Relief for Long-standing Postchikungunya Viral Myalgic and Arthralgic Pains Effected by Neuromodulation of Ultrasound-Guided Dry Needling of Affected Muscles and Steroid-Based Interventions

Chronic myalgias and arthralgias occur after Chikungunya virus infections (pCHIKV- M&A). We report details of treating a 6-years lasting CHIKV-M&A pains with a combination of medications and interventions. The patient had severe pain in bilateral shoulders and elbows; right thumb and back. Response to steroids, sulphasalazine and methotrexate was poor. Examination revealed M&A pains. Medications initiated included Pregabalin, Paracetamol, Tramadol and vitamin D. At two weeks, despite improvement, there were residual pains in bilateral shoulders and elbows. Four weekly sessions (two on each side), of ultrasound-guided dry needling (USGDN) of all muscles of the upper limb was done. Patient reassessment revealed moderate, residual pains at bilateral supraspinatus muscles, bicipital tendons and radio-humeral joints. These pains were addressed by USG guided steroid injection of bilateral- suprascapular nerves, bicipital tendons and radio-humeral joints. Medications reduced pains especially of back and thumb. USGDN of muscles further reduced it by 60%. The interventions at the nerves, entheses and joints gave 90%-100% relief. The pre-intervention Disability of Arm, Shoulder and Hand (DASH) score of 52.7 reduced to 5.4. At fifth month follow-up, the DASH was15.8, but patient reported satisfaction over pain relief, improvement in daily activities and quality-of-life. There are no evidence-based treatment guidelines or corroborative evidence for rheumatic pathology (most times) for persistent CHIKV-M&A pains. This case-report highlights the successful management of CHIKV-M&A pains by multi-modal approach. USGDN and steroids have neuro-modulatory effects. We have proposed that USGDN aids pain relief by an integrative role with the biologically inherent “chaos theory.

Clinical and Trichoscopic Patterns of Discoid Lupus Erythematosus of Scalp in Patients with Systemic Lupus Erythematosus: An Observational Study

Background: Discoid lupus erythematosus (DLE) is a specific cutaneous manifestation of systemic lupus erythematosus (SLE), which results in scarring alopecia of the scalp. Methods: A prospective cross-sectional observational study on scarring alopecia among SLE patients was done between September 2016 and August 2017. The clinical and trichoscopic patterns of scalp DLE among these patients were studied. The DLE lesions were categorised into active and inactive based on clinical features. Trichoscopy was done and photographs were obtained using a non-polarised videodermoscope. Results: There were 26 patients with scalp DLE, out of which 15 patients (57.69%) had active DLE and 11 (42.30%) had inactive DLE. The trichoscopic findings seen were structureless white areas, loss of follicular units, blue-grey dots and globules, follicular keratotic plugs and telangiectasia. The trichoscopic features seen in active versus inactive DLE were blue-grey dots and globules (93.33% vs 63.63%), structureless white areas (93.33% vs 90.90%), loss of follicular units (86.66% vs 72.72%) and follicular keratotic plugs (80% vs 45.45%), yellow dots with arborising vessels (33.33% vs 72.72%), exaggerated honeycomb pigmentation (46% vs 63.63%) and telangiectasia (66.67% vs 54.54%). Scaling (P = 0.033) and blue-grey dots (P = 0.021) were significantly higher in active and yellow dots with arborising vessels (P = 0.047) in inactive DLE. Conclusions: On comparing trichoscopic features between active and inactive DLE scaling and blue-grey dots were significantly higher in active and yellow dots with arborising vessels in inactive DLE

Favourable Functional Outcomes In Idiopathic Inflammatory Myositis- A Single Centre Experience Over 15 Years

Abstract Background: To describe the long term clinical outcome and prognostic factors associated with outcome in a longitudinal cohort of idiopathic inflammatory myositis (IIM). Methods: In this retrospective cohort study, IIM patients were classified as per Bohan and Peter criteria. In those with ≥ 24 months of follow-up; treatment response, functional outcomes [health assessment questionnaire-disability index(HAQ-DI) and modified Rankin score(MRS)], Myositis damage index(MDI) at last follow-up was recorded. Results: The cohort consists of 175 patients, with a mean age of 40.9(+12.6) years, M:F 1:3.3; the IIM subsets were dermatomyositis(DM) 78(44.6%), overlap myositis(OM) 45(25.7%), antisynthetase syndrome(ASS) 11(6.3%), polymyositis(PM) 25(14.3%) and juvenile DM/OM in 15(8.6%) patients. Mortality rate was 13.4% and disease related deaths was 9.1%. Ninety-four patients have followed up for &gt;24 months, the median (IQR) of 65(35,100.7) months. At last follow-up, 13.8% were in treatment free remission, 73.4%, 11.7% had complete clinical response and partial clinical response with treatment respectively. HAQ-DI and MRS were favourable in &gt; 90% of patients. At last follow-up, one-third were off-steroids. Discontinuation of steroids was associated with HAQ-DI of 0 and lower MRS. Complete clinical response on/off medication at last follow-up was associated with HAQ-DI of 0[OR10.9; 95%CI(3.3,160)], better MRS[OR 3.2; 95%CI(1.4,7.3)] and lesser MDI[OR 1.7; 95% CI(1.1,2.7)] at the last follow-up as compared to partial response. Baseline parameters and IIM subsets did not significantly influence outcome.Conclusion: Our longitudinal cohort of IIM had a good outcome in all major myositis subsets. Partial clinical response on treatment is associated with worse functional outcomes and damage accrual.</jats:p

Nondigital skin ulcers in systemic sclerosis: A neglected entity

Background: Skin ulcers (SUs) are a common and difficult to manage problem in systemic sclerosis (SSc) and can be broadly classified into two types: digital ulcers (DUs) and non-DUs. Objective: The objective of this study was to analyze prevalence, associated factors, and response to therapy for non-DU. Patients and Methods: All patients with SSc who fulfilled the 2013 ACR/EULAR criteria were included in the study. SUs were divided into DU and various types of non-DU (SU on bony prominences, SU on calcinosis, SU on lower limbs, and SU with gangrene). Results: We included 146 patients with SSc (83.6' females) with a median follow-up of 20.5 months (interquartile range: 52). Eighty-four patients (57.5') had at least one episode of DU. Recurrent DUs despite vasodilators were seen in 36 (24.7') patients. Thirty-four patients (23.3') had non-DU. The most common type of non-DU was SU of lower limbs (23), followed by SU on bony prominences (19). The most common ulcer site was on the malleoli in the lower limbs and elbow in the upper limbs. Most of the ulcers healed in 3–6 months. Three patients developed osteomyelitis. The presence of non-DU was associated with longer duration of disease (P = 0.0009), occurrence of DU (P = 0.011), presence of gangrene (P < 0.001), or calcinosis (P < 0.001), and higher modified Rodnan skin score (P = 0.0013). Conclusion: Non-DUs were found in a quarter of patients with SSc. They are associated with advanced disease and vasculopathy. There is an unmet need to incorporate non-DU in clinical trial outcomes and address them in patient management guidelines