Thai Journal of Rheumatology

Image Challenge

Sumapa Chaiamnuay — Fri, 09 Oct 2026 00:00:00 +0700

An 80-year-old female with osteoporosis presented to the clinic in September 2026 reporting acute, severe, and spontaneous mid-to-lower back pain. Baseline dual-energy X-ray absorptiometry (DXA) in April 2022 demonstrated a T-score of -3.0 at the femoral neck, -2.8 at the total hip, and -3.2 at the lumbar spine (L1–L4). She had no prior history of fragility fractures. She had received denosumab 60 mg subcutaneously every 6 months for 6 doses between April 2022 and April 2025 (total exposure 7 doses). She was lost to follow-up because she felt well and did not receive her scheduled dose in October 2025 or any subsequent antiresorptive therapy. Approximately 17 months after her last denosumab injection, she developed sudden, debilitating thoracic and lumbar back pain without preceding trauma. Physical examination revealed 3 centimeters of height loss since the April 2025 visit, thoracic spine tenderness, and increased kyphosis compared with prior visits. Thoracolumbar radiographs were obtained (Figures 1 and 2).

Introduction

Editor-in-Chief — Fri, 09 Oct 2026 00:00:00 +0700

The Thai Journal of Rheumatology is committed to serving as a platform for the dissemination of current knowledge, clinical experience, and academic discussion in the field of rheumatology and autoimmune diseases. Through the publication of high-quality review articles, case reports, and educational features, the journal aims to support lifelong learning and promote excellence in patient care.

This issue offers engaging content in several formats. The original article examines the prevalence and clinical characteristics of rheumatoid arthritis-associated interstitial lung disease. The review article provides a comprehensive account of VEXAS syndrome, including its pathogenesis, clinical manifestations, and therapeutic strategies.

In addition, the case report describes severe Raynaud’s phenomenon leading to digital amputation in a patient with systemic lupus erythematosus. The Image Challenge presents multiple vertebral fractures following denosumab discontinuation, inviting readers to consider the radiographic findings, diagnosis, and management of this important clinical problem.

The Editorial Board sincerely hopes that the knowledge shared in this issue will contribute to continuing medical education and support clinicians, trainees, researchers, and allied healthcare professionals in delivering high-quality care for patients with rheumatic diseases.

Editor-in-Chief

Editor-in-Chief — Fri, 09 Oct 2026 00:00:00 +0700

1. Prevalence and Clinical Characteristics of Rheumatoid Arthritis-Associated Interstitial Lung Disease at Srinagarind Hospital: A Retrospective Cross-sectional Study
Amphay Khounthep, Ajanee Mahakkanukrauh, Siraphop
Suwannaroj, Chingching Foocharoen, Patnarin Pongkulkiat, Tippawan Onchan
1 – 11

2. VEXAS Syndrome: A Comprehensive Review of Pathogenesis, Clinical Manifestations, and Therapeutic Strategies
Chatpong Makmee, Sumapa Chaiamnuay, Rattapol Pakchotanon
12 – 23

3. Severe Raynaud's phenomenon Leading to digital amputation in a patient with systemic lupus erythematosus.
Kamonwan Mulalin, Parisom Wongsukda, Rumphaphatt Musikachartpakkapong
24 - 30

4. Image Challenge
Sumapa Chaiamnuay
31 – 36

Prevalence and Clinical Characteristics of Rheumatoid Arthritis-Associated Interstitial Lung Disease at Srinagarind Hospital: A Retrospective Cross-sectional Study

Fri, 09 Oct 2026 00:00:00 +0700

Background: Interstitial lung disease (ILD) is a severe extra-articular manifestation of rheumatoid arthritis (RA) associated with increased mortality. Data characterizing RA-associated ILD (RA-ILD) in Thailand remain limited. This study aimed to estimate the prevalence of clinically recognized, HRCT-confirmed RA-ILD and describe the clinical, serological, radiological, and functional characteristics of affected patients at Srinagarind Hospital.

Methods: We conducted a retrospective cross-sectional study of adult patients with RA who attended Srinagarind Hospital, Khon Kaen University, from 2020 to 2024. RA-ILD was confirmed by high-resolution computed tomography (HRCT). The prevalence of clinically recognized, HRCT-confirmed RA-ILD was calculated using all identified patients with RA as the denominator. Characteristics of patients with RA-ILD were summarized using descriptive statistics.

Results: Among 1,054 patients with RA, 21 had clinically recognized, HRCT-confirmed RA-ILD, corresponding to a prevalence of 2.0% (95% CI 1.3–3.0%). The mean age of patients with RA-ILD was 62.8 ± 10.9 years, 81.0% were female, and 4.8% had a smoking history. Mean RA duration was 13.5 ± 8.9 years, and 76.2% had low disease activity or remission when ILD was identified. All patients were rheumatoid factor positive and had radiographic bone erosion, whereas 47.6% were anti-CCP positive. The usual interstitial pneumonia (UIP) pattern was the most common HRCT finding (52.4%), followed by non-specific interstitial pneumonia (NSIP; 38.1%). FVC impairment was recorded in 81.0%.

Conclusion: Clinically recognized, HRCT-confirmed RA-ILD affected 2.0% of patients with RA at Srinagarind Hospital. Patients with RA-ILD commonly had long-standing RA, RF positivity, radiographic bone erosion, a UIP pattern, and impaired FVC. Because this descriptive study did not include a non-ILD comparison group, the observed characteristics should not be interpreted as independent risk factors.

VEXAS Syndrome: A Comprehensive Review of Pathogenesis, Clinical Manifestations, and Therapeutic Strategies

Chatpong Makmee, Sumapa Chaiamnuay, Rattapol Pakchotanon — Fri, 09 Oct 2026 00:00:00 +0700

Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic (VEXAS) syndrome is a recently characterized, adult-onset systemic hematoinflammatory disease driven by acquired somatic mutations in the UBA1 gene.¹ This genetic aberration disrupts the cellular ubiquitylation cascade, precipitating profound innate immune hyperactivation and subsequent multiorgan inflammation.²

VEXAS syndrome demonstrates a highly heterogeneous clinical phenotype, predominantly presenting with recurrent fever, treatment-refractory neutrophilic dermatosis, relapsing polychondritis, pulmonary infiltrates, and systemic vasculitis.³ Concurrently, patients exhibit progressive hematologic anomalies, including macrocytic anemia, thrombocytopenia, characteristic myeloid and erythroid cytoplasmic vacuolization, and a substantial predisposition to myelodysplastic syndrome (MDS).⁴

Diagnosis relies on the identification of pathogenic UBA1 variants, optimized by targeted next-generation sequencing (NGS), integrated with comprehensive bone marrow evaluations.⁵ Due to its complex pathophysiology, disease management requires a multidisciplinary strategy.

Current therapeutic paradigms focus on eradicating UBA1-mutated clones utilizing hypomethylating agents (e.g., azacitidine) or allogeneic hematopoietic stem cell transplantation (AHSCT), alongside suppressing the autoinflammatory cascade via high-dose glucocorticoids and targeted biologicals, particularly Janus kinase (JAK) inhibitors.⁶ Considering the elevated mortality risk associated with VEXAS syndrome, early recognition, precise genetic screening, and individualized targeted therapies are imperative to optimize clinical outcomes and patient survival.⁷

Severe Raynaud's phenomenon Leading to digital amputation in a patient with systemic lupus erythematosus.

Kamonwan Mulalin, Parisom Wongsukda, Rumphaphatt Musikachartpakkapong — Fri, 09 Oct 2026 00:00:00 +0700

A 15-year-old female presented with low grade fever for one month. She developed hyperpigmented rash on her face for 2 weeks. She went to the hospital due to fever and drowsiness. Her vital signs showed hypotension and fever. She was treated as septic shock. She received antibiotic, intravenous fluid loading and vasopressor drug. Her physical examination showed hyperpigmented rash at face, sparing the nasolabial folds with maculopapular rash all over her body, no hepatosplenomegaly. Her laboratories showed anemia, leukopenia, transaminitis, high ferritin, ANA 1:160 coarse speckled with nRNP/Sm, anti Sm and anti SSA positive, anti-dsDNA negative, low C3, low C4, APL negative, Echocardiogram showed pericardial effusion 4 mm, clear fluid, EF 55%, no vegetation. Her bone marrow aspiration showed hemophagocytosis. She developed severe Raynaud’s phenomenon despite intensive vasodilator and immunosuppressive therapy. Progressive digital gangrene eventually required amputation of all her fingers on both hands.