Autoimmune Diseases and Therapeutic Approaches

Objective: Methotrexate (MTX) is used for the treatment of inflammatory disorders but can cause liver enzyme abnormalities. Liver enzyme elevations are neither specific nor sensitive for detecting liver fibrosis. Liver biopsy is an imperfect gold standard with its own limitations. Fibro scan is a non-invasive technique used to evaluate liver fibrosis. The objective of this study was to review the literature to characterize the utility of Fibroscan for detection of liver fibrosis compared to biopsy in patients with inflammatory conditions treated with MTX. 

Methods: A systematic literature search was carried out of all English publications. The search was limited to studies involving subjects greater than 18 years of age, meeting criteria for the diagnosis of Crohn's Disease (CD), Rheumatoid Arthritis (RA), psoriasis (Ps) or psoriatic arthritis (PsA).Studies where liver biopsy was not performed were excluded. 

Results: Among 18 references identified, three publications met the criteria. The selected studies were prospective, cross-sectional studies (n=21-518).The cutoffs for significant or severe fibrosis based on Fibroscan score (FSS) differed amongst the studies (7kPA-8.7kPa). FSS did not reflect biopsy findings in a large portion of patients (40%-69%).The accuracy of Fibroscan for the detection of no or mild fibrosis (F<2) ranged from 0%-88%.The accuracy of Fibroscan for the detection of significant fibrosis or cirrhosis (F2-4) ranged from 0%-30%.  

Conclusions: There is insufficient evidence to support the use of Fibroscan for detecting liver fibrosis in a MTX-taking population with inflammatory disorders. 

Keywords: Fibroscan; Liver fibrosis; Crohn's Disease; Psoriatic Arthritis; Rheumatoid Arthritis; MTZ

Granulomatosis with polyangiitis (GPA) or Wegener’s granulomatosis is a systemic necrotizing vasculitis with small sized vessel involvement and granulomatous inflammation of ENT and/or Lung and/or Kidney that is associated with ANCA positivity. Upon the clinical /laboratory/imaging judgement of an expert Rheumatologist in cooperation with an expert otolaryngologist and an expert infectious disease specialist the diagnosis of GPA can be established. There have been three criteria for GPA including: 
• The 1990 ACR classification criteria for Wegener’s granulomatosis 
• The EMA diagnostic criteria of systemic GPA 
• Iran criteria for early diagnosis of GPA 
The 1990 ACR criteria is not sensitive enough and it cannot detect the cases of GPA in early stages. The EMA criteria has been made for diagnosis of systemic GPA in the absence of biopsy and its sensitivity is too much low. Iran criteria for early diagnosis of GPA is highly sensitive but there is a lag period of about a few months between the initial presentation of disease and the time of confirmation of it. You have to know that with a little changes within Iran criteria a new criteria is created by the author of this letter called 2017 ACR/EMA revised criteria by which the diagnosis of GPA can be established too earlier with a lag period of a few weeks only. 
 
Keywords: GPA; 1990 ACR Criteria; EMA Criteria; Iran Criteria; 2017 ACR/EMA Revised Criteria 

Sjogren’ Syndrome (SS) is a chronic autoimmune disease presenting with clinical hallmark of dry eyes, dry mouth and salivary gland swelling and histological hallmark of lymphocytic infiltration of exocrine glands.  There are three key items for approaching towards Sjogren’s Syndrome (SS) including: 
• Dry eyes 
• Dry mouth 
• Salivary gland swelling 
A. If there are at least 2 items of above in a patient he/she has to be referred to a Rheumatologist by General Practitioners (GP). 
B. If there is only one item of above in a patient, he/she will be referred to a Rheumatologist, when a GP 
i.   Confirms that the finding is pathologic and 
ii.   Rule outs its other causes in cooperation with related specialists. 
C. If there is not any item of above: the GP should forget about Sjogren’s syndrome for the time being. The dryness of eyes is pathologic if there is at least one of below features: 
• Duration of at least 3 months 
• Gritty or sandy sensation in the eyes 
• Use of a tear substitute more than 3 times daily 
Dry mouth is pathologic if there is at least one of below features: 
• Duration of at least 3 months 
• Patient has to wake up at night to drink water because his/her mouth is too dry 
• Patient frequently drinks liquids to help in swallowing dry foods 
We have to know that salivary gland swelling is always pathologic and chronic or recurrent bilateral parotid glands enlargement is the compatible state with Sjogren’s syndrome when its other etiologies can be ruled out. 
 
Keywords: Dry Eye; Dry Mouth; Salivary Gland Swelling; Sjogren’s syndrome 

Ankylosing Spondylitis (AS) is a chronic inflammatory systemic disease belonging to the SpondyloArthritidies with axial joint involvement and enthesitis, with or without peripheral arthritis and systemic involvement. We know that the clinical/paraclinical judgement of an expert Rheumatologist is the gold standard for diagnosis of AS. It is mentioned that the 1984 modified New York criteria is applied for classification of AS and it is not a good instrument for early detection of disease. The author by this letter delivers a new criteria called 2016 New York revised criteria that is applied for too early diagnosis of AS. With the addition of pelvic MRI, HLA-B27 positivity, positive family history of AS, Enthesitis/arthritis and positive sacral push test to the 1984 modified New York criteria and deletion of limited chest expansion from it, this new criteria has been created. 

Keywords: Ankylosing Spondylitis; 2016 New York Revised Criteria; Pelvic MRI; HLA-B27 Positivity