Search

Objectives To identify potential predictors of COVID-19 vaccine hesitancy (C19-VH) in adults with immune-mediated inflammatory diseases (IMID). Methods A total of 1000 IMID patients were enrolled in this web-based cross-sectional study. A standardised and self-administered survey was designed by members of the Brazilian Society of Rheumatology Steering Committee for Infectious and Endemic diseases and distributed to IMID patients spread across Brazil. Results Of the 908 (90.8%) respondents eligible for analysis, 744 (81.9%) were willing to get vaccinated against COVID-19. In our multivariable logistic regression model, concurrent malignancy, fibromyalgia, hydroxychloroquine use, and recent corticosteroid pulse therapy were independently associated with higher odds of C19-VH. The short duration of COVID-19 vaccine clinical trials was the main reason for C19-VH. Conclusion We identified novel characteristics potentially associated with C19-VH among adults with IMID. Greater awareness on the safety and efficacy of COVID-19 vaccines is needed for both IMID patients and attending physicians.

Background In Brazil, we are facing an alarming epidemic scenario of Yellow fever (YF), which is reaching the most populous areas of the country in unvaccinated people. Vaccination is the only effective tool to prevent YF. In special situations, such as patients with chronic immune-mediated inflammatory diseases (CIMID), undergoing immunosuppressive therapy, as a higher risk of severe adverse events may occur, assessment of the risk-benefit ratio of the yellow fever vaccine (YFV) should be performed on an individual level. Main body of the abstract Faced with the scarcity of specific orientation on YFV for this special group of patients, the Brazilian Rheumatology Society (BRS) endorsed a project aiming the development of individualized YFV recommendations for patients with CIMID, guided by questions addressed by both medical professionals and patients, followed an internationally validated methodology (GIN-McMaster Guideline Development). Firstly, a systematic review was carried out and an expert panel formed to take part of the decision process, comprising BRS clinical practitioners, as well as individuals from the Brazilian Dermatology Society (BDS), Brazilian Inflammatory Bowel Diseases Study Group (GEDIIB), and specialists on infectious diseases and vaccination (from Tropical Medicine, Infectious Diseases and Immunizations National Societies); in addition, two representatives of patient groups were included as members of the panel. When the quality of the evidence was low or there was a lack of evidence to determine the recommendations, the decisions were based on the expert opinion panel and a Delphi approach was performed. A recommendation was accepted upon achieving ≥80% agreement among the panel, including the patient representatives. As a result, eight recommendations were developed regarding the safety of YFV in patients with CIMID, considering the immunosuppression degree conferred by the treatment used. It was not possible to establish recommendations on the effectiveness of YFV in these patients as there is no consistent evidence to support these recommendations. Conclusion This paper approaches a real need, assessed by clinicians and patient care groups, to address specific questions on the management of YFV in patients with CIMID living or traveling to YF endemic areas, involving specialists from many areas together with patients, and might have global applicability, contributing to and supporting vaccination practices. We recommended a shared decision-making approach on taking or not the YFV.

ResumoO lúpus eritematoso sistêmico (LES) é uma doença autoimune multissistêmica que tem como uma das manifestações mais marcantes a nefrite. Apesar de poder coexistir com outras doenças autoimunes e determinar a predisposição a diversas complicações infecciosas, o LES raramente é descrito em associação a nefropatias de etiologia não lúpica. Relatamos o caso da rara associação entre LES e nefropatia por IgA (NIgA) primária, a glomerulopatia primária mais frequente na população mundial. A paciente foi diagnosticada com LES pela ocorrência de eritema malar, alopecia, derrame pleural, proteinúria, pancitopenia, FAN 1:1.280 padrão nuclear pontilhado fino e anticardiolipina IgM 280 U/mL. A biópsia renal revelou hipercelularidade mesangial com depósitos isolados de IgA, compatível com NIgA primária. Foi tratada com antimalárico, prednisona e inibidor da enzima conversora de angiotensina e apresentou boa evolução. Por consistirem em doenças relativamente frequentes, a coexistência de LES e NIgA pode ser de fato um achado incomum por motivos desconhecidos ou uma condição subdiagnosticada. Este relato atenta para a importância da distinção entre a atividade de doença renal do LES e nefropatias não lúpicas, em especial a NIgA, definição que tem implicações importantes sobre o prognóstico renal e regimes terapêuticos a serem adotados em curto e longo prazo.AbstractSystemic erythematosus lupus (SLE) is a multisystemic autoimmune disease which has nephritis as one of the most striking manifestations. Although it can coexist with other autoimmune diseases, and determine the predisposition to various infectious complications, SLE is rarely described in association with non‐lupus nephropathies etiologies. We report the rare association of SLE and primary IgA nephropathy (IgAN), the most frequent primary glomerulopathy in the world population. The patient was diagnosed with SLE due to the occurrence of malar rash, alopecia, pleural effusion, proteinuria, ANA 1: 1,280, nuclear fine speckled pattern, and anticardiolipin IgM and 280 U/mL. Renal biopsy revealed mesangial hypercellularity with isolated IgA deposits, consistent with primary IgAN. It was treated with antimalarial drug, prednisone and inhibitor of angiotensin converting enzyme, showing good progress. Since they are relatively common diseases, the coexistence of SLE and IgAN may in fact be an uncommon finding for unknown reasons or an underdiagnosed condition. This report focus on the importance of the distinction between the activity of renal disease in SLE and non‐SLE nephropathy, especially IgAN, a definition that has important implications on renal prognosis and therapeutic regimens to be adopted in the short and long term.

Systemic erythematosus lupus (SLE) is a multisystemic autoimmune disease which has nephritis as one of the most striking manifestations. Although it can coexist with other autoimmune diseases, and determine the predisposition to various infectious complications, SLE is rarely described in association with non-lupus nephropathies etiologies. We report the rare association of SLE and primary IgA nephropathy (IgAN), the most frequent primary glomerulopathy in the world population. The patient was diagnosed with SLE due to the occurrence of malar rash, alopecia, pleural effusion, proteinuria, ANA 1: 1280, nuclear fine speckled pattern, and anticardiolipin IgM and 280U/mL. Renal biopsy revealed mesangial hypercellularity with isolated IgA deposits, consistent with primary IgAN. It was treated with antimalarial drug, prednisone and inhibitor of angiotensin converting enzyme, showing good progress. Since they are relatively common diseases, the coexistence of SLE and IgAN may in fact be an uncommon finding for unknown reasons or an underdiagnosed condition. This report focus on the importance of the distinction between the activity of renal disease in SLE and non-SLE nephropathy, especially IgAN, a definition that has important implications on renal prognosis and therapeutic regimens to be adopted in both the short and long terms.

We read with great interest the paper published by D’Silva et al 1 regarding the main outcomes in rheumatic patients with COVID-19. According to this cohort, there was a mortality rate of 6%, slightly similar to the frequency observed in individuals without rheumatic diseases (RDs) (around 4%). On the other hand, there was a threefold higher risk of intensive care admission and mechanical ventilation in patients with RDs, suggesting some difficulties to handle this subgroup. More recently, Favalli et al 2 stated that the incidence of COVID-19 was also quite similar between patients with RD and individuals from the general population in Lombardia (0.62% vs 0.66%, respectively). Moreover, the disease activity was not worsened or triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in rheumatic patients. Brazil had its first confirmed case of COVID-19 on 26 February, and, to date, it accounts for more than one million cases and more than 50 000 deaths. The lethality rate has …

ResumoO maior entendimento das bases fisiopatológicas e do comportamento das vasculites sistêmicas, aliado ao desenvolvimento de regimes terapêuticos com perfil de segurança e eficácia cada vezes melhores, modificou drasticamente o prognóstico dos pacientes diagnosticados com essas entidades clínicas. Recentemente, o emprego do rituximabe no tratamento de pacientes com vasculites ANCA associadas em ensaios clínicos randomizados se mostrou uma opção importante em casos selecionados, especialmente pacientes refratários ou intolerantes à terapia‐padrão com ciclofosfamida e corticosteroides. O presente artigo traz o relato de sete casos de vasculites sistêmicas com tratamento bem‐sucedido com rituximabe.AbstractThe greater understanding of pathophysiology and behavior of systemic vasculitis, together with the development of therapeutic regimens with increasingly better safety and efficacy profiles, dramatically changed the prognosis of patients diagnosed with these clinical entities. Recently, the use of rituximab in the treatment of patients with ANCA‐associated vasculitis in randomized clinical trials showed an important alternative in selected cases, especially patients refractory or intolerant to standard therapy with cyclophosphamide and corticosteroids. This article presents the report of seven cases of systemic vasculitis successfully treated with rituximab.

Chikungunya fever has become a relevant public health problem in countries where epidemics occur. Until 2013, only imported cases occurred in the Americas, but in October of that year, the first cases were reported in Saint Marin island in the Caribbean. The first autochthonous cases were confirmed in Brazil in September 2014; until epidemiological week 37 of 2016, 236,287 probable cases of infection with Chikungunya virus had been registered, 116,523 of which had serological confirmation. Environmental changes caused by humans, disorderly urban growth and an ever-increasing number of international travelers were described as the factors responsible for the emergence of large-scale epidemics. Clinically characterized by fever and joint pain in the acute stage, approximately half of patients progress to the chronic stage (beyond 3 months), which is accompanied by persistent and disabling pain. The aim of the present study was to formulate recommendations for the diagnosis and treatment of Chikungunya fever in Brazil. A literature review was performed in the MEDLINE, SciELO and PubMed databases to ground the decisions for recommendations. The degree of concordance among experts was established through the Delphi method, involving 2 in-person meetings and several online voting rounds. In total, 25 recommendations were formulated and divided into 3 thematic groups: (1) clinical, laboratory and imaging diagnosis; (2) special situations; and (3) treatment. The first 2 themes are presented in part 1, and treatment is presented in part 2. Resumo A febre chikungunya tem se tornado um importante problema de saúde pública nos países onde ocorrem as epidemias. Até 2013, as Américas haviam registrado apenas casos importados quando, em outubro desse mesmo ano, foram notificados os primeiros casos na Ilha de Saint Martin, no Caribe. No Brasil, os primeiros relatos autóctones foram confirmados em setembro de 2014 e até a semana epidemiológica 37 de 2016 já haviam sido registrados 236.287 casos prováveis de infecção pelo chikungunya vírus (CHIKV), 116.523 confirmados sorologicamente. As mudanças ambientais causadas pelo homem, o crescimento urbano desordenado e o número cada vez maior de viagens internacionais têm sido apontados como os fatores responsáveis pela reemergência de epidemias em grande escala. Caracterizada clinicamente por febre e dor articular na fase aguda, em cerca de metade dos casos existe evolução para a fase crônica (além de três meses), com dor persistente e incapacitante. O objetivo deste trabalho foi elaborar recomendações para diagnóstico e tratamento da febre chikungunya no Brasil. Para isso, foi feita revisão da literatura nas bases de dados Medline, SciELO e PubMed, para dar apoio às decisões tomadas para definir as recomendações. Para a definição do grau de concordância foi feita uma metodologia Delphi, em duas reuniões presenciais e várias rodadas de votação on line. Foram geradas 25 recomendações, divididas em três grupos temáticos: (1) diagnóstico clínico, laboratorial e por imagem; (2) situações especiais e (3) tratamento. Na primeira parte estão os dois primeiros temas e o tratamento na segunda.

Chikungunya fever has become an important public health problem in countries where epidemics occur because half of the cases progress to chronic, persistent and debilitating arthritis. Literature data on specific therapies at the various phases of arthropathy caused by chikungunya virus (CHIKV) infection are limited, lacking quality randomized trials assessing the efficacies of different therapies. There are a few studies on the treatment of musculoskeletal manifestations of chikungunya fever, but these studies have important methodological limitations. The data currently available preclude conclusions favorable or contrary to specific therapies, or an adequate comparison between the different drugs used. The objective of this study was to develop recommendations for the treatment of chikungunya fever in Brazil. A literature review was performed via evidence-based selection of articles in the databases Medline, SciELO, PubMed and Embase and conference proceedings abstracts, in addition to expert opinions to support decision-making in defining recommendations. The Delphi method was used to define the degrees of agreement in 2 face-to-face meetings and several online voting rounds. This study is part 2 of the Recommendations of the Brazilian Society of Rheumatology (Sociedade Brasileira de Reumatologia - SBR) for the Diagnosis and Treatment of chikungunya fever and specifically addresses treatment. Resumo A febre chikungunya tem se tornado um importante problema de saúde pública nos países onde ocorrem as epidemias, visto que metade dos casos evolui com artrite crônica, persistente e incapacitante. Os dados na literatura sobre terapêuticas específicas nas diversas fases da artropatia ocasionada pela infecção pelo vírus chikungunya (CHIKV) são limitados, não existem estudos randomizados de qualidade que avaliem a eficácia das diferentes terapias. Há algumas poucas publicações sobre o tratamento das manifestações musculoesqueléticas da febre chikungunya, porém com importantes limitações metodológicas. Os dados atualmente disponíveis não permitem conclusões favoráveis ou contrárias a terapêuticas específicas, bem como uma adequada avaliação quanto à superioridade entre as diferentes medicações empregadas. O objetivo deste trabalho foi elaborar recomendações para o tratamento da febre chikungunya no Brasil. Foi feita uma revisão da literatura com seleção de artigos baseados em evidência, nas bases de dados Medline, SciELO, PubMed e Embase e de resumos de anais de congressos, além da opinião dos especialistas para dar apoio às decisões tomadas para definir as recomendações. Para a definição do grau de concordância foi feita uma metodologia Delphi, em duas reuniões presenciais e várias rodadas de votação on line. Este artigo refere-se à parte 2 das Recomendações da Sociedade Brasileira de Reumatologia para Diagnóstico e Tratamento da Febre Chikungunya, que trata especificamente do tratamento.

OBJETIVOS: Determinar a frequência de remissão total e parcial no tratamento da nefrite lúpica aos 12 e 24 meses de seguimento. Comparar esses subgrupos aos 12 meses, correlacionando as variáveis renais iniciais com a resposta ao tratamento. Analisar e comparar os resultados terapêuticos do subgrupo com glomerulonefrite proliferativa difusa por correlação clínico-patológica ("classe IV clínica") com aqueles de "classe IV histológica", isto é, com biópsia renal comprovada pela Organização Mundial da Saúde. MATERIAL E MÉTODOS: Foram estudados 100 pacientes consecutivos com diagnóstico de lúpus eritematoso sistêmico (LES) e nefrite, atendidos no Serviço de Reumatologia da Santa Casa de Misericórdia de São Paulo e acompanhados por dois anos. Os portadores de comorbidades que comprometem os rins foram excluídos. Foram analisadas as variáveis demográficas, clínicas, laboratoriais e o índice de atividade da doença (SLEDAI). Os pacientes com classe histológica III, IV ou V receberam corticosteroide e ciclofosfamida como tratamento de indução da nefrite lúpica e aqueles com classe II receberam apenas corticosteroide. RESULTADOS: A idade média ao diagnóstico de LES foi de 24,71 ± 10,14 anos, com predomínio do sexo feminino (88%). O SLEDAI calculado ao diagnóstico foi de 16,09 ± 6,48. Em relação às variáveis renais iniciais, a creatinina média foi de 1,02 ± 0,49 mg/dL, a proteinúria de 24 horas média foi de 2,57 ± 2,39 g e o anticorpo anti-dsDNA foi encontrado em 66% dos casos. Todos os pacientes receberam corticosteroide e 75% utilizaram a ciclofosfamida. Cinquenta e seis pacientes foram submetidos à biópsia renal. Os subtipos II e IV foram os mais prevalentes (33,9% e 32,2%, respectivamente). Após 12 meses de acompanhamento, todos os pacientes apresentaram redução significativa da proteinúria de 24 horas, melhora do sedimento urinário e dos valores das frações do complemento (C3, C4, CH50). A frequência de remissão total aos 12 meses foi 72,7% e, aos 24 meses, 85,7% (p = 0,013). A remissão parcial ocorreu em 27,3% dos doentes aos 12 meses e em 14,3% aos 24 meses. O sexo masculino apresentou menor frequência de remissão total comparado ao feminino aos 12 meses de acompanhamento (45,5% versus 81,6%, p = 0,007). Dentre as diferentes variáveis estudadas, nenhuma se correlacionou com remissão total ou parcial aos 12 meses. O subgrupo "classe IV clínica" apresentou maior frequência de remissão total que o subgrupo "classe IV histológica". CONCLUSÃO: Com o esquema terapêutico usado em nosso serviço, verificou-se um excelente desfecho em dois anos. Não foram observadas correlações entre variáveis clínico-laboratoriais e remissão total ou parcial. O sexo masculino apresentou menores taxas de remissão total comparado ao feminino. Apesar do pequeno número de pacientes estudados e das controvérsias quanto à biópsia renal, a taxa de remissão total foi maior nos pacientes com "classe IV clínica" em relação àqueles com "classe IV histológica". OBJECTIVES: To assess the frequency of total and partial remission in the treatment of lupus nephritis at 12 months and 24 months. To compare these subgroups at 12 months and correlate the initial renal variables with the therapeutic response. To analyze and to compare the therapeutic results of the subgroup with diffuse proliferative glomerulonephritis by clinicopathological correlation ("clinical class IV") with those with biopsy-proven WHO class IV ("histological class IV"). PATIENTS AND METHODS: One hundred consecutive patients with diagnosis of systemic lupus erythematosus (SLE) and nephritis who attended to the department of rheumatology of a tertiary referral center were studied. The length of the follow up was 2 years. Patients with comorbidities that compromise the kidneys had been excluded. The demographic, clinical and laboratory variables and the disease activity index (SLEDAI) were analyzed. Patients with lupus nephritis WHO class III, IV or V received glucocorticoid and cyclophosphamide for induction of remission and those with class II received only glucocorticoid. RESULTS: The average age at SLE diagnosis was of 24.71 + 10.14 years, with a predominance of female gender (88%). The initial SLEDAI was 16.09 ± 6.48. At the time of the diagnosis of nephritis, mean serum creatinine was 1.02 ± 0.49 mg/dL, mean 24-hour urinary protein level was of 2.57 ± 2.39g and the antibody anti-dsDNA was found in 66% of the cases. All the patients had received glucocorticoids and 75% had used cyclophosphamide. Fifty-six patients had been submitted to renal biopsy. The most prevalent subtypes were class II and IV (33.9% and 32.2%, respectively). After 12 months, all the patients had significant reduction in the 24-hour urinary protein level, improvement in the urinary sediment and increase in the fractional values of the complement (C3, C4, CH50). The frequency of total remission at 12 months was 72.7% and, at 24 months, 85.7% (p =0.013). Partial remission occurred in 27.3% at 12 months and, in 14.3%, at 24 months. Male gender presented a lower rate of total remission compared with women at 12 months (45.5% versus 81.6%, p = 0.007). Among several factors studied, none was correlated with total or partial remission at 12 months. The subgroup "clinical class IV" presented a higher frequency of total remission than the subgroup "histological class IV". CONCLUSION: Our therapeutic approach achieved an excellent outcome in two years. Correlations between clinical and laboratory variables and total or partial remission were not observed. Male gender presented a lower rate of total remission compared with women. Despite the small number of patients studied and the controversies of renal biopsy, the rate of total remission was higher in patients with "clinical class IV" than in those with "histological class IV".