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1</a>&#41;&#46; Electrocardiogram and echocardiogram were normal&#46; Laboratory tests revealed iron-deficiency anemia &#40;hemoglobin 8&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; hematocrit 27&#37;&#44; iron 12<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dL&#44; transferrin 339<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; ferritin 4<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#44; leukocytes 4250&#47;&#956;L&#44; lymphocytes 510&#47;&#956;L &#40;12&#37;&#41;&#44; neutrophils 3620&#47;&#956;L &#40;85&#37;&#41; and platelets 359&#44;000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">&#8722;1</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> The coagulation study was normal &#40;prothrombin activity 118&#37; &#91;normal 70&#8211;120&#93; and activated partial thromboplastin time 29&#46;7<span class="elsevierStyleHsp" style=""></span>s &#91;23&#8211;36&#93;&#41;&#46; Immunoglobulin &#40;Ig&#41; G and IgM anticardiolipin antibodies and lupus anticoagulant were negative&#44; and CRP and ESR were normal&#44; as were thyroid function tests&#46; Direct Coombs was negative and haptoglobin normal at 159<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;30&#8211;200&#41;&#46; She was positive for ANA and anti-double stranded DNA &#40;dsDNA&#41; and negative for ENA and antineutrophil cytoplasmic antibodies&#59; complement C3 and C4 were normal&#44; and proteins normal&#46; During her hospital stay&#44; treatment was begun with low-molecular weight heparin with acetyl salicylic acid &#40;ASA&#41; and intravenous alprostadil&#46; The corticosteroid dose was increased and she continued with MTX and leflunomide &#40;which she had continued to take although she did not come for checkups&#41;&#46; She was discharged from the hospital&#44; while awaiting the results of an analysis for cryoglobulins&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In successive checkups in our offices&#44; the patient showed improvement in terms of ischemia but polyarthritis persisted&#46; The result for cryoglobulins was positive&#46; Given the persistence of polyarthritis &#40;although she continued to take MTX and leflunomide&#41; and cryoglobulinemia&#44; it was decided that she begin rituximab&#46; Anticoagulation was maintained with acenocoumarol for a year&#44; until the cryoglobulins were negative&#44; when antiplatelet therapy was begun with ASA&#46; During follow-up&#44; the patient was repeatedly positive for ANA at low titers&#44; with a homogeneous pattern&#44; and was negative for anti-dsDNA&#46; The immunological study was extended and we found antinucleosome antibodies and antibodies against the collagen-like region of C1q&#46; The patient has continued to take rituximab&#44; MTX&#44; HCQ and ASA&#46; She has not had any further ischemic episodes and there is no evidence of involvement of kidneys or of any other organ&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">We report the case of a patient with polyarthritis&#44; a frequent cause for seeking advice from a rheumatologist&#44; and a challenge for the latter because of its extensive differential diagnosis&#46; Initially&#44; given the clinical features and the findings revealed by the ancillary tests performed&#44; the patient was diagnosed with rheumatoid arthritis&#44; according to the 2010 classification criteria of the American College of Rheumatology and European League Against Rheumatism &#40;ACR&#47;EULAR&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Thus&#44; treatment with disease-modifying antirheumatic drugs &#40;DMARD&#41; and corticosteroids was begun&#44; and her clinical course was favorable for more than a year&#46; However&#44; the development of new symptoms and analytical data recorded during follow-up&#44; can make you reconsider the initial diagnosis or even change it&#44; as occurred in the case we present&#46; Ultimately&#44; the patient met the criteria for a diagnosis of SLE&#44; as she was ANA-positive and anti-dsDNA-positive and had arthritis&#44; lymphopenia &#40;according to the 2012 criteria of the Systemic Lupus International Collaborating Clinics&#41;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> and mixed cryoglobulinemia&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We found antinucleosome and anti-C1q antibodies in this patient&#46; The antinucleosome antibodies could be a more accurate marker for the diagnosis of SLE&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;5</span></a> with a similar specificity and a slightly higher sensitivity than anti-dsDNA&#44; but with a highly superior diagnostic odds ratio &#40;41 vs 27&#46;8&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Nucleosomes mediate the binding of autoantibodies to the basement membranes&#46; These antibodies are capable of binding to different components of the glomerular basement membrane like collagen&#44; membrane surface proteins&#44; DNA-histone complexes and chromatin&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> producing renal damage&#46; For this&#44; they are considered nephritogenic&#44; and have also been associated with disease activity measured using different questionnaires &#40;Systemic Lupus Erythematosus Disease Activity Index&#44; European Consensus Lupus Activity Measurement&#44; etc&#46;&#41;&#46; The activation of the classical complement pathway begins with the molecule C1q&#44; which is essential in the clearance of immune complexes and apoptotic cell debris&#46; Hereditary C1q deficiency is associated with high susceptibility for the development of SLE&#44; especially the mucocutaneous manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> Its level usually decreases during flares of the disease and is associated with anti-C1q antibodies &#40;antibodies against the collagen-like region&#41;&#44; especially in patients with active lupus nephritis&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> The presence of anti-DNA and anti-C1q antibodies leads to the formation of immune complexes&#44; with the subsequent triggering of the immune response&#44; which is usually associated with a higher risk of renal involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9&#44;10</span></a> However&#44; the expression of these antibodies and their levels do not always correlate with disease activity and&#44; thus&#44; their pathogenic role is not yet completely understood&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> Nevertheless&#44; the patient has not had renal involvement over the nearly 5 years of follow-up&#44; possibly because of the treatment with DMARD and&#44; ultimately&#44; with anti-CD20 monoclonal antibodies&#46; In any case&#44; the use of corticosteroids and immunosuppressive therapy may have contributed to the maintenance of negative anti-dsDNA antibodies throughout her course&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Moreover&#44; the presence of cryoglobulins coincided in time with the autoimmune conditions described above&#46; Cryoglobulins are monoclonal and&#47;or polyclonal Ig that reversibly precipitate when serum is incubated at temperatures below 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Their presence in blood can produce a systemic vasculitic process affecting small and medium-sized vessels&#46; They are classified according to 3 forms depending on the composition of the precipitate&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Type I cryoglobulinemia involves a single type of monoclonal immunoglobulin&#46; It is usually associated with lymphoproliferative diseases and multiple myeloma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Type II cryoglobulinemia involves a polyclonal IgG and a monoclonal IgM with rheumatoid factor activity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Type III cryoglobulinemia involves a polyclonal IgG and a polyclonal IgM with rheumatoid factor activity&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">Types II and III are referred to as mixed cryoglobulinemia &#40;MC&#41; and are usually associated with CTD and lymphoproliferative processes and infections&#44; but hepatitis C virus infection is the disease with which they are most frequently linked &#40;60&#37;&#8211;90&#37; of cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Cryoglobulinemia is usually manifested with fever&#44; myalgia&#44; arthralgia &#40;arthritis alone has only been reported in less than 10&#37; of the cases&#41;&#44; palpebral purpura in lower limbs &#40;the most characteristic manifestation&#41; and neurological and renal involvement&#46; Regarding the last two&#44; 17&#37;&#8211;60&#37; of the patients will have peripheral neuropathy&#44; which can be the first sign of a MC&#44; and up to 30&#37; will develop microhematuria and proteinuria&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Its presentation as a peripheral acute arterial ischemia&#44; with no other associated signs of vasculitis&#44; as occurred in our patient&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> is exceptional&#46; The digital necrosis is adverse in the prognosis of MC&#44; as it has been associated with a high risk of infections&#44; sepsis and death&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> Computed tomography angiography did not identify lesions compatible with vasculitic or atherosclerotic involvement&#44; and the patient did not have any of the abovementioned symptoms&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The pathogenic role of antinucleosome and anti-C1q antibodies in the case reported is unknown to us&#46; We consider that they are serological markers of SLE&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The final diagnosis was MC secondary to a CTD &#40;SLE&#41;&#46; The usual clinical signs are the consequence of the deposition of circulating immune complexes in the wall of small and medium-sized vessels&#44; which triggers an inflammatory response that leads to systemic vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> Treatment consists of glucocorticoids and immunosuppressive agents&#46; The use of plasmapheresis has been reported when the remaining approaches have been ineffective&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> In this case&#44; given the clinical manifestations of the patient and the association of MC with SLE&#44; we opted for rituximab&#46; The utilization of anti-CD20 monoclonal antibodies has been found to be beneficial in the treatment of systemic vasculitis and&#44; although the data we have in cryoglobulinemic vasculitis not associated with hepatitis C virus is limited&#44; certain case series support the use of rituximab in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion&#44; the particular feature of this case lies in the presentation of the MC in the setting of SLE&#44; as an acute arterial ischemia &#40;right radial artery occlusion&#41; in a patient who had initially been diagnosed as having a seronegative polyarthritis&#46; Despite the presence of nephritogenic antibodies&#44; the patient has not developed renal involvement&#44; remains in remission and continues to take rituximab&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cryoglobulins are immunoglobulins that precipitate at cold temperatures&#46; Their presence can be related to a type of vasculitis referred to as cryoglobulinemia&#46; This condition&#44; especially mixed cryoglobulinemia&#44; has been associated with viral infections like hepatitis C virus in 60&#37;&#8211;90&#37; of cases&#44; but it has also been reported in relation to connective tissue diseases&#44; usually resulting in a more severe course&#46; We describe the case of a patient with seronegative polyarthritis who developed acute arterial ischemia in association with cryoglobulinemia&#44; with a good response to rituximab therapy&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las crioglobulinas son inmunoglobulinas que precipitan con el fr&#237;o&#46; Su presencia puede asociarse a un tipo de vasculitis denominada crioglobulinemia&#46; Estas&#44; especialmente las mixtas&#44; se asocian a infecciones como el virus de la hepatitis C hasta en el 60&#8211;90&#37; de los casos&#44; aunque tambi&#233;n se ha descrito su asociaci&#243;n a enfermedades del tejido conectivo&#44; en las que suele tener un curso m&#225;s agresivo&#46; Se presenta el caso de una paciente con poliartritis seronegativa que desarroll&#243; isquemia arterial aguda en el contexto de una crioglobulinemia y que ha respondido al tratamiento con rituximab&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Soro Mar&#237;n S&#44; J&#250;dez Navarro E&#44; Alamillo Sanz AS&#44; S&#225;nchez Nievas G&#46; Isquemia arterial aguda en paciente con poliartritis&#46; Reumatol Clin&#46; 2017&#59;13&#58;110&#8211;112&#46;</p>"
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Case Report
Acute Arterial Ischemia in a Patient With Polyarthritis
Isquemia arterial aguda en paciente con poliartritis
Sandra Soro Marína,
Corresponding author
sandrasoromarin@hotmail.com

Corresponding author.
, Enrique Júdez Navarrob, Antonio Salvador Alamillo Sanzc, Ginés Sánchez Nievasb
a Unidad de Reumatología, Hospital General de Villarrobledo, Albacete, Spain
b Sección de Reumatología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
c Servicio de Medicina Interna, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Polyarthritis is a common reason for seeing the doctor and is a challenge for rheumatologists because of its extensive differential diagnosis&#46; In clinical practice&#44; the development of new symptoms and analytical findings during patient follow-up can lead to a change in the diagnosis and&#44; thus&#44; of the treatment begun&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Cryoglobulinemia is a vasculitis characterized by the involvement of small and medium-sized vessels&#46; Three types of cryoglobulinemia have been described&#44; types II and III being those that are associated with connective tissue diseases &#40;CTD&#41;&#46; The clinical manifestations of cryoglobulinemia can range from nonspecific symptoms to renal&#44; neuropathic&#44; joint and skin involvement&#46; This means that&#44; on occasion&#44; these symptoms can be confounded with or overlap those linked to the CTD with which they are associated&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a patient whose presenting symptom was polyarthritis and who&#44; during follow-up&#44; was diagnosed with cryoglobulinemia associated with systemic lupus erythematosus &#40;SLE&#41;&#44; with a good response to immunosuppressive therapy with rituximab&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Observation</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a 41-year-old Paraguayan woman who was noteworthy only in that she smoked 40 cigarettes&#47;day&#46; She presented with a 2-month history of polyarthritis in hands&#44; feet and ankles&#46; Treatment was initiated with nonsteroidal anti-inflammatory drugs and prednisone&#44; and she was scheduled to undergo a complete study of polyarthritis&#46; Laboratory tests showed a C-reactive protein &#40;CRP&#41; of 24&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and an erythrocyte sedimentation rate &#40;ESR&#41; of 34<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#59; tests for rheumatoid factor and anti-cyclic citrullinated peptide were negative&#59; she had an antinuclear antibody &#40;ANA&#41; titer of 1&#58;80 with a speckled pattern and was negative for anti-extractable nuclear antigen &#40;ENA&#41; antibodies&#46; Thyroid hormones&#44; liver function and renal function were normal&#46; Mantoux and booster&#44; and serological testing for hepatitis B and C and human immunodeficiency virus were negative&#46; Radiographs of hands&#44; feet and thorax were normal&#46; Despite the treatment&#44; arthritis persisted in hands&#44; carpal bones&#44; feet and ankles&#46; With the diagnosis of seronegative polyarthritis&#44; treatment was begun with methotrexate &#40;MTX&#41; at 10<span class="elsevierStyleHsp" style=""></span>mg&#47;week and hydroxychloroquine &#40;HCQ&#41;&#44; with a partial response and&#44; thus&#44; the latter was interrupted and leflunomide was added&#44; with good control of the disease for more than a year&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient stopped coming to our office&#46; In October of 2012&#44; she suddenly began to detect cyanosis and cold in the distal phalanx of the index finger of her right hand&#44; and she was admitted to the hospital&#46; She underwent computed tomography angiography&#44; which showed an occlusion of the right radial artery at the level of the anatomical snuffbox&#59; the rest of the study &#40;including supra-aortic trunks&#44; study of upper limb arteries&#44; lower limb arteries and abdominal aortography&#41; was normal&#44; and there were no signs of vasculitis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Electrocardiogram and echocardiogram were normal&#46; Laboratory tests revealed iron-deficiency anemia &#40;hemoglobin 8&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; hematocrit 27&#37;&#44; iron 12<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dL&#44; transferrin 339<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; ferritin 4<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#44; leukocytes 4250&#47;&#956;L&#44; lymphocytes 510&#47;&#956;L &#40;12&#37;&#41;&#44; neutrophils 3620&#47;&#956;L &#40;85&#37;&#41; and platelets 359&#44;000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">&#8722;1</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> The coagulation study was normal &#40;prothrombin activity 118&#37; &#91;normal 70&#8211;120&#93; and activated partial thromboplastin time 29&#46;7<span class="elsevierStyleHsp" style=""></span>s &#91;23&#8211;36&#93;&#41;&#46; Immunoglobulin &#40;Ig&#41; G and IgM anticardiolipin antibodies and lupus anticoagulant were negative&#44; and CRP and ESR were normal&#44; as were thyroid function tests&#46; Direct Coombs was negative and haptoglobin normal at 159<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;30&#8211;200&#41;&#46; She was positive for ANA and anti-double stranded DNA &#40;dsDNA&#41; and negative for ENA and antineutrophil cytoplasmic antibodies&#59; complement C3 and C4 were normal&#44; and proteins normal&#46; During her hospital stay&#44; treatment was begun with low-molecular weight heparin with acetyl salicylic acid &#40;ASA&#41; and intravenous alprostadil&#46; The corticosteroid dose was increased and she continued with MTX and leflunomide &#40;which she had continued to take although she did not come for checkups&#41;&#46; She was discharged from the hospital&#44; while awaiting the results of an analysis for cryoglobulins&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In successive checkups in our offices&#44; the patient showed improvement in terms of ischemia but polyarthritis persisted&#46; The result for cryoglobulins was positive&#46; Given the persistence of polyarthritis &#40;although she continued to take MTX and leflunomide&#41; and cryoglobulinemia&#44; it was decided that she begin rituximab&#46; Anticoagulation was maintained with acenocoumarol for a year&#44; until the cryoglobulins were negative&#44; when antiplatelet therapy was begun with ASA&#46; During follow-up&#44; the patient was repeatedly positive for ANA at low titers&#44; with a homogeneous pattern&#44; and was negative for anti-dsDNA&#46; The immunological study was extended and we found antinucleosome antibodies and antibodies against the collagen-like region of C1q&#46; The patient has continued to take rituximab&#44; MTX&#44; HCQ and ASA&#46; She has not had any further ischemic episodes and there is no evidence of involvement of kidneys or of any other organ&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">We report the case of a patient with polyarthritis&#44; a frequent cause for seeking advice from a rheumatologist&#44; and a challenge for the latter because of its extensive differential diagnosis&#46; Initially&#44; given the clinical features and the findings revealed by the ancillary tests performed&#44; the patient was diagnosed with rheumatoid arthritis&#44; according to the 2010 classification criteria of the American College of Rheumatology and European League Against Rheumatism &#40;ACR&#47;EULAR&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Thus&#44; treatment with disease-modifying antirheumatic drugs &#40;DMARD&#41; and corticosteroids was begun&#44; and her clinical course was favorable for more than a year&#46; However&#44; the development of new symptoms and analytical data recorded during follow-up&#44; can make you reconsider the initial diagnosis or even change it&#44; as occurred in the case we present&#46; Ultimately&#44; the patient met the criteria for a diagnosis of SLE&#44; as she was ANA-positive and anti-dsDNA-positive and had arthritis&#44; lymphopenia &#40;according to the 2012 criteria of the Systemic Lupus International Collaborating Clinics&#41;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> and mixed cryoglobulinemia&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We found antinucleosome and anti-C1q antibodies in this patient&#46; The antinucleosome antibodies could be a more accurate marker for the diagnosis of SLE&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;5</span></a> with a similar specificity and a slightly higher sensitivity than anti-dsDNA&#44; but with a highly superior diagnostic odds ratio &#40;41 vs 27&#46;8&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Nucleosomes mediate the binding of autoantibodies to the basement membranes&#46; These antibodies are capable of binding to different components of the glomerular basement membrane like collagen&#44; membrane surface proteins&#44; DNA-histone complexes and chromatin&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> producing renal damage&#46; For this&#44; they are considered nephritogenic&#44; and have also been associated with disease activity measured using different questionnaires &#40;Systemic Lupus Erythematosus Disease Activity Index&#44; European Consensus Lupus Activity Measurement&#44; etc&#46;&#41;&#46; The activation of the classical complement pathway begins with the molecule C1q&#44; which is essential in the clearance of immune complexes and apoptotic cell debris&#46; Hereditary C1q deficiency is associated with high susceptibility for the development of SLE&#44; especially the mucocutaneous manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> Its level usually decreases during flares of the disease and is associated with anti-C1q antibodies &#40;antibodies against the collagen-like region&#41;&#44; especially in patients with active lupus nephritis&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> The presence of anti-DNA and anti-C1q antibodies leads to the formation of immune complexes&#44; with the subsequent triggering of the immune response&#44; which is usually associated with a higher risk of renal involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9&#44;10</span></a> However&#44; the expression of these antibodies and their levels do not always correlate with disease activity and&#44; thus&#44; their pathogenic role is not yet completely understood&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> Nevertheless&#44; the patient has not had renal involvement over the nearly 5 years of follow-up&#44; possibly because of the treatment with DMARD and&#44; ultimately&#44; with anti-CD20 monoclonal antibodies&#46; In any case&#44; the use of corticosteroids and immunosuppressive therapy may have contributed to the maintenance of negative anti-dsDNA antibodies throughout her course&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Moreover&#44; the presence of cryoglobulins coincided in time with the autoimmune conditions described above&#46; Cryoglobulins are monoclonal and&#47;or polyclonal Ig that reversibly precipitate when serum is incubated at temperatures below 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Their presence in blood can produce a systemic vasculitic process affecting small and medium-sized vessels&#46; They are classified according to 3 forms depending on the composition of the precipitate&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Type I cryoglobulinemia involves a single type of monoclonal immunoglobulin&#46; It is usually associated with lymphoproliferative diseases and multiple myeloma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Type II cryoglobulinemia involves a polyclonal IgG and a monoclonal IgM with rheumatoid factor activity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Type III cryoglobulinemia involves a polyclonal IgG and a polyclonal IgM with rheumatoid factor activity&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">Types II and III are referred to as mixed cryoglobulinemia &#40;MC&#41; and are usually associated with CTD and lymphoproliferative processes and infections&#44; but hepatitis C virus infection is the disease with which they are most frequently linked &#40;60&#37;&#8211;90&#37; of cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Cryoglobulinemia is usually manifested with fever&#44; myalgia&#44; arthralgia &#40;arthritis alone has only been reported in less than 10&#37; of the cases&#41;&#44; palpebral purpura in lower limbs &#40;the most characteristic manifestation&#41; and neurological and renal involvement&#46; Regarding the last two&#44; 17&#37;&#8211;60&#37; of the patients will have peripheral neuropathy&#44; which can be the first sign of a MC&#44; and up to 30&#37; will develop microhematuria and proteinuria&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Its presentation as a peripheral acute arterial ischemia&#44; with no other associated signs of vasculitis&#44; as occurred in our patient&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> is exceptional&#46; The digital necrosis is adverse in the prognosis of MC&#44; as it has been associated with a high risk of infections&#44; sepsis and death&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> Computed tomography angiography did not identify lesions compatible with vasculitic or atherosclerotic involvement&#44; and the patient did not have any of the abovementioned symptoms&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The pathogenic role of antinucleosome and anti-C1q antibodies in the case reported is unknown to us&#46; We consider that they are serological markers of SLE&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The final diagnosis was MC secondary to a CTD &#40;SLE&#41;&#46; The usual clinical signs are the consequence of the deposition of circulating immune complexes in the wall of small and medium-sized vessels&#44; which triggers an inflammatory response that leads to systemic vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> Treatment consists of glucocorticoids and immunosuppressive agents&#46; The use of plasmapheresis has been reported when the remaining approaches have been ineffective&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> In this case&#44; given the clinical manifestations of the patient and the association of MC with SLE&#44; we opted for rituximab&#46; The utilization of anti-CD20 monoclonal antibodies has been found to be beneficial in the treatment of systemic vasculitis and&#44; although the data we have in cryoglobulinemic vasculitis not associated with hepatitis C virus is limited&#44; certain case series support the use of rituximab in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion&#44; the particular feature of this case lies in the presentation of the MC in the setting of SLE&#44; as an acute arterial ischemia &#40;right radial artery occlusion&#41; in a patient who had initially been diagnosed as having a seronegative polyarthritis&#46; Despite the presence of nephritogenic antibodies&#44; the patient has not developed renal involvement&#44; remains in remission and continues to take rituximab&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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            2 => "Acute arterial ischemia"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cryoglobulins are immunoglobulins that precipitate at cold temperatures&#46; Their presence can be related to a type of vasculitis referred to as cryoglobulinemia&#46; This condition&#44; especially mixed cryoglobulinemia&#44; has been associated with viral infections like hepatitis C virus in 60&#37;&#8211;90&#37; of cases&#44; but it has also been reported in relation to connective tissue diseases&#44; usually resulting in a more severe course&#46; We describe the case of a patient with seronegative polyarthritis who developed acute arterial ischemia in association with cryoglobulinemia&#44; with a good response to rituximab therapy&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las crioglobulinas son inmunoglobulinas que precipitan con el fr&#237;o&#46; Su presencia puede asociarse a un tipo de vasculitis denominada crioglobulinemia&#46; Estas&#44; especialmente las mixtas&#44; se asocian a infecciones como el virus de la hepatitis C hasta en el 60&#8211;90&#37; de los casos&#44; aunque tambi&#233;n se ha descrito su asociaci&#243;n a enfermedades del tejido conectivo&#44; en las que suele tener un curso m&#225;s agresivo&#46; Se presenta el caso de una paciente con poliartritis seronegativa que desarroll&#243; isquemia arterial aguda en el contexto de una crioglobulinemia y que ha respondido al tratamiento con rituximab&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Soro Mar&#237;n S&#44; J&#250;dez Navarro E&#44; Alamillo Sanz AS&#44; S&#225;nchez Nievas G&#46; Isquemia arterial aguda en paciente con poliartritis&#46; Reumatol Clin&#46; 2017&#59;13&#58;110&#8211;112&#46;</p>"
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Article information
ISSN: 21735743
Original language: English
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Idiomas
Reumatología Clínica (English Edition)
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