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The treatment of inflammatory arthritides has been changed dramatically in the past two decades with the introduction of the biological (b) disease-modifying anti-rheumatic drugs (DMARDs) as well as the targeting synthetic (ts) DMARDs that can be used as monotherapy or in combination with conventional synthetic (cs) DMARDs. The concept of treat to target (T2T) and tight control monitoring of disease activity represents a therapeutic paradigm of modern rheumatology. In rheumatoid arthritis (RA), this treatment approach has proven to be effective in many clinical trials and is now a well-established approach. The most common treatment strategies rely on the combination of csDMARDs (mainly methotrexate, sulfasalazine and hydroxychloroquine). This comes from different studies which compare the outcomes of combination therapies versus csDMARD monotherapy or versus methotrexate plus biologics in early RA patients. Here, we review the literature of the most important T2T studies for RA patients. The results showed that a tight control strategy appears to be more important than a specific drug to control RA. T2T approach aiming for remission or low disease activity can be achieved in early RA patients using less expensive drugs in comparison to newer drugs and this may need to be recognised in the future recommendations for the management of RA. KEY POINTS: • Tight-control and treat-to-target (T2T) strategies are the cornerstone in achieving remission or low disease activity in rheumatoid arthritis (RA) • A plethora of clinical trials has confirmed the efficacy of csDMARDs when the tight-control and T2T strategies are applied • T2T and tight-control strategies are a less expensive option in comparison to newer drugs and may be recognised in the future recommendations for the management of RA. • Treatment decisions and strategies are more important than just the drugs.

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis. Pulmonary involvement is a rare extra-articular manifestation of the disease characterized by rigidity of the chest wall and apical pulmonary fibrosis. Pleural effusion is uncommon in PsA. We present four cases of patients with PsA who developed pleural effusions. We report for the first time a PsA patient who was drug-naïve and developed unilateral pleuritis. We also describe one PsA case with pleuritis while he was on methotrexate (MTX) and two PsA cases on tumor necrosis factor (TNF) inhibitors. The literature review revealed six cases with pleural effusion, which were drug-induced. These patients presented pleural effusions while they were treated with MTX (2 patients) and TNF inhibitors (4 patients). In PsA patients with pleuritis, a detailed investigation to rule out infections is necessary. In addition, increased pharmacovigilance will detect cases of drug-induced serositis.

The treatment of inflammatory arthritides has been changed dramatically in the past two decades with the introduction of the biological (b) disease-modifying anti-rheumatic drugs (DMARDs) as well as the targeting synthetic (ts) DMARDs that can be used as monotherapy or in combination with conventional synthetic (cs) DMARDs. The concept of treat to target (T2T) and tight control monitoring of disease activity represents a therapeutic paradigm of modern rheumatology. In rheumatoid arthritis (RA), this treatment approach has proven to be effective in many clinical trials and is now a well-established approach. The most common treatment strategies rely on the combination of csDMARDs (mainly methotrexate, sulfasalazine and hydroxychloroquine). This comes from different studies which compare the outcomes of combination therapies versus csDMARD monotherapy or versus methotrexate plus biologics in early RA patients. Here, we review the literature of the most important T2T studies for RA patients. The results showed that a tight control strategy appears to be more important than a specific drug to control RA. T2T approach aiming for remission or low disease activity can be achieved in early RA patients using less expensive drugs in comparison to newer drugs and this may need to be recognised in the future recommendations for the management of RA. KEY POINTS: • Tight-control and treat-to-target (T2T) strategies are the cornerstone in achieving remission or low disease activity in rheumatoid arthritis (RA) • A plethora of clinical trials has confirmed the efficacy of csDMARDs when the tight-control and T2T strategies are applied • T2T and tight-control strategies are a less expensive option in comparison to newer drugs and may be recognised in the future recommendations for the management of RA. • Treatment decisions and strategies are more important than just the drugs.

Anxiety and depressive symptoms as well as cognitive variables are important in determining outcome in rheumatic diseases. We aimed to compare psychological distress symptoms and illness perceptions in ankylosing spondylitis (AS) and rheumatoid arthritis (RA) and to test whether their associations with health-related quality of life (HRQoL) were similar in these rheumatologic disorders. In 55 AS and 199 RA patients, we administered the Patient Health Questionnaire (PHQ-9), the Symptom Check-List and the Brief-Illness Perception Questionnaire to assess psychological variables and the World Health Organization Quality of Life Instrument, Short Form to assess HRQoL. We used hierarchical regression analyses to determine the associations between psychological variables and HRQoL after adjusting for demographic variables and disease parameters. The prevalence of clinically significant depressive symptoms (PHQ-9 ≥ 10) was 14.8 % in AS and 25.1 % in RA patients, but adjustment for demographics rendered these differences in depressive symptoms' severity non-significant. Psychological distress levels and HRQoL were similar in both disorders. Illness concern (b = -0.37) was the only significant independent correlate of physical HRQoL in AS. In RA, depression (b = -0.25), illness concern (b = -0.14) and worries about the consequences of the disease (b = -0.31) were the independent correlates of physical HRQoL. These findings suggest that cognitive variables are important correlates of HRQoL in AS, whereas in RA depressive symptoms and illness perceptions equally contribute to HRQoL. Our data encourage the design of psychotherapeutic trials targeting disease-related cognitions in AS in an attempt to improve patient's physical HRQoL.

This report seeks to describe the clinical efficacy and safety of infliximab in a patient with psoriatic arthritis on hemodialysis and to review the literature on the topic. We present a patient with psoriatic arthritis on hemodialysis treated with infliximab and we review the literature. Our case includes a patient with severe psoriasis and dactylitis with chronic renal failure requiring regular hemodialysis. At presentation the patient had a psoriasis area and severity index (PASI) score of 35.1 and dactylitis affecting the right thumb. Evaluation of laboratory parameters revealed a slight increase of erythrocyte sedimentation rate (21 mm/h) and a mild normocytic anemia (Hct 36.4). The rest of the laboratory and imaging tests were within normal limits. Infliximab was initiated at the loading dose of 5 mg/kg body weight at weeks 0, 2, 6, and every 8 weeks thereafter. On retreatment at week 14 the PASI score was measured to 3.4. After the conclusion of 6 months of treatment, the reduction of PASI score was sustained reaching the point of 0.8. In addition, dactylitis, as well as laboratory parameters, showed a striking improvement. On the other hand, during the same period of time, no changes of renal functions were noted and no complications were reported and the patient continued his hemodialysis on a regular basis. Our case is in accordance with other reports supporting that infliximab treatment in patients undergoing hemodialysis can be safe, well tolerated, and effective. However, larger trials are needed to prove its use in these patients.

We present a 54-year-old man, a heavy smoker, with clinical and laboratory evidence of familial hypercholesterolemia and an asymptomatic solitary pulmonary nodule (SPN) increasing in size on follow-up chest X-ray. Laboratory work-up revealed high titers of rheumatoid factor and the presence of acute phase reactants. Because of the patient's age and history of smoking, open lung biopsy was performed to rule out malignancy. The biopsy showed histological features compatible with a rheumatoid nodule. Identical features were noted in the histological examination of the subcutaneous nodule. Usually, rheumatoid nodules occur in patients with active, long-standing rheumatoid arthritis (RA) with other extra-articular manifestations. The presence of a single pulmonary rheumatoid nodule as the first manifestation of RA is extremely rare. Histologic proof is often required since pulmonary carcinoma can present an identical clinical and radiological pattern. The diagnostic work-up and the differential diagnosis of an SPN, particularly in a heavy smoker, is a common clinical request and remains a diagnostic challenge. Clin Rheumatol

We describe three cases with visceral leishmaniasis (VL) associated with autoimmune manifestations. The patients presented with anemia, leukopenia, thrombocytopenia, renal involvement and low complement levels. Autoimmune features were present (antinuclear and anticardiolipin antibodies, VDRL, RF, positive direct Coombs’ test), which subsided after therapy. Leishmaniasis should be taken into consideration in the differential diagnosis of autoimmune disorders.

Erythema nodosum (EN) is a cutaneous reaction consisting of inflammatory, tender nodular lesions and is associated with a wide variety of disease processes. The aim of our study was to investigate the frequency of different aetiologies of EN. One hundred and thirty-two EN patients were investigated in a prospective study during the period 1984-1990. The evaluation of all patients began with a medical and family history and completed with a thorough physical examination and detailed laboratory and immunological work-up. In addition, various diagnostic procedures were performed where and when indicated. One hundred and ten patients (83%) were women. Their mean age was 41.0+/-14.0 years, range 18-79 years. In 35% the cause of EN was not found. Sarcoidosis was revealed in 28% of the patients, infections in 17.3% and tuberculosis in 1.5%. Other aetiologic factors were Adamantiadis-Behcet's syndrome (3.8%), pregnancy (6%), oral contraceptives (3.8%) and other drugs (3.8%). The aetiology of EN was not found in 35% of the patients. Sarcoidosis and infections were frequent causes of EN, whereas autoimmune rheumatic diseases rarely cause EN.

Specific inhibition of the cytokine tumor necrosis factor alpha has resulted in significant clinical and laboratory improvement of patients with chronic inflammatory diseases of Th1 phenotype. Etanercept is a recombinant fusion protein of two p75 soluble receptors, while infliximab is a chimeric monoclonal antibody. Both have been considered to be immunogenic and cause various immune-mediated skin reactions. On the other hand, adalimumab, a human monoclonal antibody, was expected to cause little or no immune-mediated skin reactions. Herein, we report a patient with rheumatoid arthritis treated with adalimumab, who after the seventh injection, developed angiedema affecting the lips and face, as well as an urticaria-like skin reaction affecting the trunk. These reactions were followed by hypotension. The patient was treated appropriately and after 2 h, the rashes and the edema disappeared and the patient gradually recovered completely. Adalimumab was discontinued.

We report a patient with relapsing polychondritis (RP) who developed pyoderma gangrenosum (PG) during pregnancy and gave birth to a healthy female infant. A 30-year-old woman, para 1, presented to our antenatal clinic at 6 weeks of gestation. She had been treated with corticosteroids for RP since she was 11 years old [1]. She had conceived spontaneously and until the 6th week of gestation she was receiving methylprednisolone 32 mg every other day. At the 8th week of gestation she presented a large painful skin ulcer involving the extensor surface of the right leg. Histological examination showed a necrotic ulcer (Fig. 1). The diagnosis of PG was made [2]. Oral azathioprine (AZA) 150 mg/ day was added after the 12th week and the PG showed a good response. After the 28th week, fetal growth and condition, assessed by ultrasound and Doppler velocimetry of the umbilical artery, were found to be accurate for gestation. At 37 weeks and 3 days she gave birth to a healthy 3080 g female infant by Caesarian section, because of failure of the trial of labour. RP and PG are considered to have an autoimmune basis [1,2]; both conditions were well controlled by immunosuppressive drugs such as corticosteroids and AZA [3]. These drugs are considered to be safe in pregnant women [3,4]. In order to achieve a better outcome of pregnancy in RP and PG patients, it is essential to control disease activity. Close follow-up, monitoring and ultrasound studies will improve fetal survival and reduce disease flare rates in these patients.