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Relevance. Pneumococci are among the most common causative agents of severe bacterial infections in humans. The prevalence of invasive pneumococcal infections among people with autoimmune inflammatory rheumatic diseases is 3–4 times higher than in the general population. Aim. To evaluate the effectiveness of vaccination with 13-valent pneumococcal conjugate vaccine (PCV 13) in patients with rheumatoid arthritis (RA). Materials and Methods. The data of scientific publications PubMed, Web of Science, elibrary, the National Inpatient Database of the USA, the Moscow Unified Register of Arthritis, the V. A. Nasonova Research Institute of Rheumatology were used in the review. V. A. Nasonova Research Institute of Rheumatology. Conclusion. In the presented review in adult patients with rheumatoid arthritis (RA) receiving various antirheumatic drugs, the immunogenicity (humoral response, opsonophagocytic activity), safety of vaccines of 13-valent conjugated pneumococcal vaccine (PCV13) was assessed. Based on the data presented, a conclusion was made about the safe management of PCV13 and the formation of antibodies to pneumococcus in RA patients with targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs), biologic (bDMARDs) and Glucocorticoids (GCs < 15 mg daily). Methotrexate (MTX) in RA patients reduced the pneumococcal response and the functional activity of antibodies.

Introduction. A clinical case of an 80-year-old patient with clinical and instrumental manifestations of amyloidosis caused by the deposition of non-mutant (“wild type”) transthyretin (Amyloidosis “wild type” TransThyRetin, ATTRwt) is described. A special feature of this case was the diagnosis of amyloidosis at the same time as the identification of symmetrical polyarthritis.Aim. To present an example of successful diagnosis and timely treatment of ATTRwt amyloidosis.Materials and methods. Male patient (80 years old) consulted a rheumatologist in an outpatient clinic with complaints of weakness and pain in the muscles of the upper and lower extremities, swelling and soreness of both wrist joints; with manifestations of multiple tunnel syndromes (ulnar canal, Guyon canals, bilateral carpal tunnel syndrome). In addition, the patient had a heart involvement which appeared as left ventricle hypertrophy, paroxysmal form of atrial fibrillation, chronic heart failure with preserved ejection fraction, intraventricular conduction defect and low QRS voltage. Due to the presence of cardiac manifestations along with neuropathy, transthyretinic amyloidosis was suspected.Results. Polyneuropathy was confirmed by the results of electroneuromyography. AL-amyloidosis (immunoglobulin Light chain Amyloidosis) is excluded due to the absence of monoclonal proteins in the blood. The diagnosis was confirmed by the results of scintigraphy with with labeled technetium-99m pyrophosphate. Intensive accumulation of radiopharmaceutical was detected in the myocardium of the left ventricle. The study also confirmed the presence of polyarthritis, manifested by increased accumulation, in the area of the I metatarsophalangeal joint on the left, both wrist, shoulder and knee joints. The hereditary nature of ATTR amyloidosis was excluded by the results of genetic analysis, which did not reveal mutations in the transthyretin gene. The singularity of this case was in development of a symmetrical polyarthritis during amyloidosis manifestation. Pathogenetic therapy with tafamidis was initiated. Arthritis regressed after starting treatment with methotrexate.Conclusion. Transthyretin amyloidosis is a chronic progressive life-threatening disease caused by the formation and deposition of transthyretin-derived amyloid fibrils. The variety of amyloid tropicity to various organs and tissues leads to it phenotypic heterogeneity, which makes it difficult to make a diagnosis on early stages. However, the detection of «red flags» symptoms signaling the presence of transthyretin amyloidosis can shorten the time before initiation of targeted treatment, contributing to the improvement of the patient’s quality of life.

Aim. To determine the factors that contribute to the prediction of the volume of pulmonary lesion in patients with systemic scleroderma (SSc).Materials and methods. The analysis included patients with SSc observed in the Registry of Myositis, systemic sclerosis and mixed connective tissue disease (REMISSIS), who underwent high-resolution computed tomography (HRCT) of the lungs. For the immunological characteristic, all patients were tested for anti-topoisomerase (anti-Scl-70), and anti-centromeric (anti-CENP-B) antibodies, and anticentromere antibodies (anti-Pm-Scl).Results. The study included 79 patients with SSc. There was 94.9 % women. Average age – 64.4 ± 11.5 years. Signs of interstitial lung disease (ILD), according to HRCT were detected in 50 patients. The largest extent of lung injury was noted in patients with SSc sine scleroderma (32.7 ± 29.3 %), a smaller extent in patients with diffuse form SSc (16.9 ± 17.1 %) and the lowest in patients with limited SSc (8.5 ± 14.2 %). In addition to the type of disease, the extent of lung injury in patients with SSc-ILD was statistically significantly higher in patients with arthralgia, dyspnea and the presence of antibodies to topoisomerase I and combined autoantibodies. Also, a statistically significant feedback was established with all indicators of the test with a 6-minute walk and forced vital capacity and a direct relationship with indicators of pulmonary artery systolic pressure. When evaluating the correlation between the extent of lung injury and the degree of dyspnea according to Borg, it was found that in patients who assessed dyspnea less than 3 points, the extent of lung injury was less than 25 %. Due to the high degree of correlation, a regression formula was created for the dependence of the extent of lung injury on the distance in the test with a 6-minute walk: extent of lung injury = (52.7–0.1) × distance 6MWT. A multivariate model was also obtained for predicting the extent of lung injury in SSc, in which the patient’s immunotype, distance in the 6-minute walk test, saturation after the 6-minute walk test, and the presence of dyspnea became the most effective.

In patients with systemic sclerosis (SSc), interstitial lung disease (ILD) is a factor in the decline of functional capacity up to disability and is also the leading cause of death. Therefore, one of the most important tasks in the treatment of this group of patients is not only to detect involvement of respiratory system, but also to predict the likelihood of its development.Objective: to study the possibility of predicting the development of ILD and advanced ILD in patients with SSc.Material and methods. The study included 79 patients with SSc (mean age 64.4±11.5 years; 94.9% women) from the Registry of myositis, SSc and Mixed Connective Tissue Diseases (РЕМИССиС) who underwent high-resolution computed tomography (HRCT) of the lungs. Classification trees (CTr) were constructed to predict the development of widespread ILD using the CHAID algorithm (exhaustive). All patients were tested for antibodies against Scl-70 (anti-Scl-70), CENP-B (anti-CENP-B), and PmScl (anti-PmScl).Results and discussion. ILD signs according to HRCT were detected in 53 patients. Fibrotic (34.2%) and cellular (15.2%) types of nonspecific interstitial pneumonia were the most common, and common interstitial pneumonia was less frequent (11.4%).The presence of ILD and advanced ILD (involvement of more than 20% of the lung parenchyma) were significantly associated with the detection of any autoantibodies, except anti-centromere antibodies, an increase in pulmonary artery systolic pressure, a decrease in forced vital capacity, diffusing capacity of the lungs, blood oxygen saturation at rest, and all parameters of six-minute walk test (6MWT), and complaints of shortness of breath. In addition, the presence of extensive ILD was also significantly associated with diffuse SSc and with SSc without skin manifestations.In establishing the CTr, it was found that the development of widespread ILD was unlikely in individuals who were able to walk more than 440 m in 6MWT and had neither anti-Scl-70 nor anti-PmScl.Significant associations were also found between the radiological pattern of ILD and the types of disease-specific antibodies.Conclusion. The 6MWT data in conjunction with the results of testing for SSc-specific autoantibodies provide a very accurate prediction of the presence and extent of ILD. It is advisable to include these indicators in the algorithm for screening and monitoring patients with SSc.

Currently, a large number of highly effective biologic disease modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs) are used for the treatment of rheumatoid arthritis (RA). However, in addition to effectiveness, it is necessary to evaluate the risk of adverse events (AEs) when using them.Objective: to determine the predictors of bDMARDs and tsDMARDs discontinuation due to AEs in patients with RA.Patients and methods. The study included 661 patients with RA who took bDMARDs and tsDMARDs. The search for predictors of targeted therapy discontinuation due to AEs was carried out in two stages. At the first stage, using the Kaplan-Meier method, we selected indicators that showed the greatest significant single-factor relationship with the duration of retention on therapy. At the second stage, significant independent indicators were obtained by iterative selection of variables within the multivariate proportional risk model according to Cox.Results and discussion. The presence of rheumatoid nodules (p

Hypogammaglobulinemia is a condition caused by low levels of immunoglobulins in the blood serum. It can be a manifestation of primary immunodeficiency, characterized by a violation of the production of immunoglobulins, in particular common variable immunodeficiency (CVID). A typical clinical sign of CVID is various severe infections, among which infectious arthritis is not uncommon. At the same time, the clinical picture of infections can differ significantly from that in individuals with a normal immune response, including the spectrum of infectious arthritis pathogens.The article describes a clinical case of an unusual course of infectious arthritis in a patient with newly diagnosed hypogammaglobulinemia. The peculiar features of the case were a long (more than 1.5 years) course of the disease, without the development of septic complications, no increase in ESR and CRP, recurrence of arthritis after a 2-month course of antibiotic therapy, and the presence of generalized edema. The causes and diagnosis, features of infectious complications, including infectious arthritis, and probable causes of edematous syndrome in CVID are discussed.

Introduction. Biopsy of prostate is a routine urologic procedure. More than 1 million biopsies are performed worldwide annually. The frequency of infectious-inflammatory complications remain high, despite the recommended antibiotic prophylaxis schemes.Aim. The evaluation of effectiveness and safety of combined antimicrobial prophylaxis: Fosfomycin and Fluoroquinolones of 3rd generation.Materials and methods. 80 patients underwent prostate biopsy in our study and were divided into 2 groups: the first group of 40 patients received routine prophylaxis: Levofloxacin 500 mg 6 hours before the biopsy and 500 mg per day during 4 days after biopsy. The second group of 40 patients, along with standard prophylaxis as in the first group, additionally after biopsy received Fosfomycin 3 gr single-shot.Results and discussion. In the first group, infectious and inflammatory complications occurred in 8 patients (20%). 12.5% of patients from the first group were hospitalized for paranteral antibiotic therapy. The average length of stay in hospital was 3.4 ± 1.45 days. In all cases, in the first group of patients, E. coli was detected, in 70% of cases fluoroquinolone-resistant strain of the bacterium was received. In the second group of patients now hospitalization was required. One patient out of forty (2.5%) from this group showed signs of urinary tract infection, which was not accompanied by an increase of body temperature, as well as changes in blood and urine tests.Conclusion. Our results show good effectiveness and safety of fosfomicin for antibiotic prophylaxis for transrectal prostate biopsy.

Introduction. Biopsy of prostate is a routine urologic procedure. Nevertheless the frequency of infectious-inflammatory complications remain high, despite the recommended antibiotic prophylaxis schemes.Purpose. The evaluation of effectiveness and safety of combined antimicrobial prophylaxis: fosfomycin trometamol and fluoroquinolones of 3rd generation.Materials and methods. Our clinical study included 80 patients who underwent prostate biopsy were divided into 2 groups. The first group of 40 patients received routine prophylaxis: levofloxacin 500 mg 6 h before the biopsy and 500 mg per day during 4 days after biopsy. The second group of 40 patients, along with standard prophylaxis as in the first group, additionally after biopsy received fosfomycin trometamol 3 gr single-shot.Results. In the first group, infectious and inflammatory complications occurred in 8 (20 %) patients, 12.5 % of patients from the first group were hospitalized for parenteral antibiotic therapy. The average length of stay in hospital was 3.4 ± 1.45 days. In all cases, in the first group of patients, Escherichia coli was detected, in 70 % of cases fluoroquinolone-resistant strain of the bacterium was received. In the second group of patients no hospitalization was required. One (2.5 %) patient out of forty from this group showed signs of urinary tract infection, which was not accompanied by an increase of body temperature, as well as changes in blood and urine tests.Conclusions. Our results show good effectiveness and safety of combined antibiotic prophylaxis for transrectal prostate biopsy. Since fluoroquinolone resistance grows, it is necessary to introduce alternative schemes, as well as monitoring of nosocomial infection and controlling of antimicrobial therapy.

Background. EULAR experts include osteoscintigraphy of joints in the list of promising methods for the diagnosis of joint diseases. However, the method remains little used in rheumatology in our country.Aim of the study – to develop an algorithm for differential diagnosis for the most common arthropathies based on quantitative osteoscintigraphy.Materials and methods. 3 hours after the injection of pyrophosphate labeled with Tc-99m, scintigraphy of skeletal bones was performed according to the “whole body” program. The joint/adjacent bone uptake ratio was calculated. The CHAID algorithm was used for classification tree constructing.Results. The study included 266 patients aged 46.6±14.3 years, 134 men (50.4%). Axial spondyloarthritis (including ankylosing spondylitis) was diagnosed in 40 patients, peripheral spondyloarthritis (including reactive arthritis) – in 87, rheumatoid arthritis– in 45, osteoarthritis – in 68, psoriatic arthritis – in 26 people. A total of 2279 joints were included in the analysis. A classification tree algorithm for differential diagnosis of arthropathies was constructed. Key indicators for identifying subgroups in the algorithm were the intensity of radiopharmaceutical uptake in the wrist, knee and hip joints. The significance level of differences between the resulting groups at all points of the algorithm branching, taking into account the Bonferroni adjustment, was p=0.001 or less. In the training sample, 51.5% of the observations were correctly classified. According to results of the cross-validation, the expected rate of correct classifications in the actual application of the algorithm is 38.0%.Conclusions. An algorithm for differential diagnosis of the most common inflammatory diseases of the joints has been developed. It allows the use of quantitative osteoscintigraphy data in the diagnosis of arthritis.

Objective: to analyze the results of tofacitinib (TOFA) therapy in real clinical practice according to the All-Russian Arthritis Registry (OREL). Subjects and methods. The OREL Registry included 347 patients (286 (82%) women and 61 (18%) men) with rheumatoid arthritis (RA) who initiated TOFA therapy. The male:female ratio was 1:4.7. The patients’ median age at onset of the disease was 42 years; its duration was 8 years. Most of the patients included in the registry had extended- (n=171 (52%)) or late- (n=148 (45%)) stage of RA. Results and discussion. Prior to initiation of TOFA therapy, RA activity according to DAS28 was high and moderate in 91 (64.5%) and 40 (28.4%) patients, respectively; the median DAS28 value was 5.5 [4.6; 6.2]; SDAI – 30.5 [21.4; 42.9], and CDAI – 28.2 [20.0; 37.1]. The use of TOFA was accompanied by significant decrease of disease activity. After 12 weeks, high RA activity was persistent in 32 (22.7%) patients; the number of patients with moderate activity increased to 77 (54.6%), that of those with low activity rose to 15 (10.6%); remission was observed in 17 (12.1%) patients. 216 (62.6%) and 76 (22%) patients received TOFA as first- and second-line therapy, respectively. TOFA was most frequently prescribed when tumor necrosis factor-á inhibitors (19.6%), rituximab (7.8%), tocilizumab (4.3%), and abatacept (5.2%) were insufficiently effective or poorly tolerated. Conclusion. The results of using TOFA in real clinical practice may suggest that the drug has high efficacy in patients with RA. TOFA can be used at a dose of 5 or 10 mg twice daily as both alone and in combination with disease-modifying anti-rheumatic drugs. TOFA showed similar efficacy in patients who had earlier taken biological agents and in those who had not.

The conclusion of the Expert Council presents the results of discussing the diagnosis and therapy of interstitial lung diseases in systemic scleroderma. The reason for this discussion was the emergence of new data on the use of nintedanib in this category of patients.

In the present article, the authors provide detailed material on the 13-year observation of a patient with such a rare disease as Whipple’s disease. Pathophysiological aspects, in particular changes in immunity within the framework of this nosology, clinical picture are also described in detail, and the emphasis is placed on the interrelation of certain symptoms, their intensification and regression. Taking into account the absence of clear recommendations for the management of such patients, the article considers various options of therapeutic schemes, and also reflects the own results of treatment.

Authors report new recommendations of All-Russian Public Organization «Association of Rheumatologists of Russia» (ARR) on treatment of rheumatoid arthritis (RA), which adapts contemporary concept accepted in the respective field of pharmacotherapy known as «Treat to Target». According to it, the main objective of RA pharmacotherapyis a remission (or low disease activity). To achieve it, disease modifying anti-rheumatic drugs (DMARD) should be administered to all RA patients as early as possible, with efficacy monitoring and therapy correction according to the disease activity. Special attention has been paid to the use of methotrexate (MTX) as «the gold standard» of RA pharmacotherapy and the key component of «Treat to Target» strategy. Early MTX administration (including subcutaneous injections) should become an obligatory component of RA treatment at all stages of the disease. If MTX is not efficient or not well tolerated (including subcutaneous form of the drug) as monotherapy or combined with conventional DMARD, biological agents should be used. Those include TNFα inhibitors, antagonist of interleukin-6 receptor (Tocilizumab), anti-B-cell drugs Rituximab) and agents blocking T-cell activation (Abatacept). Tofacitinib therapy (JAK inhibitor) is indicated in patients who are resistant to conventional DMARDs and biologics. All biologics and Tofacitinib are more effective in combination with MTX (or other DMARD).

Authors report new recommendations of All-Russian Public Organization «Association of Rheumatologists of Russia» (ARR) on treatment of rheumatoid arthritis (RA), which adapts contemporary concept accepted in the respective field of pharmacotherapy known as «Treat to Target». According to it, the main objective of RA pharmacotherapy is a remission (or low disease activity). To achieve it, disease modifying anti-rheumatic drugs (DMARD) should be administered to all RA patients as early as possible, with efficacy monitoring and therapy correction according to the disease activity. Special attention has been paid to the use of methotrexate (MTX) as «the gold standard» of RA pharmacotherapy and the key component of «Treat to Target» strategy. Early MTX administration (including subcutaneous injections) should become an obligatory component of RA treatment at all stages of the disease. If MTX is not efficient or not well tolerated (including subcutaneous form of the drug) as monotherapy or combined with conventional DMARD, biological agents should be used. Those include TNFα inhibitors, antagonist of interleukin-6 receptor (Tocilizumab), anti-B-cell drugs (Rituximab) and agents blocking T-cell activation (Abatacept). Tofacitinib therapy (JAK inhibitor) is indicated in patients who are resistant to conventional DMARDs and biologics. All biologics and Tofacitinib are more effective in combination with MTX (or other DMARD).

Diagnosis of acute rheumatic fever.

The case of a giant-cell arteritis is presented. First clinical signs of the disease were fewer and development of infarction in the basin of the left vertebral artery. Magnetic resonance angiography showed its prolonged diminution. Laboratory results were remarkable for the high rate of erythrocyte sedimentation and the increase of C-reactive protein (CRP) concentration. Physical examination revealed acrotism in temporal arteries. Diagnosis was proven by biopsy results which included giant multinucleate cells. Authors discuss problems of diagnosis of the disease, the role of radiological methods (angio-ultrasonography, magnetic resonance and computed tomography aided angiography, positron-emission tomography) and the necessity to pay particular attention to the elderly patients with high rate of erythrocyte sedimentation and the increased CRP concentration.

Authors report new recommendations of All-Russian Public Organization «Association of Rheumatologists of Russia» (ARR) on treatment of rheumatoid arthritis (RA), which adapts contemporary concept accepted in the respective field of pharmacotherapy known as «Treat to Target». According to it, the main objective of RA pharmacotherapy is a remission (or low disease activity). To achieve it, disease modifying anti-rheumatic drugs (DMARD) should be administered to all RA patients as early as possible, with efficacy monitoring and therapy correction according to the disease activity. Special attention has been paid to the use of methotrexate (MTX) as«the gold standard» of RA pharmacotherapy and the key component of «Treat to Target» strategy. Early MTX administration (including subcutaneous injections) should become an obligatory component of RA treatment at all stages of the disease. If MTX is not efficient or not well tolerated (including subcutaneous form of the drug) as monotherapy or combined with conventional DMARD, biological agents should be used. Those include TNFα inhibitors, antagonist of interleukin-6 receptor (Tocilizumab), anti-B-cell drugs (Rituximab) and agents blocking T-cell activation (Abatacept). Tofacitinib therapy (JAK inhibitor) is indicated in patients who are resistant to conventional DMARDs and biologics. All biologics and Tofacitinib are more effective in combination with MTX (or other DMARD).