosa (PAN) are two distinct, but potentially overlapping, autoimmune disorders that are characterized by vascular morbidities. We present a case of probable APS that manifested as rapidly progressive peripheral gangrene with a positive test for lupus anticoagulant (LAC), alongside with angiographic evidence of suspected renal and hepatic artery aneurysms commonly associated with PAN, but also the presence of diffuse thrombosis over the distal arterial branches in the four limbs. Through this case, we aim to review the overlapping features and potential interplay between APS and PAN, highlighting the necessary considerations for optimizing management to salvage the ongoing limb ischemia.

Infections following treatment of rheumatic diseases are common and potentially life threatening. Severe infections may be related to the overall susceptibility in rheumatic diseases, neutropenia in connective tissue diseases, as well as secondary hypogammaglobulinemia (SHG) due to the use of immunosuppressants. Herein, a case of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) with recurrent cytomegalovirus (CMV) infections and SHG was described, followed by discussion of pathophysiology, clinical presentation, risk factors, and management of SHG, emphasizing the importance of baseline immunoglobulin level monitoring.

This clinical quiz discusses a condition that can cause generalized nodular lesions, its underlying immunological reactions, and its management.