Global collaboration is the cornerstone of scientific advancement. Frontiers in Medicine has organized a series of special edition Research Topics, with the goal of highlighting the latest advancements in Rheumatology across the globe, showcasing the academic excellence and high-quality work of internationally recognized researchers. These collections aim to shed light on the recent progress made across the entire breadth of the Rheumatology field, and reflect on the future challenges faced by researchers across borders.

University of the Witwatersrand

University of KwaZulu-Natal

International University of Rabat

Frontiers in Medicine

Rheumatology

Global Excellence in Rheumatology: Africa

The United Nations estimates that in 2023 over 1.4 billion people, or 16.7% of the world's population, reside in Africa. Africa faces many healthcare challenges due to multiple factors, including socioeconomic factors, poor infrastructure, and lack of human resources. Much of its health resources are devoted to combating often lethal communicable diseases such as tuberculosis, HIV infection, and malaria. It is not surprising, therefore, that the subspecialty of rheumatology has been a late bloomer within the wider internal medicine fraternity (<a href="#B1">1</a>). A recent survey of the 54 African countries, with responses from 44 countries (81%), showed that most of the 2,970 rheumatologists on the continent are based in North African countries, while 12 (27%) countries have between one and 10 rheumatologists, and 17 (39%) have no rheumatologists (<a href="#B2">2</a>). The current themed series, Global excellence in Rheumatology: Africa, is a timely reminder of the challenges and steady progress of rheumatology in Africa.<a href="https://doi.org/10.3389/fmed.2022.1032122">Hmamouchi and Adebajo</a> recognize the contributions of outstanding African women in rheumatology amongst the many women who have provided excellent rheumatology care to patients in many countries for decades. The vision and foresight of Professors Najia Hajjaj-Hassouni and Aicha Ladjouze over more than four decades have played a key role in the establishment of national rheumatology associations and associated scientific congresses in Morocco and Algeria, respectively. Both have served on the African League of Associations for Rheumatology (AFLAR) executive as President-Elect and then President of AFLAR.Dr. Dey and Professor Migowa, on the other hand, represent the dynamism of the present and future of rheumatology on the continent. Dzifa Dey, the current AFLAR President, having just completed her term as Secretary-General, has been instrumental in recent years for raising the profile and growth of AFLAR. Despite her clinical and academic commitments in Ghana, her excellent organizational skills have led to greater awareness and recognition of African rheumatology in Africa and globally. Angela Migowa in Kenya and Professor Chris Scott in South Africa are very much the nexus of African pediatric rheumatology. Angela is the founder and current President of PAFLAR (pediatric arm of AFLAR). Her energy, vision, and motivation have led to increased awareness of childhood rheumatic diseases through regular scientific meetings and congresses that attract audiences from the continent and beyond. Finally, it would be remiss of us not to recognize the work and contributions of the late Dr. Marie Louise Doulla of Cameroon, who tragically passed away in 2018 during her term as President-Elect of AFLAR.<a href="https://doi.org/10.3389/fmed.2021.665028">Nada et al.</a> report their positive experience of a 1-year open-labeled study with tocilizumab in the treatment of systemic juvenile idiopathic arthritis (sJIA) in patients who were treated with conventional therapy. Of the 65 Egyptian children with sJIA included in the study, just over a third achieved clinically inactive disease, and a further quarter achieved minimal disease activity. Less than 10% had a hypersensitivity reaction to the drug. Much like in previous studies, children ≤7 years, a disease duration ≤3 years, lower disease activity, and higher serum ferritin, and the systemic manifestations had a more favorable outcome. These findings provide further reassuring evidence of the effectiveness and safety of tocilizumab for a potentially disabling and fatal condition.Tuberculosis (TB) remains a major concern in Africa, despite the WHO's End TB Strategy that was adopted in 2014. South Africa belongs to the 30 high TB burden countries with more than 500 cases/100,000 people. The study by <a href="https://doi.org/10.3389/fmed.2023.1118390">Al-arbi et al.</a> of TB in systemic lupus erythematosus (SLE) patients is a stark reminder of the impact of TB in systemic autoimmune rheumatic diseases (SARDs). The treatment and prognosis of SLE has improved substantially in recent decades, but this records review study of a multi-ethnic population at a single academic center in Durban, South Africa, found that of the 72 (14.1%) out of the 512 SLE patients that had contracted TB, the majority (58%) had extrapulmonary TB (E-PTB). The ethnic differentiation of TB prevalence, highest in patients of mixed ancestry and Black Africans, while there is no prevalence in the White population, reflects in part the persistent inter-ethnic socioeconomic differences in South Africa. Compared to the control SLE patients without TB, TB patients had higher disease activity and cumulative prednisone use over the preceding 3 months. Compared to the patients with pulmonary TB only, the EPTB patients had higher disease activity, more renal involvement, and were more likely to have IV methylprednisolone (IVMP) or mycophenolate mofetil therapy. Notwithstanding the limitations of the study as indicated by the authors, the study provides further evidence of the burden of TB on SLE patients in Africa.Idiopathic inflammatory myopathies (IIM) are a group of rare SARDs for which there is a paucity of data in Africa. <a href="https://doi.org/10.3389/fmed.2023.1097824">Birch et al.</a> undertook a retrospective records review study of the clinical spectrum and outcomes of 94 patients fulfilling the Bohan and Peter criteria for IIM and attending a tertiary rheumatology center in South Africa. Most were indigent Black people mainly with dermatomyositis (DM) and polymyositis (PM). Despite an earlier onset of disease compared to patients in developed countries, the clinical, biological, and therapeutical data were similar. The predominance of DM could be explained by high UV light exposure in tropical and subtropical regions. Dysphagia, which requires pulse IVMP therapy, was considered a strong indicator of severity, more often reported in PM than DM patients. The Jo-1 antibody test was present in one-fifth of patients and occurred more often in patients with PM and those with ILD; this latter finding is congruent with the reports from the EuroMyositis registry (25–30%) (<a href="#B3">3</a>). This antibody occurred most frequently in association with the anti-synthetase syndrome. Malignancies were documented in only three patients (3.2%). Patients were treated according to the current international standard of care, and the drug therapy comprised either oral corticosteroids or IVMP, with methotrexate and azathioprine as corticosteroid-sparing agents. Despite its significant limitations, this study delineates the features of these rare conditions in Black Africans.These papers provide a glimpse of the steady growth of African rheumatology. With advances and improved access to laboratory technologies, African rheumatology will make a greater contribution to the global quest to conquer rheumatic musculoskeletal diseases.GM, MT, and NH-H: conception, review of information and preparation of part of editorial, and review of final paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Editorial: Global excellence in rheumatology: Africa

Objective:Infections are common in systemic lupus erythematosus (SLE), with tuberculosis (TB) being important in an endemic environment. We studied the prevalence and spectrum of TB in SLE in Durban, South Africa.</sec>Methods:A medical records review of SLE patients seen over 13-year period, and the demographic data, clinical manifestations, laboratory findings, treatment and outcome were noted.</sec>Results:There were 512 SLE patients and 72 (14.1%) had TB. Thirty (41.7%) had pulmonary TB (PTB) and 42 (58.3%) had extra-pulmonary TB (EPTB). The prevalence of TB among the different ethnic groups was 36/282 (12.8%) for Indian people, 29/184 (15.8%) Black African people, 7/26 (26.9%) admixed African people and none among the 18 White people. Comparison of the 72 SLE-TB patients with 72 SLE controls showed no difference in gender, age at SLE diagnosis and disease duration. The SLE-TB patients had a significant increase in the clinical and laboratory features of disease activity (arthritis, mucocutaneous lesions, renal involvement, vasculitis, low complement, raised ds-DNA antibodies), and cumulative prednisone use over the preceding 3 months.Compared to PTB, the EPTB patients were significantly younger, developed TB earlier after SLE diagnosis, and had higher disease activity. The EPTB patients also had increase in features of disease activity (renal, thrombocytopenia, ds–DNA antibodies), and increase in ever use of intravenous methylprednisolone (IV-MP) and mycophenolate mofetil (MMF). On multivariate analysis, the independent risk factors for EPTB were ever use of MMF (p = 0.003) and IV-MP (p = 0.027). Analysis of the cumulative SLE criteria showed renal involvement was an independent risk factor for EPTB. The outcome was similar in both groups.</sec>Conclusion:We show an increased prevalence of TB (14.1%) and EPTB (58.3%) in SLE in an endemic area and confirm that features of disease activity and use of immunosuppressive therapy are the major risk factors. Renal involvement (as a cumulative criterion) is an independent risk factor for EPTB.</sec>

Objective:: Infections are common in systemic lupus erythematosus (SLE), with tuberculosis (TB) being important in an endemic environment. We studied the prevalence and spectrum of TB in SLE in Durban, South Africa.Methods:: A medical records review of SLE patients seen over 13-year period, and the demographic data, clinical manifestations, laboratory findings, treatment and outcome were noted.Results:: There were 512 SLE patients and 72 (14.1%) had TB. Thirty (41.7%) had pulmonary TB (PTB) and 42 (58.3%) had extra-pulmonary TB (EPTB). The prevalence of TB among the different ethnic groups was 36/282 (12.8%) for Indian people, 29/184 (15.8%) Black African people, 7/26 (26.9%) admixed African people and none among the 18 White people. Comparison of the 72 SLE-TB patients with 72 SLE controls showed no difference in gender, age at SLE diagnosis and disease duration. The SLE-TB patients had a significant increase in the clinical and laboratory features of disease activity (arthritis, mucocutaneous lesions, renal involvement, vasculitis, low complement, raised ds-DNA antibodies), and cumulative prednisone use over the preceding 3 months.Compared to PTB, the EPTB patients were significantly younger, developed TB earlier after SLE diagnosis, and had higher disease activity. The EPTB patients also had increase in features of disease activity (renal, thrombocytopenia, ds–DNA antibodies), and increase in ever use of intravenous methylprednisolone (IV-MP) and mycophenolate mofetil (MMF). On multivariate analysis, the independent risk factors for EPTB were ever use of MMF (p = 0.003) and IV-MP (p = 0.027). Analysis of the cumulative SLE criteria showed renal involvement was an independent risk factor for EPTB. The outcome was similar in both groups.Conclusion:: We show an increased prevalence of TB (14.1%) and EPTB (58.3%) in SLE in an endemic area and confirm that features of disease activity and use of immunosuppressive therapy are the major risk factors. Renal involvement (as a cumulative criterion) is an independent risk factor for EPTB.

Tuberculosis remains a major burden in systemic lupus erythematosus patients in Durban, South Africa

BackgroundIdiopathic inflammatory myopathies (IIM) are rare diseases for which there is a paucity of data in Africa. We undertook a retrospective records review of clinical and laboratory features of patients with IIM attending a tertiary service in Gauteng, South Africa.</sec>Materials and methodsCase records of patients seen between January 1990 and December 2019 and fulfilling the Bohan and Peter criteria for IIM were reviewed for demographics, clinical features, special investigations and drug therapy.</sec>ResultsOf 94 patients included in the study, 65 (69.1%) had dermatomyositis (DM) and 29 (30.9%) had polymyositis (PM). Overall, the mean (SD) age at presentation and disease duration were 41.5 (13.6) and 5.9 (6.2) years, respectively. 88 (93.6%) were Black Africans. The most common cutaneous features in DM patients were Gottron’s lesions (72.3%) and abnormal cuticular overgrowth (67.7%). Dysphagia was the most common extra-muscular feature (31.9%), more so in PM than DM (p = 0.02). Creatine kinase, total leucocyte count and CRP were similarly higher in PM than DM patients (p = 0.006, 0.002, and 0.01, respectively). Anti-nuclear and anti-Jo-1 antibodies were positive in 62.2 and 20.4% of patients tested, respectively, the latter significantly more in PM than DM patients (OR = 5.1, p = 0.03) and more likely to be positive with ILD (p = 0.001). Corticosteroids were prescribed in all patients, 89.4% had additional immunosuppressive drugs and 6.4% required intensive/high care. Malignancies occurred in three patients, all of whom had DM. There were seven known deaths.</sec>ConclusionThe present study provides further insights into the spectrum of clinical features of IIM, especially cutaneous features of DM, anti-Jo-1 antibodies and associated ILD, in a cohort of predominantly black African patients.</sec>

Background: Idiopathic inflammatory myopathies (IIM) are rare diseases for which there is a paucity of data in Africa. We undertook a retrospective records review of clinical and laboratory features of patients with IIM attending a tertiary service in Gauteng, South Africa.Materials and methods: Case records of patients seen between January 1990 and December 2019 and fulfilling the Bohan and Peter criteria for IIM were reviewed for demographics, clinical features, special investigations and drug therapy.Results: Of 94 patients included in the study, 65 (69.1%) had dermatomyositis (DM) and 29 (30.9%) had polymyositis (PM). Overall, the mean (SD) age at presentation and disease duration were 41.5 (13.6) and 5.9 (6.2) years, respectively. 88 (93.6%) were Black Africans. The most common cutaneous features in DM patients were Gottron’s lesions (72.3%) and abnormal cuticular overgrowth (67.7%). Dysphagia was the most common extra-muscular feature (31.9%), more so in PM than DM (p = 0.02). Creatine kinase, total leucocyte count and CRP were similarly higher in PM than DM patients (p = 0.006, 0.002, and 0.01, respectively). Anti-nuclear and anti-Jo-1 antibodies were positive in 62.2 and 20.4% of patients tested, respectively, the latter significantly more in PM than DM patients (OR = 5.1, p = 0.03) and more likely to be positive with ILD (p = 0.001). Corticosteroids were prescribed in all patients, 89.4% had additional immunosuppressive drugs and 6.4% required intensive/high care. Malignancies occurred in three patients, all of whom had DM. There were seven known deaths.Conclusion: The present study provides further insights into the spectrum of clinical features of IIM, especially cutaneous features of DM, anti-Jo-1 antibodies and associated ILD, in a cohort of predominantly black African patients.

Clinical spectrum and outcomes of idiopathic inflammatory myopathies in South Africans

Over the last few decades, the development of Rheumatology on the African continent has made great strides. Alongside an increasing recognition of the prevalence and burden of disease from these conditions, has been a determination to raise awareness of these disorders in Africa together with an appreciation of the associated disease impact on individuals, families and society as a whole. Great improvements have also been made across the continent with regards to the education of medical students, trainee doctors and allied health professionals of these conditions. Furthermore, high quality rheumatological research is now emanating from Africa. Taken together, these actions mean that Africa is making a significant contribution to global excellence in Rheumatology. Although this achievement has been made possible by visionary, hardworking and inspirational men and women, we believe that it is vital to bring to light the extraordinary efforts of African female rheumatologists in this endeavor. Their contribution is all the more remarkable because of the barriers that women still face in medicine in general and in academia in particular. We showcase here, four women of distinction who in their own unique way, have exemplified the contribution of African female rheumatologists to global excellence in Africa. We pay tribute to them and to their ongoing efforts to act as beacons of excellence in rheumatology in Africa to men and especially to other women.

Over the last few decades, the development of Rheumatology on the African continent has made great strides. Alongside an increasing recognition of the prevalence and burden of disease from these conditions, has been a determination to raise awareness of these disorders in Africa together with an appreciation of the associated disease impact on individuals, families and society as a whole. Great improvements have also been made across the continent with regards to the education of medical students, trainee doctors and allied health professionals of these conditions. Furthermore, high quality rheumatological research is now emanating from Africa. Taken together, these actions mean that Africa is making a significant contribution to global excellence in Rheumatology. Although this achievement has been made possible by visionary, hardworking and inspirational men and women, we believe that it is vital to bring to light the extraordinary efforts of African female rheumatologists in this endeavor. Their contribution is all the more remarkable because of the barriers that women still face in medicine in general and in academia in particular. We showcase here, four women of distinction who in their own unique way, have exemplified the contribution of African female rheumatologists to global excellence in Africa. We pay tribute to them and to their ongoing efforts to act as beacons of excellence in rheumatology in Africa to men and especially to other women.

Global excellence in rheumatology: Africa–The contribution of African women rheumatologists

Background: Systemic Juvenile Idiopathic Arthritis (sJIA) is a unique category of juvenile arthritis in which interleukin 6 plays a major pathogenic role. This study aimed to describe the therapeutic short-term outcomes among patients with sJIA starting tocilizumab (TCZ) therapy and to identify possible predictors of treatment response.Methods: We conducted a prospective observational study including 65 patients with sJIA meeting ILAR classification criteria with active disease despite conventional therapy that were treated by TCZ between August 2019 and October 2020 as the first-line biological therapy. Clinical and serological parameters were recorded at baseline and after 1 year of TCZ therapy.Results: After 1 year, 25% of the patients achieved minimal disease activity and 35% achieved clinically inactive disease. A significant reduction of the 10-joint juvenile arthritis disease activity score and acute phase reactants was also observed. Patients with younger age (≤7 years), shorter disease duration (≤3 years), lower disease activity, and higher serum ferritin and systemic manifestations showed more favorable results.Conclusion: Patients with sJIA showed favorable disease outcomes with TCZ treatment for 1 year, especially if the drugs were administered earlier in the disease course and in younger patients with a more pronounced inflammatory status. Our results may help to define the profile of patients with sJIA who are more likely to benefit from IL-6 blockade.

Background: Systemic Juvenile Idiopathic Arthritis (sJIA) is a unique category of juvenile arthritis in which interleukin 6 plays a major pathogenic role. This study aimed to describe the therapeutic short-term outcomes among patients with sJIA starting tocilizumab (TCZ) therapy and to identify possible predictors of treatment response.Methods: We conducted a prospective observational study including 65 patients with sJIA meeting ILAR classification criteria with active disease despite conventional therapy that were treated by TCZ between August 2019 and October 2020 as the first-line biological therapy. Clinical and serological parameters were recorded at baseline and after 1 year of TCZ therapy.Results: After 1 year, 25% of the patients achieved minimal disease activity and 35% achieved clinically inactive disease. A significant reduction of the 10-joint juvenile arthritis disease activity score and acute phase reactants was also observed. Patients with younger age (≤7 years), shorter disease duration (≤3 years), lower disease activity, and higher serum ferritin and systemic manifestations showed more favorable results.Conclusion: Patients with sJIA showed favorable disease outcomes with TCZ treatment for 1 year, especially if the drugs were administered earlier in the disease course and in younger patients with a more pronounced inflammatory status. Our results may help to define the profile of patients with sJIA who are more likely to benefit from IL-6 blockade.