Indonesian Journal of Rheumatology is a peer-reviewed open access journal on rheumatic diseases and connective tissue disorders. This is an official journal of Indonesian Rheumatology Association (IRA) and published twice a year since 2009. Our mission is to encourage the development of scientific and medical practice in rheumatic diseases and connective tissue disorders. This journal is self-focused on rheumatic disease and connective tissue disorders in the form of original article (extended and/or concise reports), review articles, editorial letters, leaders, lesson from memorable cases, book reviews, and matter arising. Both in clinical and laboratory including animal studies.
Inflammatory Cascade in Aortic Wall: Latent Tuberculosis Complicating Takayasu Arteritis in a Young Bangladeshi Lady- The Silent Duo
Takayasu disease or pulseless disease is a rare chronic granulomatous panarteritis of unknown aetiology affecting large vessels, particularly the aorta and its main branches. It mainly affects females more than males with the ratio of 8:1 and in the second and third decade of life. Mechanism may be transmural fibrous thickening of the arterial walls. Takayasu arteritis is characterized by inflammation of the vessel wall, leading to occlusion of the vessel wall. It is represented with claudication, fever, and arthralgia. Clinical features are chest pain, vascular bruits, hypertension. There is indirect evidence signifying a potential link between tuberculosis (TB) and Takayasu’s arteritis (TAK); however, the exact mechanism and relationship between TAK and Mycobacterium tuberculosis (TB) remain elucidated. This case intends to highlight the association between latent TB and TAK, as early detection can avoid devastating consequences.
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The Characteristics of Septic Arthritis Patients at Dr. Kariadi Hospital Semarang
Background: Septic arthritis is an inflammatory disease caused by microbial infections such as bacteria, fungi, and viruses. Late diagnosis can lead to permanent joint damage, while overdiagnosis may result in unnecessary medical procedures. Although the incidence is relatively low, septic arthritis remains a medical concern due to its impact on joint function and patient quality of life. Determining the characteristics is needed to improve the diagnosis, treatment strategies, and prognosis of septic arthritis. Methods: This descriptive study utilized a retrospective design and was conducted on adult patients diagnosed with septic arthritis at dr. Kariadi General Hospital, Semarang, from January 2017 to August 2023. The analyzed variables included clinical manifestations, comorbidities, laboratory test results, synovial fluid analysis, synovial fluid culture, and antibiotic resistance. Results: Among the 49 patients, most were under 60 years old (67.4%) and male (61.2%). The knee joint was the most commonly affected site (87.8%) with the main symptoms such as joint pain, edema, and reduced range of motion (100%), along with inflammatory signs such as joint warmth (89.9%) and redness (83.7%). Synovial fluid analysis revealed that 53.06% of patients had cloudy and foul-smelling synovial fluid, with an average white blood cell count of 93,679.43/mm³ and a predominance of neutrophils (80.37%). Synovial fluid culture identified Staphylococcus aureus as the most common pathogen (34.7%), followed by Klebsiella pneumoniae (4.1%) and Salmonella sp. (2%). Antibiotic sensitivity tests showed Ampicillin/Sulbactam as the most effective treatment, while antibiotic resistance was observed in Gentamicin, Penicillin, and Linezolid. Conclusion: Staphylococcus aureus is the dominant pathogen, and rising antibiotic resistance remains a concern. Early diagnosis and targeted therapy are crucial for better patient outcomes.
The Relationship between Disease Activity Level and the Incidence of Depression in Systemic Lupus Erythematosus Patients at Haji Adam Malik Hospital Medan
Background: Systemic Lupus Erythematosus (SLE) is a autoimmune disease that affects many organs of the body. SLE is a disease that cannot be completely cured. Life is difficult with SLE because the symptoms may come and go and it is unpredictable what will happen next. This condition causes the SLE patients feel unhappy, frustrated, angry, and sad. If this happens for a long time, it can cause SLE patients to experience depression. Methods: This study used a cross sectional design of 63 respondents at H. Adam Malik General Hospital Medan. This research data was obtained through history taking using primary data in the form of MEX SLEDAI questionnaires and Patient Health Questionnaire 9 (PHQ 9) and secondary data in the form of patient medical records. Results: It was found that SLE patients at H. Adam Malik General Hospital were all female, most of them were in the late adolescent age group with an age range of 17-25 years (39.7%), the last high school education level (68.3%), not working (81%), Married (54%), duration of SLE disease 1-2 years (36.5%), most SLE patients had mild disease activity levels (49.2%), most SLE patients have a mild depression (34,9%). There is a significant relationship between the level of disease activity and the incidence of depression in SLE patients at H. Adam Malik General Hospital (p ≤ 0.05) with a strong and unidirectional relationship (ρ = 0.64). Conclusion: There is a significant relationship between the level of disease activity and the incidence of depression in SLE patients at H. Adam Malik Hospital Medan with a strong relationship.
Indonesian Rheumatology Association (IRA) Recommendations for Diagnosis and Management of Hyperuricemia and Gouty Arthritis
Background: Gout is a progressive systemic disease caused by deposition of monosodium urate (MSU) crystals in various tissues such as joints, kidneys, and other connective tissues as a result of chronic hyperuricemia. If this condition is not adequately treated, it may progress to chronic gout, tophus formation, and even serious kidney function problems, which will lower quality of life. With the emergence of new treatment options in the last several years, a better understanding of diagnosis and management is required by every physician in Indonesia. Methods: A panel of eighteen selected rheumatologists from the Indonesian Rheumatologist Association (IRA) developed recommendations based on key questions formulated by a steering committee from IRA. These recommendation materials were taken from several online databases such as PubMed, Science Direct, and Google Scholar. Level of evidence and grades of recommendation were then assigned, and each member of the panellist team will assign a score to express their level of agreement. Results: A total of 16 recommendations discussing the diagnosis, non-pharmacological and pharmacological therapies, as well as monitoring for hyperuricemia and gouty arthritis were formulated. Conclusion: These recommendations can be used to help clinicians in accurately diagnosing hyperuricemia and gouty arthritis and choosing the most suitable therapy for their patients. All recommendation statements were tailored to the clinical setting, facility, and drug availability in Indonesia.
Indonesian Rheumatology Association (IRA) Recommendations for Diagnosis and Management of Systemic Sclerosis
Background: Systemic Sclerosis (SSc) or Scleroderma is a systemic autoimmune rheumatic disease characterized by dysregulation of the immune system, fibrosis of the skin and visceral organs and vasculopathy. The global prevalence of SSc reaches 17.6 per 100,000 population and the incidence reaches 1.4 per 100,000 people per year. The prevalence and incidence of SSc in Asia reaches 6.8 per 100,000 and 0.9 per 100,000, which is lower than other continents. Women have a prevalence and incidence of SSc five times higher than men. The prevalence and incidence of SSc depends greatly on the results of the study. There has not been much research on the epidemiological studies of SSc in Indonesia. Methods: Twelve selected rheumatologists from the Indonesian Rheumatologist Association (IRA) made recommendations based on key questions formed by a steering committee from IRA. These recommendation materials were taken from several online databases such as PubMed, Science Direct, and Google Scholar. Level of evidence and grades of recommendation were then assigned, and every member of the panelist team will assign a score for level of agreement. Results: A total of 50 recommendations that discussed the diagnosis, pharmacological and non- pharmacological therapy, and prognosis for SSc were made. Conclusion: These recommendations can be used to help clinicians correctly diagnose and choose the most suitable therapy for SSc patients. All recommendation statements were created with the consideration of Indonesia’s clinical setting, facility, and drug availability.
Behcet Disease: When Laryngeal Tuberculosis Unforeseably Strikes
Behçet disease (BD) is a chronic vasculitis that can affect all organs, particularly the skin, mucous membranes, eyes and joints. It can lead to severe complications requiring immunosuppressive therapy (IS). Although the prescription of IS is indisputable and life-saving, they carry a significant risk of opportunistic infections. Tuberculosis is an infectious disease primarily caused by the bacterium Mycobacterium tuberculosis, also known as Koch's bacillus. It predominantly affects the lungs due to airborne transmission and favorable conditions for the bacillus's survival in this area; however, it can also affect other sites to a lesser extent, such as the brain, bones, skin and « ear, nose and throat » (ENT) regions. Laryngeal tuberculosis (LT) is a rare and underdiagnosed localization that often occurs in immunocompromised patients. This article reports the case of a patient with BD under IS who developed LT secondary to subclinical pulmonary tuberculosis. The outcome after discontinuing azathioprine and initiating antituberculous treatment was favorable. The case report aims to shed light on the rare and underrecognized presentation of tuberculosis in BD and in case of immune vulnerability, unraveling the intricate interplay between immunosuppression and opportunistic infections. Its significance lies in underscoring the critical need for heightened clinical vigilance, as LT can masquerade as BD-related manifestations, posing diagnostic dilemmas.
Evidence Based Case Report: Secukinumab versus golimumab for Ankylosing Spondylitis Patients
Background: Ankylosing spondylitis is a chronic inflammation of the axial spine and joints that can lead to a wide spectrum of clinical manifestations, with chronic back pain and progressive vertebrae stiffness being two hallmark symptoms. The choice of medication for ankylosing spondylitis depends on both efficacy and cost. This study aims to compare Secukinumab, the cheapest and only available anti-interleukin-17, against Golimumab, a TNF-alpha inhibitor, in terms of efficacy and cost. Methods: A systematic search was conducted until October 30th, 2023, using keywords such as ankylosing spondylitis, secukinumab, golimumab, ASAS20, and their synonyms on databases including PubMed, Embase, SCOPUS, and Cochrane to find relevant studies. Critical appraisal of included studies was performed using the Oxford Center of Evidence-based Medicine (CEBM) tools for harm scenarios. Results: Three eligible articles were collected, observing both Secukinumab and Golimumab with different doses and administration routes. Chen et al.'s comparative analysis between secukinumab 150 mg and golimumab 50 mg revealed an odds ratio (OR) (95% confidence interval (CI)) of 1.19 (0.03-8.94), while secukinumab 150 mg against golimumab 100 mg presented an OR of 1.45 (0.03- 11.98). Zhang et al.'s comparison results between golimumab and secukinumab yielded an OR of 0.62 (0.20-1.89). Finally, Deodhar et al. analyzed different doses of secukinumab and golimumab with an OR range of 1.04-1.15 (0.4-3.11). Conclusion: Both secukinumab and golimumab showed comparable results in ASAS20, exhibiting insignificant differences in the superiority of ASAS20 improvement. However, the cost-effectiveness and personal drug choice need to be evaluated to add further considerations to the medication choice.
The The Correlation Between Serum Vitamin D Level and Quality of Life inSystemic Sclerosis Patients
Background: Systemic sclerosis (SSc) is an autoimmune rheumatic disease that is associated with disability and a reduced quality of life. Patients with SSc have lower levels of vitamin D than healthy people. Vitamin D influences the pathological mechanisms of SSc such as autoimmunity, vasculopathy, and fibrosis. The aim of this study was to know the correlation between serum vitamin D levels and the quality of life in SSc patients. Methods: This study was a cross-sectional study. Data were taken from the SSc patient registry at the Rheumatology Clinic of Dr. Hasan Sadikin General Hospital Bandung from September to November 2023. Vitamin D level were assessed by measuring serum 25-hydroxyvitamin D levels. The quality of life was measured using the Indonesian version of the Short Form (SF-36), which was divided into physical component summary (PCS) and mental component summary (MCS). Statistical analysis was performed using the Rank-Spearman test. Results: There were 81 SSc patients enrolled in this study. Vitamin D levels were found low in 44 subjects (54.3%), which were divided into 23 subjects deficiency and 21 subjects insufficiency. Thirty seven subjects (46.7%) had normal vitamin D levels. The results of this study showed that there was a significant weak positive correlation between serum vitamin D levels and PCS SF-36 (r=0.222, p=0.023) and MCS SF-36 (r=0.209, p=0.031) quality of life in SSc patients. Conclusion: Serum vitamin D levels of SSc patients had a significant weak positive correlation with physical and mental quality of life component.
Relationship Between Interleukin 6 (IL-6) and Organ Damage Based on SLICCDamage Index -SDI Score in Systemic Lupus Erythematosus Patients
Background: Systemic Lupus Erythematosus (SLE) is a heterogeneous and complex chronic autoimmune disease. Interleukin 6 (IL-6) is a cytokine known to be elevated in people with SLE. This research was conducted to determine the relationship between IL-6 levels and organ damage based on the SLICC Damage Index-SDI Score in SLE patients. Method: The study was a retrospective cross-sectional study involving 67 SLE patients conducted based on the SLICC 2012/ACR EULAR 2019 criteria at least 6 months prior to their inclusion. They were patients treated at the Rheumatology Clinic of Adam Malik General Hospital in Medan from June to August 2023, who met the inclusion and exclusion criteria. Organ damage assessment was done using the SLICC Damage Index (SDI) score, while disease activity degree was measured using the SLE Disease Activity Index (SLEDAI-2K) scoring system. Results: 94 % subject were women with a median SLEDAI-2K score of 6 (10 – 16) where the moderate degree of activity was the majority in this study (41.8%), followed by the mild degree (37.3%), severe (16, 4%), and remission (4.5%). The median IL-6 level was 63.3932 pg/ml (8.88 – 5966.67) where a significant correlation was found between IL-6 levels and the SDI score (p=0.017) and the degree of disease activity and the SDI score (P<0.001). Conclusion: A significant positive correlation was found between IL-6 levels and SDI scores in SLE patients (p=0.017).
Plasmapheresis as a Promising Therapeutic Option to TreatMacrophage Activation Syndrome
Macrophage activation syndrome (MAS) is a lethal complication of autoimmune conditions. Its diagnosis and management remains challenging till date in view of paucity of standard protocols. Plasmapheresis has shown promise if used early in the course of disease. We hereby describe a case report of a young male patient who presented with multiorgan failure. He was diagnosed with MAS triggered by systemic lupus erythematosus (SLE). He was successfully treated with steroids, cyclophosphamide and plasmapheresis.
Correlation Between sCD28 and sCD80 Levels with Disease Actiity of SystemicLupus Erythematosus (SLE) Patients Based on SLEDAI Score
Background: Systemic Lupus Erythematosus (SLE) is an autoimmune disease with multisystem involvement that is caused by multifactorial. Prolonged exposure to autoantigens and sustained immune system activation, particularly in memory T lymphocytes, can contribute to premature immunosenescence. Soluble costimulatory molecules such as sCTLA-4 and sCD86, originating from CTLA-4 and CD86 respectively, contribute to the progression of immunosenescence in patients with SLE. This condition is associated with higher morbidity and mortality. This study aimed to investigate the relationship between elevated levels of sCTLA-4 and sCD86 and the severity of SLE disease activity, as assessed by the SLEDAI score. Methods: The study employed an analytical observational design with a cross-sectional approach, involving 35 female participants diagnosed with SLE according to the 2012 SLICC criteria. SLE disease activity was assessed using the SLEDAI score, and serum levels of sCD28 and sCD80 were measured using the ELISA method. The Mann-Whitney test was used for group comparisons, while the Spearman test was conducted for correlation analysis, with statistical significance defined as p < 0.05. Results: SLE patients had an average sCD28 and sCD80 level of 24.93 and 27.41, respectively. Spearman test results showed that sCD28 level had a significant correlation with SLEDAI score [R=0.364; p=0.031 (p<0.05)], while sCD80 level did not correlate significantly with SLEDAI score [R=0.048; p=0.786 (p<0.05)]. Conclusion: The rise in sCD28 levels showed a positively correlation with the SLE severity activity, as indicated by the SLEDAI score.
Is It Obesity or Metabolic Syndrome Which Has a Greater Prevalence ToCause Muscoloskeletal Complaints? A Cross Sectional Study in theCepokomulyo District, Malang Regency
Introduction: Musculoskeletal (MSK) complaints including pain, swelling, stiffness, or immobility of joints and muscles are among the most common health issues that biomechanical factors are one of the risk factors. Metabolic syndrome is a combination of several risk factors including obesity, hypertension, low HDL-C levels, hypertriglyceridemia, and impaired glucose tolerance. These issues are known to influence the incidence of metabolic inflammation associated with several MSK diseases, in which obesity is one of the main biomechanical factors. Aim: To compare the Prevalence Odd Ratio (POR) of MSK complaints associated with metabolic syndrome (MetS) and obesity. Conclusion: This study included 260 patients, with 49.6% (n=129) of them having metabolic syndrome. The most common MSK complaint region was the right knee (n=85). MSK complaints were most common in the group of patients with MetS and obesity (n=109), compared to the group with MetS or obesity alone. Prevalence Odd Ratio (POR) results show that Group III (group of patients with obesity and without MetS) has the highest prevalence of MSK complaints when compared to the other three groups.
Factors Contributed to a Difficult-To-Treat Juvenile IdiopathicArthritis: A Systematic Review and Meta Analysis
Background: Juvenile Idiopathic Arthritis is the foremost common unremitting rheumatic illness in childhood, with a global prevalence ranging from 16 to 150 per 100.000 population. However, in some cases, clinician may face a difficult-to-treat Juvenile Idiopathic Arthritis (D-JIA), which indicate to a group of patients who have not affected by administration of standard anti-rheumatic drugs. This study aims to identify factors that correlate to D-JIA. Methods: We conducted a systematic review and meta analysis, collecting studies from PubMed, Scopus, Embase, Cochrane, and Google Scholar. Eligible Studies were trials that analyze factors that may contribute to D-JIA. Results: Six studies were included, enrolling 1.177 patients. Female composes 70.9% (835) of the population (OR 1.04, CI 95% 0.83-1.31, p=0.72). Median of age and duration of disease respectively were 5.79 years and 11.06 months. Some factors correlate with occurancy of DJIA including Caucasian race (OR 0.96, CI 95% 0.44-2.07, p=0.91), ANA negative (OR 1.77, CI 95% 1.42-2.22, p<0.00001), HLA B27 positive (OR 1.86, CI 95% 0.85-4.08, p=0.12), prescence of atypical skin lesion (OR 8.5, CI 95% 1.6-72.4, p=0.022), and spesific subtype of JIA such as Oligoarthritis (OR 0.86, CI 95% 0.70-1.07, p=0.17), Poliarthritis (OR 1.77, CI 95% 1.422.22, p<0.00001), Systemic-type (OR1.22, CI 95% 0.60-2.49, p=0.58), Psoriatic (OR1.61, CI 95% 0.69-3.78, p=0.27), Enteritis-related (OR 1.33, CI 95% 0.68-2.59, p=0.40), and Undiffrentiated (OR 1.46, CI 95% 0.55-3.83, p=0.45). Conclusion: Eventhough many factors identified, but only ANA negativity, presence of atypical skin lesion, and Poliarthritis subtype that have been statistically proved related in the development of D-JIA. This finding may be due to the study's limitations and remaining differences in subsequent results. Future studies are needed for further analysis regarding this issue.
Massive Pericardial Effusion – An Uncommon Initial Presentation in aMale Patient With Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) is an autoimmune disease which has predilection for female gender. Usually, it manifests as myriad of clinical signs and symptoms which can involve any organ system of the body, however cardiovascular involvement solely as an initial presentation is uncommon. Here we present a case of a male patient who initially presented with a large pericardial effusion. Later, on extensive workup he was diagnosed with SLE with lupus nephritis.
Relationship between Knowledge Level and Preventive Behavior of SepticArthritis in Student Batch 2019-2020, Faculty of Medicine, University of NorthSumatra
Background: Septic arthritis is an infectious disease that severely damages the joints with clinical manifestations such as swelling, erythema and warmth of the affected joint. The most common cause of this disease is the result of hematogenous spread of microorganisms. Some of the risk factors include injection drug use, prosthetic joints and skin infection. The incidence of septic arthritis is 5 to 8 per 100,000 population per year with 5-10% mortality rate, therefore preventive behavior is needed to minimize the incidence of septic arthritis. Methods: This study is an observational analytic study with a cross-sectional approach. The research population consisted of students from batch 2019-2020 of the Faculty of Medicine, University of North Sumatra and the sample was determined using stratified random sampling method. Primary data were obtained directly from research subjects using questionnaires via Google Forms. Results: The univariate research analysis found that the knowledge level of the majority of respondents was in the good category, with 45 subjects (53.6%). The most predominant behavior observed in the respondents was negative behavior, with 49 subjects (58.3%). Bivariate analysis found that there was no significant relationship between knowledge level and septic arthritis prevention behavior with p value = 0.809. Conclusion: Students from batch 2019-2020 of the Faculty of Medicine, University of North Sumatra, on average have a good level of knowledge and negative behavior on the prevention of septic arthritis. There is no relationship between the level of knowledge with septic arthritis prevention behavior.
Correlation between sCTLA-4 and sCD86 Levels with Disease Activity of SystemicLupus Erythematosus (SLE) Patients Based on SLEDAI Score
Background. Systemic Lupus Erythematosus (SLE) is an autoimmune disease with multisystem involvement which arises from multifactorial causes. Continuous exposure to autoantigens and chronic activation of the immune system, especially memory T lymphocytes, contribute to premature immunosenescence. sCTLA-4 and sCD86 are soluble costimulatory molecules of CTLA-4 and CD86, which play a role in the occurrence of immunosenescence in SLE. The presence of immunosenescence will cause higher morbidity and mortality. This research was conducted to establish the correlation between the increased levels of sCTLA-4 and sCD86 and the severity of SLE, as measured by the SLE Disease Activity Index (SLEDAI) score. Methods. This analytical observational research utilized a crosssectional approach involving 35 female SLE patients diagnosed according to the SLICC 2012 criteria. SLE disease activity was measured using SLEDAI score. Serum sCTLA-4 and sCD86 levels were measured using the ELISA method. Statistical analysis was conducted using the Mann-Whitney test for comparisons and the Spearman test for correlation analysis, with a significance level of p<0.05. Results. sCTLA-4 levels were higher and significantly different in patients with moderate SLE (p=<0.001; p<0.05), and there was no significant difference in sCD86 levels (p=0.915; p>0.05). Increased sCTLA-4 levels were positively correlated with the severity of SLE (r =0.361, p=0.033), while no significant correlation was observed in sCD86 levels (r=-0.094, p=0.591). Conclusion. Elevated sCTLA-4 levels were positively correlated with increased severity of SLE based on the SLEDAI score.
The The Role of 25-Hydroxy Vitamin D and Cartilage Oligomeric Matrix Protein(COMP) Serum in Knee Osteoarthritis
Background. Osteoarthritis (OA) is a prevalent disease of the musculoskeletal system that affects over 528 million individuals worldwide, with 73% of those diagnosed being aged 55 or older. The knee joint is most commonly affected, along with the hip and hand joints. Vitamin D is essential for maintaining bone and cartilage metabolism. In chondrocytes, the presence of the vitamin D receptor (VDR) regulates the expression of metalloproteinase. The purpose of this investigation is to examine the correlation between vitamin D (25(OH)D) and cartilage oligomeric matrix protein (COMP) serum in knee osteoarthritis. Methods. The cross-sectional study was conducted by the Rheumatology Division at RSMH Palembang. Patients diagnosed with knee osteoarthritis based on the 1990 ACR criteria were included. The chemoluminescent immunoassay and the Human Cartilage Oligometric Matrix Protein ELISA Reagent were used to measure the levels of vitamin D (25(OH)D) and COMP serum. Results. Thirty participants took part in this study from July to December 2022. According to this study, 33% had insufficiency and 67% had a deficiency of vitamin D. Spearman's Rho test shows that there is a strong negative correlation between vitamin D (25(OH)D) and COMP serum. Conclusion. Vitamin D (25(OH)D) and COMP serum levels were significantly correlated in knee osteoathritis.
Initial Clinical Presentation of Systematic Lupus Erythematosus (SLE) Patientsin Cipto Mangunkusumo Hospital
Background. Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease characterized by highly diverse and nonspecific symptoms with clinical presentations involving more than one organ system which often leads to delayed diagnosis and poor prognosis. This study aims to understand patients’ initial clinical presentation in order to enhance early detection and establish an early diagnosis. Methods. This descriptive crosssectional quantitative study included patients who commenced their visits to the Rheumatology Clinic at RSCM from May 2021-December 2022. A consecutive sampling method was used, and data were analyzed for age, gender, symptom onset, as well as patients' initial clinical presentations (SPSS 25.0). Results. Out of 231 subjects, 96.1% were females. A total of 38.1% of the patients belonged to the 21-30 age group, and symptom onset was most commonly observed in the 0-1 year age group, accounting for 67.5%. Approximately 24.2% of the patients exhibited constitutional manifestations with involvement of other organs, including musculoskeletal (87.4%), mucocutaneous (84%), hematologic (3.,5%), renal (33.3%), and neuropsychiatric (8.7%) systems. Lungs, heart, blood vessels, gastrointestinal and hepatic systems, eyes, obstetric, and endocrine involvements were not found in this study. Among the 231 subjects, 44.2% of them had simultaneous involvement of two organs, which emerged as their initial clinical presentation. Conclusion. Musculoskeletal and mucocutaneous involvement were most commonly observed as th e initial clinical presentation of SLE patients at RSCM, followed by hematologic, renal, and neuropsychiatric involvement.
Perfect Timing for Canakinumab Use in Gout
Gout is an inflammatory disease caused by the deposition of monosodium urate (MSU) crystals. Recently, the American College of Rheumatology (ACR) has recommended the usage of interleukin (IL)-1 inhibitor in gout patients who are refractory to typical anti-inflammatory drugs. An example of IL-1 inhibitor is canakinumab. Not much is known regarding the usage of canakinumab in gout arthritis. Thus, we decided to conduct a narrative review that summarizes the efficacy and safety of canakinumab in gout patients. In this review, we found that canakinumab is superior to nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids in treating acute gout flares. In addition, canakinumab may also be considered as a preventive therapy for gout flares in patients receiving urate-lowering therapy. Overall, canakinumab has mild side effects but may occasionally cause serious infections. Canakinumab is also generally safe for use during pregnancy. Due to the lack of studies, the safety of canakinumab in lactating women, geriatric patients, and patients with hepatic or renal impairment is still unknown.
Acute Lupus Pneumonitis with Cytomegalovirus Co-infection in Patients withLupus Nephritis
Introduction: Most patients with systemic lupus erythematosus (SLE) show signs of pulmonary involvement. The clinical manifestations of Lupus Pneumonitis are the similar to those of acute interstitial pneumonia. The use of cyclophosphamide in lupus nephritis (LN) is associated with high CMV titers. Ganciclovir is the main choice of therapy for CMV pneumonia infection. Case presentation: A 19-year-old female with previous history of lupus nephritis presented with worsening dyspnea, productive cough with yellowish sputum and hemoptysis. Following physical, laboratory and radiological examinations, the patient was diagnosed with acute lupus pneumonitis, with a differential diagnosis of pneumonia infection. During treatment in the intensive care unit (ICU), she was put on ventilator and received routine hemodialysis due to pulmonary edema. She was given intravenous antibiotics before the culture results came out, but there was no clinical improvement. Once the culture results returned negative, the antibiotics were discontinued and IV pulse methylprednisolone was started. There was significant clinical, radiological, and laboratory improvements. After discharge, the patient experienced hemoptysis again due to CMV pneumonia infection and was given ganciclovir therapy with satisfactory results. Conclusion: In patients with advanced LN and pulmonary involvement, distinguishing between infection and SLE flares may be challenging, which can cause dilemma in diagnosis and treatment decisions. Adequate oxygenation with ventilator, hemodialysis, and administration of ganciclovir and mycophenolic acid provides significant improvements in patient care.
Characteristics and Treatment Responses of Rheumatoid Arthritis Patients at Dr.Cipto Mangunkusumo National General Hospital
Introduction. Rheumatoid arthritis (RA) is a chronic progressive autoimmune rheumatic disease that primarily affects the joints. The goal of RA treatment is to achieve remission or low disease activity, using a treatto-target approach. This study aims to explore the characteristics of RA patients and evaluate their treatment responses in Dr. Cipto Mangunkusumo National General Hospital (RSCM). Methods. This crosssectional study is conducted by collecting demographic and clinical data, as well as interviewing adult patients that have been diagnosed with RA at the Rheumatology Clinic of RSCM and have been on disease-modifying antirheumatic drugs (DMARD) treatment for a minimum of 6 months. Results. A total of 94 patients were included in this study. Subjects were predominantly female (93.6%) and had no formal jobs (64.9%). A majority of RA patients exhibited moderate disease activity (48.9%, based on Disease Activity Score-28 with erythrocyte sedimentation rate [DAS-28 ESR]), with a relatively high level of steroid use (86.2%). Notably, most patients started DMARD treatment more than 2 years after the onset of symptoms (45.7%). The proportion of patients achieving therapy target (remission to low disease activity) was 41.5%, with 13.8% attaining remission. Furthermore, Health Assessment Quality (HAQ) scores were found to be significantly lower among the target-achieving group, indicating better quality of life. Conclusion. Therapy target was achieved in 41.5% of RA patients in RSCM, with 13.8% achieving remission. Further research can be conducted to evaluate factors which may affect treatment response among RA patients.
Effect of Vitamin D Supplementation on Regulatory T Cells of Systemic LupusErythematosus: A Systematic Review
Background. Systemic lupus erythematosus (SLE) is associated with a global reduction in regulatory T cells (Tregs). Vitamin D supplementation that is efficacious, safe, and reasonably priced has the potential to reduce morbidity in SLE. This study was aimed to systematically assess the efficacy of vitamin D supplementation in enhancing Tregs concentration or Tregsrelated marker. Methods. A systematic review of the literature for clinical studies was performed on Pubmed, Proquest, and Google Scholar. Studies were assessed for risk of bias using Newcastle Ottawa Scale. All clinical studies that investigated the effects of vitamin D supplementation on Tregs in SLE patients were included. Key evidence was analyzed and qualitatively synthesized. Results. Three relevant studies were included. All studies were of high-quality. Vitamin D supplementation consistently increased Tregs concentration across all included studies. Conclusion. The current study supports the evidence that vitamin D supplementation enhanced Tregs concentration in SLE patients.
Sjögren's Syndrome: A Rare Clinical Entity in Children
Background. Sjögren's syndrome (SS) is a rare autoimmune disease in children, with only a few hundred reported cases. Its clinical presentation is atypical. We report the case of a 14-year-old boy diagnosed with recurrent parotitis. Case Presentation. Our patient, a 14-year-old male, presented with a one-year history of recurrent bilateral parotid swellings. Clinical examination revealed an objective oculo-buccal dryness. Ultrasound imaging showed hypoechoic hypertrophy of the parotid glands. Anti-SSA/SSB antibodies were strongly positive. Histological study of the accessory salivary glands revealed lymphocytic sialadenitis with a focus score of 3. The diagnosis of SS was confirmed according to the ACR/EULAR 2016 criteria. The combination of treatment with hydroxychloroquine and corticosteroids resulted in the resolution of clinical signs and biological inflammatory markers. Conclusion. Given the rarity of SS in children, several diagnostic and therapeutic difficulties arise, in the absence of classification criteria adapted to the juvenile form of the disease, and the absence of therapeutic recommendations consolidated by clinical trials in children.
Use of Methotrexate for More Than 4 Years Is Not Associated with Liver Fibrosisin Rheumatoid Arthritis Patients
v Background. Methotrexate is an anchor drug in the management of rheumatoid arthritis (RA). However, the association between methotrexate and development of liver fibrosis remains a subject of controversy. Non invasive methods to assess liver fibrosis, such as the FIB-4 score, have been developed. RA patients on methotrexate therapy should be monitored for any signs of liver fibrosis. This study aims to investigate the correlation between methotrexate cumulative dose and the FIB-4 score in rheumatoid arthritis patients who received methotrexate therapy to assess the hepatotoxic effects of methotrexate. Methods. This cross-sectional study involved rheumatoid arthritis patients who received methotrexate therapy at Dr. Hasan Sadikin General Hospital Bandung from September 2022 to November 2022. Clinical data, laboratory tests (including platelet values and liver function test), and cumulative methotrexate doses were extracted from medical records. Data were analyzed using the Spearman correlation test. Results. This study involved 100 subjects aged between 22-82 years, comprising 93% women and 7% men. The median FIB-4 score was 0.73 (0.24-6.80), while the median methotrexate cumulative dose was 2477.5 mg, with a range of 1005-10400 mg. The results showed that correlation coefficient between the FIB-4 score and methotrexate cumulative dose in rheumatoid arthritis patients was 0.089 (p=0.378).Conclusion. There is no significant correlation between FIB 4 score and cumulative dose of methotrexate inrheumatoid, arthritis, patients. The use of methotrexate in RA patients over 4 years is relatively safe as it does not increase the risk of liver fibrosis.
Indonesian Rheumatology Association (IRA) Recommendations for Diagnosis and Management of Sjogren’s Syndrome
Background. Sjogren’s syndrome (SS) is a systemic autoimmune disease that affects exocrine glands. Dealing with SS is challenging due to the low level of awareness and knowledge about SS, as well as the difficulty in diagnosing and treating the disease. Diagnosing SS requires many supporting examinations from many medical specialties. Therefore, these recommendations were developed to serve as a guide for health practitioners in diagnosing and treating SS. Methods. Six selected rheumatologists from the Indonesian Rheumatologist Association (IRA) formulated the recommendations based on key questions formed by a steering committee from IRA. These recommendation materials were taken from several online databases such as PubMed, Science Direct, and Google Scholar. Level of evidence and grades of recommendation were then assigned, and every member of the panellist team will assign a score for level of agreement. Results. The panel generated a total of 19 recommendations discussing the diagnosis, pharmacological and non-pharmacological therapy, and prognosis for SS. Conclusion. These recommendations can be used to help clinicians correctly diagnose and choose the most suitable therapy for SS patients. All recommendation statements were created with the consideration of Indonesia’s clinical setting, facility, and drug availability.
Secondary Trimester Pregnancy in Systemic Lupus Erythematosus Patients withPneumonia: A Case Report
Background. Systemic lupus erythematosus (SLE) is an autoimmune disease that can attack multiple organs and has a high prevalence in women. Due to its treatment and resulting pathological conditions, SLE makes the patient susceptible to infections. Furthermore, physiological changes in the body that occur during pregnancy renders pregnant women with SLE vulnerable to disease exacerbation. Therefore, the management of such cases necessitates the evaluation and intervention of a multidisciplinary medical team. Case Presentation. We present the case of a female patient in her second trimester of pregnancy who complained of shortness of breath. The patient has a history of SLE diagnosed five years ago. Within 7 days of treatment, the patient experienced an improvement in symptoms. Conclusion. This is a rare case, and we report on the outcomes of treatment and our limitations to ensure better future treatment for pregnant women with SLE to prevent maternal and fetal death.
Simultaneous Cervical and Lumbar Spinal Degenerative Stenosis: Diagnostic andTreatment Challenge
Background: In simultaneous cervical and lumbar degenerative stenosis (tandem spinal stenosis), the cervical clinical signs may mask the lumbar ones. Treatment is initially conservative in non-plegic cases. In the event of surgery, there is no consensus regarding the segment to be approached first. The purpose of this work was to describe our management of this condition. Methods: This was a 6-year retrospective study in the rheumatology and neurosurgery departments. All usable medical records of cases of simultaneous degenerative stenosis of the cervical and lumbar spine were included. Results: We retained 84 squares. The average age was 57.1 years; the sex ratio 0.9. All the patients presented cervical and lumbar clinical signs. They had started at the lumbar spine in 46 cases (54.8%) and cervical in 38 cases (45.2%). A full spinal MRI had been performed in 50%. Conservative treatment was effective in 36 patients (42.9%). Of the 32 patients (66.7%) operated, 16 had been operated both the cervical and lumbar spine (7 simultaneous surgeries including percutaneous discolysis in one of the segments in 4 cases). The cervical spine had been operated on first in 7 of the 9 cases of staggered surgery. After an average follow-up of one month, the evolution was favorable in 47 cases (56%); stationary 21 (25%). Conclusion: Conservative treatment was effective in about half of the cases. Full spine MRI and staggered surgery were the most commonly performed. However, simultaneous surgery prioritizing the least aggressive gestures seems better.
Efficacy and Safety of Stem Cell Transplantation in Rheumatoid Arthritis: ASystematic Review of Trials
Background: Rheumatoid arthritis (RA) is an autoimmune disorder that deteriorates the quality and function of the synovium membrane, resulting in chronic inflammation, pain, and progressive joint destruction. Based on previous clinical research, stem cell transplantation has shown a promising therapeutic effect for RA based on its anti-inflammatory, immunomodulatory, and regenerative properties. This systematic review aims to evaluate the efficacy and safety of stem cell transplantation for rheumatoid arthritis therapy. Methods: A literature search was performed via PubMed, ProQuest, EBSCOHost, EMBASE, SCOPUS, Cochrane, DOAJ, and clinicaltrial.gov databases, selecting studies that evaluated the effect of stem cells on rheumatoid arthritis from inception to April 7, 2023. The Cochrane Risk of Bias was used to assess randomized controlled trials and ROBINS-I was used to assess clinical trials. Results: 7 randomized controlled trials (RCTs) and 12 non-randomized studies involving 682 subjects were included in this review. Stem cell transplantation was related with better outcomes based on significant improvement of the DAS28 score, HAQ score, ACR score, and laboratory parameters. There were no significant changes in safety parameters compared to the baseline value and control group. Fever, flu-like symptoms, nausea, and vomiting were the most frequently reported adverse effects. Nevertheless, this review revealed a moderate risk of bias and high heterogeneity of the efficacy outcomes of RCTs. Conclusion: Stem cell-based therapies provide clinical benefits for rheumatoid arthritis patients with satisfactory safety measures.
A Patient with Granulomatosus with Polyangiitis (Wegener’s Granulomatosis): ACase Report
Background: Granulomatosus with Polyangiitis (GPA) is an Antineutrophilic Cytoplasmic Antibodies (ANCA) Associated Vasculitis (AAV) which involves small to moderate-sized vessels. GPA has a variety of clinical manifestations caused by tissue ischemia and organ affected. Diagnosis of GPA remains challenging, and its actual incidence may be higher than reported. In 1990, the American College of Rheumatology (ACR) published diagnostic criteria for GPA. Guidelines of management of GPA has improved survival in last decade, but results remain unsatisfactory. Induction agents with immunosuppressive agents and glucocorticoid, and the newer agent Rituximab are recommended as first choice treatment. Case presentation: A 64-year-old male presented with current episode of joint pain and a history of recurrent respiratory tract infections. After a series of laboratory and radiologic examinations, lung biopsy was performed, and the result was suggestive of GPA. The patient was managed with induction remission agent and reported improvement in both clinical and laboratory parameters. Conclusion: Granulomatosus with Polyangiitis is a limitedly reported case. This report was presented to raise awareness of the diagnosis when faced with similar clinical symptoms. Early detection and diagnosis in GPA allow for prompt and better management with the target to achieve and maintain remission, as demonstrated in this case.
Tuberculosis Arthritis: A Diagnostic Challenges
Background: Tuberculosis infection still poses a significant health problem,especially in developing countries. While most of tuberculosis cases affect the pulmonary organ, this infection may also involve other organs such asbones and joints. Case presentation: We reported a case of 23-year-oldfemale patient with a history of recurrent pain and swelling in the right knee. On physical examination of the right knee, bulging sign was found,accompanied by tenderness, warmth on palpation, and limited active and passive movement. Radiographic examination was suggestive for septicarthritis in the right knee. Debridement and biopsy were performed, and TBPCR examination of the debridement tissue was found to be positive forMycobacterium tuberculosis. The histopathological finding was alsoconsistent with tuberculosis infection. The patient was subsequently treatedwith antituberculosis drugs and underwent rehabilitation therapy, resultingin a satisfying response. Conclusion: Diagnosis of tuberculosis arthritis inthis case was established based on the presence of clinical symptoms, radiological findings, tissue TB PCR, and histopathological findings. Both surgical and pharmacological interventions were performed, which yieldedfavorable results. Tuberculosis arthritis was often misdiagnosed as arthritis for other causes, resulting in delays in providing medical intervention. Therefore, increased understanding of tuberculosis arthritis is necessary tofacilitate early diagnosis and improve therapeutic outcome.