Risk of tuberculosis in patients with rheumatoid arthritis treated with biological and targeted drugs: meta-analysis of randomized clinical trials / 中华医学杂志(英文版)

BACKGROUND@#Concerns exist regarding the potential development of tuberculosis in patients with rheumatoid arthritis (RA) treated with biological and targeted drugs. We assessed systematically whether biological therapy increased the risk of tuberculosis in patients with RA by meta-analysis of randomized controlled trials (RCTs).@*METHODS@#A systematic literature search was conducted in PubMed, Embase, the Cochrane Library, and China Biology Medicine disc for RCTs evaluating biological therapy in patients with RA from inception through August 2021. Traditional meta-analysis and network meta-analysis were performed to compare the risk of tuberculosis for each biologics class in patients with RA. Peto odds ratio (Peto OR) and its 95% confidence interval (CI) were calculated as the primary effect measure.@*RESULTS@#In total, 39 studies with 20,354 patients were included in this meta-analysis, and 82 patients developed tuberculosis. The risk of tuberculosis was increased in patients treated with biologics compared with non-biologics (Peto OR: 3.86, 95% CI: 2.36-6.32, P < 0.001). Also, tumor necrosis factor-α (TNF-α) inhibitors had a higher probability of developing tuberculosis than placebo (Peto OR: 3.98, 95% CI: 2.30-6.88, P < 0.001). However, network meta-analysis demonstrated that there was no significant difference in the risk of tuberculosis for each biologics class in patients with RA. Noticeably, tuberculosis was significantly more common in patients treated with a high dose compared with patients receiving a low dose of tofacitinib (Peto OR: 7.39, 95% CI: 2.00-27.31, P = 0.003).@*CONCLUSION@#This meta-analysis demonstrates the evidence of an elevated risk of tuberculosis in patients with RA treated with TNF-α inhibitors, and a dose-dependent elevated risk of tuberculosis in patients treated with tofacitinib.

Meta-analysis of efficacy and safety of sinomenine combined with methotrexate in treatment of rheumatoid arthritis / 中国中药杂志

To systemically evaluate the efficacy and safety of sinomenine combined with methotrexate(SIN+MTX) in the treatment of rheumatoid arthritis(RA). Literature databases of Wanfang, CNKI, VIP, SinoMed, PubMed, Cochrane Library and Web of Science were retrieved comprehensively for relevant clinical trials. The literature retrieval time was from database establishment to February 4, 2020. The quality of literatures was assessed by the Cochrane Evaluation Handbook 5.1.0, and qualified literature was reviewed and analyzed by using the RevMan 5.3 statistical software. Twenty randomized controlled trials met the inclusion criteria, and were enrolled in the Meta-analysis. The results showed that SIN+MTX remarkably reduced DAS28(MD=-0.85, 95%CI[-1.03,-0.67], P<0.000 01), and improved total efficiency(P<0.000 01). SIN+MTX could inhibit swollen joint count(MD=-1.19, 95%CI[-1.75,-0.63], P<0.000 1), tender joint count(MD=-1.58, 95%CI[-2.89,-0.28], P=0.02) and reduce morning stiffness time(MD=-8.44, 95%CI[-11.82,-5.07], P<0.000 01) compared with control group. The results showed that SIN+MTX was equal to control group in grip strength(SMD=0.20,95%CI[-1.11,1.51],P=0.77). SIN+MTX remarkably alleviated the erythrocyte sedimentation rate(MD=-9.87, 95%CI[-14.52,-5.22], P<0.000 1), C-reactive protein(SMD=-0.30, 95%CI[-0.51,-0.09], P=0.005), and rheumatoid factor(MD=-11.23,95%CI[-13.81,-8.65],P<0.000 01). The frequency of adverse reactions were reduced compared with that in the control group(P<0.000 01). Current clinical studies demonstrate that the efficacy and safety of SIN+MTX in the treatment of RA were superior to control group. However, due to the low quality and quantity of the included studies, high-quality randomized controlled trials are necessary to support the clinical evidences.

Síndrome de DRESS inducido por sulfasalazina. ¿Consideramos esta reacción adversa grave al indicar el fármaco? Caso clínico

DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) is a severe, rare and potentially lethal idiosyncratic condition associated with the use of some drugs. Given its broad spectrum of presentation, clinical suspicion is essential for management, since it requires the immediate withdrawal of the culprit drug, support measures and the use of corticosteroids as the first line of treatment. We report a 24-year-old woman with a diagnosis of ulcerative colitis with joint involvement despite the use of infliximab, who presented symptoms, signs and laboratory compatible with DRESS syndrome on the third week after indicating sulfasalazine for her baseline disease.

Hidroxicloroquina: Mensajes desde la cardiología en tiempos de pandemia por Coronavirus / Hydroxychloroquine. Cardiology's viewpoint in times of coronavirus pandemic

Ante la pandemia de COVID-19 (del inglés coronavirus disease 2019), uno de los fármacos propuesto para su tratamiento es la hidroxicloroquina. Se revisan aquí aspectos cardiológicos del uso de cloroquina e hidroxicloroquina. Se realizó una revisión no sistemática en la literatura médica orientada a la búsqueda de información acerca de su seguridad y eficacia como antimaláricos y antivirales, así como en el tratamiento prolongado de enfermedades reumatológicas. Se halló un efecto antiinflamatorio con reducción de eventos cardiovasculares a largo plazo, una cardiopatía muy infrecuente por un efecto lisosomal del fármaco, y a nivel hemodinámico hipotensión, taquicardia, y prolongación del intervalo QT, exacerbado si se combina con azitromicina. Sin embargo, la tasa de eventos adversos cardíacos de la hidroxicloroquina y la cloroquina fue baja.

Due to the coronavirus disease 2019 (COVID-19) pandemic, a wide number of compounds are under scrutiny regarding their antiviral activity, one of them being hydroxychloroquine. Cardiac aspects of the use of chloroquine and hydroxychloroquine are reviewed in this manuscript. A non-systematic review of the medical literature was performed. Information about their safety and efficacy as antimalarials, antivirals, as well as in the long-term treatment of rheumatic diseases was collected. We found an anti-inflammatory effect with reduction of long-term cardiovascular events, a very infrequent heart disease due to a lysosomal effect of the drug, and at the hemodynamic level hypotension, tachycardia, and QT interval prolongation, exacerbated when combined with azithromycin. However, the rate of adverse cardiac events of hydroxychloroquine (and chloroquine) was low.

Non-alcoholic fatty liver disease in patients infected with human immunodeficiency virus: a systematic review

SUMMARY OBJECTIVE To evaluate the prevalence of nonalcoholic fatty liver disease (NAFLD) in patients with HIV/AIDS. METHODS The systematic review included articles indexed in MEDLINE (by PubMed), Web of Science, IBECS, and LILACS. Studies eligible included the year of publication, diagnose criteria of NAFLD and HIV, and were published in English, Portuguese, or Spanish from 2006 to 2018. The exclusion criteria were studies with HIV-infection patients and other liver diseases. Two reviewers were involved in the study and applied the same methodology, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). RESULTS One hundred and sixteen papers were selected, including full articles, editorial letters, and reviews. Twenty-seven articles were excluded because they did meet the inclusion criteria. A total of 89 articles were read, and 13 were considered eligible for this review. Four case series used imaging methods to identify NAFLD, and nine included histology. The prevalence of NAFLD in HIV-patients ranged from 30%-100% and, in nonalcoholic steatohepatitis (NASH), from 20% to 89%. A positive association between dyslipidemia, insulin resistance, and body mass index was observed. There was no agreement between the studies that evaluated the relationship between antiretroviral drugs and NAFLD. CONCLUSION This systematic review showed a high prevalence of NAFLD in HIV-patients, which was associated with metabolic risk factors. The possible association between antiretroviral therapy and NAFLD needs further studies.

RESUMO OBJETIVO Avaliar a relevância da doença hepática gordurosa não alcoólica (DHGNA) em pacientes com HIV / AIDS. MÉTODOS A revisão sistemática foi realizada utilizando instrumentos de busca de material científico indexado, incluindo MEDLINE (pela PubMed), Web of Science, IBECS e LILACS. Estudos elegíveis incluíram o ano de publicação, critérios para diagnostico de DHGNA e HIV, publicados em inglês, português e espanhol, entre 2006 a 2018. Os critérios de exclusão incluíram estudos com pacientes com outras doenças do fígado. Dois revisores foram envolvidos na pesquisa dos artigos e o PRISMA (Preferred Reporting Items for Systematic Reviews and Meta - Analyses) foi utilizado nas análises. RESULTADOS Cento e dezesseis artigos foram selecionados, 27 excluídos porque não preencheram critérios de inclusão e assim, 89 foram lidos pelos investigadores. Desses, 13 artigos foram incluídos na revisão. Quatro séries de casos utilizaram métodos por imagens para identificação de DHGNA e nove estudos utilizaram biópsia hepática. A prevalência de DHGNA em pacientes com HIV variou de 30% a 100% e esteato-hepatite não alcoólica (EHNA) entre 20% e 89%. Na avaliação das principais variáveis estudadas, observou-se a associação positiva entre dislipidemia, resistência à insulina e índice de massa corporal. Não houve concordância entre os artigos que avaliaram a relação dos antiretrovirais com a DHGNA. CONCLUSÕES A presente revisão sistemática sugere elevada prevalência de DHGNA em pacientes infectados com HIV. DHGNA nesses pacientes foi associada principalmente a fatores metabólicos. A possível associação entre terapia antiretroviral e DHGNA nesses pacientes vem sendo discutida, mas são necessários mais estudos para estabelecer essa associação.

Incidence of tuberculosis infection in spondyloarthritis patients treated with biological and conventional disease-modifying anti-rheumatic drugs in an endemic area

Introduction: Registries of spondyloarthritis (SpA) patients' follow-up provided evidence that tumor necrosis factor inhibitors (TNFi) increase the incidence of active tuberculosis infection (TB). However, most of these registries are from low burden TB areas. Few studies evaluated the safety of biologic agents in TB endemic areas. This study compares the TB incidence rate (TB IR) in anti-TNF-naïve and anti-TNF-experienced subjects with SpA in a high TB incidence setting.Methods: In this retrospective cohort study, medical records from patients attending a SpA clinic during 13 years (2004 to 2016) in a university hospital were reviewed. The TB IR was calculated and expressed as number of events per 105 patients/year; the incidence rate ratio (IRR) associated with the use of TNFi was calculated.Results: A total of 277 patients, 173 anti-TNF-naïve and 104 anti-TNF-experienced subjects, were evaluated; 35.7% (N = 35) of patients who were prescribed an anti-TNF drug were diagnosed with latent tuberculosis infection (LTBI). Total follow-up time (person-years) was 1667.8 for anti-TNF-naïve and 394.9 for anti-TNF-experienced patients. TB IR (95% CI) was 299.8 (37.4-562.2) for anti-TNF naïve and 1012.9 (25.3-2000.5) for anti-TNF experienced subjects. The IRR associated with the use of TNFi was 10.4 (2.3- 47.9).Conclusions: In this high TB incidence setting, SpA patients exposed to anti-TNF therapy had a higher incidence of TB compared to anti-TNF-naïve subjects, although the TB incidence in the control group was significant.(AU)

Evaluation of toxic retinopathy caused by antimalarial medications with spectral domain optical coherence tomography / Avaliação da frequência de retinopatia por antimaláricos com o exame tomografia de coerência óptica de domínio espectral

ABSTRACT Purpose: To investigate the frequency of toxic retinopathy in patients with lupus erythematosus and rheumatoid arthritis with long-term use of chloroquine diphosphate or hydroxychloroquine through spectral domain optical coherence tomography and the outcomes of ophthalmological exams (visual acuity - Snellen's table, color vision test - Ishihara's table, fundoscopy, and retinography - red-free). Methods: A cross-sectional study was carried out involving the ophthalmologic evaluation of patients using regular chloroquine diphosphate or hydroxychloroquine for a period of 1 year or longer. The patients completed a questionnaire on their opinions and treatment regularity. The same patients underwent ophthalmologic examination and spectral domain optical coherence tomography. Results: The prevalence of toxic retinopathy caused by antimalarials was 4.15% (9 of 217 patients), 7.4% (4 of 54 patients) following chloroquine diphosphate usage, and 0.82% (1 of 121 patients) following hydroxychloroquine usage. Only patients with advanced stage maculopathy presented abnormalities during the ophthalmologic exam: the color vision test was altered in 11.1%, and visual acuity and fundoscopy were altered in 33.3%. Identification of early toxic retinopathy, detected in six patients, was possible using spectral domain optical coherence tomography. The mean duration of antimalarial drug usage among patients with toxic retinopathy was 10.4 years. Only 31% of the patients reported some symptoms during treatment, and although 24% were afraid to use the medication, they did so as prescribed. Conclusion: Use of spectral domain optical coherence tomography was essential for the diagnosis of early-stage antimalarial toxic retinopathy in patients with the following characteristics: asymptomatic, antimalarial use 7 days a week for a period of more than 5 years, and normal clinical ophthalmologic examination.

RESUMO Objetivo: Investigar a frequência da retinopatia tóxica em pacientes com lúpus eritematoso e artrite reumatóide com uso crônico de difosfato de cloroquina ou hidroxicloroquina, através de tomografia de coerência óptica de domínio espectral e os resultados dos exames oftalmológicos (acuidade visual - tabela de Snellen, teste de visão de cor - tabela de Ishihara, fundoscopia e retinografia - red free). Métodos: Foi realizado um estudo transversal envolvendo a avaliação oftalmológica de pacientes em uso regular de difosfato de cloroquina ou hidroxicloroquina por um período de um ano ou mais. Os pacientes responderam a um questionário sobre a sua opinião e regularidade do tratamento. Os mesmos pacientes realizaram exame oftalmológico clínico e tomografia de coerência óptica de domínio espectral. Resultados: A prevalência de retinopatia tóxica por antimaláricos foi de 4,15% (9 dos 217 pacientes), 7,4% (4 de 54 pacientes) após uso de difosfato de cloroquina e 0,82% (1 de 121 pacientes) após uso de hidroxicloroquina. Apenas os pacientes com maculopatia em fase avançada apresentaram alterações durante os exames clínicos: teste de visão de cores alterado em 11,1%, e a acuidade visual e fundoscopia foram alteradas em 33,3%. A identificação de retinopatia tóxica precoce, detectada em seis pacientes, foi possível por meio da tomografia de coerência óptica de domínio espectral. A duração média do tempo de uso de drogas antimaláricas entre os pacientes com retinopatia tóxica foi de 10,4 anos. Apenas 31% dos pacientes relataram algum sintoma durante o tratamento e apesar de 24% terem medo de usar a medicação, eles o fizeram conforme prescrito. Conclusão: O uso da tomografia de coerência óptica de domínio espectral foi essencial para o diagnóstico de retinopatia tóxica antimalárica em estágio inicial em pacientes com as seguintes características: uso assintomático, antimalárico 7 dias por semana por um período maior que cinco anos e exame oftalmológico clínico normal.

Complicaciones asociadas a tratamiento biológico en pacientes con artritis reumatoide: consideraciones en relación a un caso clínico / Associated complications with biological treatment in patients with rheumatoid arthritis: considerations in relation to a clinical case

La artritis reumatoide (AR) es una enfermedad inflamatoria sistémica de origen autoinmune, caracterizada por una evolución variable, con remisiones y reacti-vaciones. Se considera que un diagnóstico y tratamiento precoz permiten evitar el daño articular, mejorar el pronóstico y la calidad de vida del paciente. El trata-miento actual está basado en el uso de fármacos antirreumáticos sintéticos mo-dificadores de la enfermedad (sDMARDS), asociado a glucocorticoides en dosis bajas. Frente al fracaso o intolerancia de este tratamiento o bien en casos de una enfermedad inicial muy severa, en especial con manifestaciones extraarticulares, se recomienda el uso de fármacos biológicos modificadores de la enfermedad (bDMARD). Estos fármacos, usados en las condiciones señaladas, han significado un avance importante en el control y pronóstico de la enfermedad. Sin embargo, no están exentos de la presencia de reacciones adversas, por lo que deben ser monitorizados permanentemente.

Rheumatoid arthritis (RA) is a systemic inflammatory disease of autoimmune ori-gin, characterized by a variable evolution, with remissions and reactivations. It is considered that a diagnosis and early treatment allow avoiding the joint damage, improving the prognosis and the quality of life of the patient. The current treat-ment is based on the use of synthetic antirheumatic drugs modifying the disease (sDMARDS), associated with low-dose glucocorticoids. Faced with the failure or intolerance of this treatment or in cases of a very severe initial disease, especially with extra-articular manifestations, the use of biological drugs that modify the disease (bDMARD) is recommended. These drugs, used in the indicated condi-tions, have meant an important advance in the control and prognosis of the dis-ease. However, they are not exempt from the presence of adverse reactions, so they should be monitored permanently.

Latent tuberculosis infection in patients with rheumatic diseases / Infecção latente por tuberculose em pacientes com doenças reumatológicas

ABSTRACT Most people infected by Mycobacterium tuberculosis (Mtb) do not have any signs or disease symptoms, a condition known as latent tuberculosis infection (LTBI). The introduction of biological agents, mainly tumor necrosis factor (TNF) inhibitors, for the treatment of immune-mediated diseases such as Rheumatoid Arthritis (RA) and other rheumatic diseases, increased the risk of reactivation of LTBI, leading to development of active TB. Thus, this review will approach the aspects related to LTBI in patients with rheumatologic diseases, especially those using iTNF drugs. For this purpose it will be considered the definition and prevalence of LTBI, mechanisms associated with diseases and medications in use, criteria for screening, diagnosis and treatment. Considering that reactivation of LTBI accounts for a large proportion of the incidence of active TB, adequate diagnosis and treatment are crucial, especially in high-risk groups such as patients with rheumatologic diseases.

RESUMO A maioria das pessoas infectadas por Mycobacterium tuberculosis (Mtb) não possui sinais ou sintomas da doença, quadro conhecido como infecção latente por tuberculose (ILTB). A introdução de agentes biológicos, sobretudo inibidores do fator de necrose tumoral (iTNF), para o tratamento de doenças imunomediadas, como artrite reumatoide (AR) e outras doenças reumatológicas, aumentou o risco de reativação de ILTB, levando ao desenvolvimento de tuberculose (TB) ativa. Assim, esta revisão abordará os aspectos relacionados à ILTB em pacientes com doenças reumatológicas, especialmente naqueles em uso de medicamentos iTNF. Para tanto, serão considerados a definição e a prevalência de ILTB, os mecanismos associados às doenças e às medicações em uso, bem como os critérios para rastreamento, diagnóstico e tratamento da ILTB. Como a reativação da ILTB é responsável pela grande proporção de casos de TB ativa, o diagnóstico e o tratamento adequados são cruciais, principalmente em grupos de alto risco, como os pacientes com doenças reumatológicas.

Challenging management of hepatitis B infection in ankylosing spondylitis patients in an endemic area during immunosuppressive therapy

Abstract Hepatitis B infection is a global health issue. When considering patients with rheumatic diseases, this is no different. By using immunosuppressant drugs, such as DMARDs and biologics, viral reactivation is possible, leading to serious consequences on the patient. We report 3 cases of association between ankylosing spondylitis and hepatitis B with the use of immunosuppressant drugs. Case 1 was a patient with previous HBV infection using DMARD. Cases 2 and 3 were patients chronically infected by HBV during immunosuppressant therapy. The management of HBV infection during immunosuppressant therapy is challenging and needs multidisciplinary support.

Retinal toxicity due to hydroxychloroquine: frequency in an Ophthalmology ambulatory / Toxicidade retiniana pela hidroxicloroquina: frequência em um ambulatório de Oftalmologia

Abstract Hydroxychloroquine is widely used by rheumatologists for the treatment of various diseases, such as systemic lupus erythematosus and rheumatoid arthritis because of its safety and low cost. However, it can cause retinal abnormalities. Until today, there is no Brazilian protocol for screening for retinal changes in these patients. We reviewed the medical records and optical coherence tomography of all patients who had attended at Hychloroquine Ambulatory of HFSE, in the period from March/ 2015 until November/2016.

Resumo A Hidroxicloroquina é amplamente utilizada por reumatologistas para o tratamento de várias condições, como os lúpus eritematoso sistêmico e artrite reumatoide, pelo seu baixo custo e relativa segurança. Porém, esta droga pode causar danos à retina. Até o presente momento, não há protocolo brasileiro para o screening de alterações retinianas devido ao uso desta medicação. Foi realizada revisão de prontuário e análise de imagens de tomografia de coerência óptica de pacientes atendidos no período de Março de 2015 a Novembro de 2016 no ambulatório de Hidroxicloroquina do Hospital Federal dos Servidores do Estado do Rio de Janeiro.

Pulmonary paracoccidioidomycosis: a case report of reactivation in a patient receiving biological therapy

Abstract Paracoccidioidomycosis is an endemic disease in Latin America that is rarely associated with immunosuppression and biological therapy. Herein, we report for the first time a case of pulmonary paracoccidioidomycosis reactivation after infliximab treatment. A 47-year-old man from Brazil received infliximab to treat psoriatic spondyloarthropathy and presented with cough, dyspnea, weight loss, and fever. Chest computed tomography revealed a pulmonary nodule and biopsy confirmed paracoccidioidomycosis. Treatment with sulfamethoxazole and trimethoprim was initiated for fungal infection and infliximab was reintroduced two months later. Considering his clinical improvement and favorable radiologic evolution, antifungal therapy was discontinued after 29 months.

Preventable adverse drug events in critically ill HIV patients: Is the detection of potential drug-drug interactions a useful tool?

OBJECTIVES: The aim of this study was to develop a strategy to identify adverse drug events associated with drug-drug interactions by analyzing the prescriptions of critically ill patients. METHODS: This retrospective study included HIV/AIDS patients who were admitted to an intensive care unit between November 2006 and September 2008. Data were collected in two stages. In the first stage, three prescriptions administered throughout the entire duration of these patients' hospitalization were reviewed, with the Micromedex database used to search for potential drug-drug interactions. In the second stage, a search for adverse drug events in all available medical, nursing and laboratory records was performed. The probability that a drug-drug interaction caused each adverse drug events was assessed using the Naranjo algorithm. RESULTS: A total of 186 drug prescriptions of 62 HIV/AIDS patients were analyzed. There were 331 potential drug-drug interactions, and 9% of these potential interactions resulted in adverse drug events in 16 patients; these adverse drug events included treatment failure (16.7%) and adverse reactions (83.3%). Most of the adverse drug reactions were classified as possible based on the Naranjo algorithm. CONCLUSIONS: The approach used in this study allowed for the detection of adverse drug events related to 9% of the potential drug-drug interactions that were identified; these adverse drug events affected 26% of the study population. With the monitoring of adverse drug events based on prescriptions, a combination of the evaluation of potential drug-drug interactions by clinical pharmacy services and the monitoring of critically ill patients is an effective strategy that can be used as a complementary tool for safety assessments and the prevention of adverse drug events.

Three cases of anti-TNF induced myositis and literature review / Três casos de miosite induzida pelo anti-TNF e revisão da literatura

Abstract Anti-tumor necrosis factor drugs are frequently preferred in the treatment of rheumatologic diseases and other inflammatory diseases. The development of myositis after using anti-tumor necrosis factor drugs is a rare clinical condition. Here we aimed to report cases who developed myositis after using anti-tumor necrosis factor drugs and review the current literature. We report two cases of rheumatoid arthritis and a case of ankylosing spondylitis developed idiopathic inflammatory myopathy following anti-tumor necrosis factor therapy. In conclusion, myositis could develop during anti-tumor necrosis factor therapy, so these patients should be evaluated carefully initially for myositis and should be closely monitored due to the potential for developing myositis in treatment process.

Resumo Os fármacos antifator de necrose tumoral (anti-TNF) são frequentemente preferidos no tratamento de doenças reumatológicas e outras doenças inflamatórias. O desenvolvimento de miosite após o uso de anti-FNT é uma condição clínica rara. Este estudo objetivou descrever casos de pacientes que desenvolveram miosite após o uso de anti-TNF e fazer uma revisão da literatura atual. Descrevem-se dois casos de artrite reumatoide (AR) e um caso de espondilite anquilosante (EA) que desenvolveram miopatia inflamatória idiopática após o tratamento com anti-TNF. Em conclusão, pode haver desenvolvimento de miosite durante o tratamento com anti-TNF, de modo que esses pacientes devem ser cuidadosamente avaliados inicialmente à procura de miosite e devem ser cuidadosamente monitorados em razão do potencial de desenvolvimento de miosite no processo de tratamento

Perioperative management of drugs commonly used in patients with rheumatic diseases: a review

Rheumatic diseases are very prevalent, affecting about 7 million people in North America; they affect the musculoskeletal system, often with systemic involvement and potential for serious consequences and limitation on quality of life. Clinical treatment is usually long-term and includes drugs that are considered either simple or complex and are occasionally unknown to many health professionals who do not know how to manage these patients in emergency units and surgical wards. Thus, it is important for clinicians, surgeons and anesthesiologists who are involved with rheumatic patients undergoing surgery to know the basic principles of therapy and perioperative management. This study aims to do a review of the perioperative management of the most commonly used drugs in rheumatologic patients. Manuscripts used in this review were identified by surveying MEDLINE, LILACS, EMBASE, and COCHRANE databases and included studies containing i) the perioperative management of commonly used drugs in patients with rheumatic diseases: and ii) rheumatic diseases. They are didactically discussed according to the mechanism of action and pharmacokinetics; and perioperative management. In total, 259 articles related to the topic were identified. Every medical professional should be aware of the types of drugs that are appropriate for continuous use and should know the various effects of these drugs before indicating surgery or assisting a rheumatic patient postoperatively. This information could prevent possible complications that could affect a wide range of patients.

Acute generalized exanthematous pustulosis induced by hydroxychloroquine: a case with atypical clinical presentation

Abstract Acute generalized exanthematous pustulosis is a rare drug-induced eruption that is characterized by acute, nonfollicular sterile pustules on an erythematous and edematous base. The most frequently implicated drugs are beta-lactam antibiotics. Hydroxychloroquine has been widely used to treat dermatologic and rheumatologic diseases and has been reported as a rare cause of acute generalized exanthematous pustulosis. A 42-year-old female presented with pustular lesions on the skin surface with erythema, facial edema, and occasional atypical target-like lesions after 21 days of treatment with 200mg/day hydroxychloroquine for rheumatoid arthritis, diagnosed one month previously. We report a case with acute generalized exanthematous pustulosis induced by hydroxychloroquine and treated with dapsone and systemic corticosteroid.

Tormenta de citoquinas: reacción adversa inhabitual por rituximab. caso clínico / Shock as an adverse reaction to rituximab: case report

Rituximab is a plausible alternative first-line treatment of ANCA-associated vasculitis. Adverse effects related to its infusion are common and usually have a benign course. However, there have been reports of refractory cardiogenic shock simulating septic shock. We report an 81-year-old male with the diagnosis of ANCA associated vasculitis. Rituximab 500 mg was administered intravenously for a relapse. The infusion proceeded without incident. However, 24 hours after its administration the patient began with fever, chills, coughing and strong malaise. The patient was transferred to the critical patient unit where a septic shock was suspected and resuscitative measures were started. However, the fast response to moderate doses of vasoactive drugs and complementary tests did not support an infectious etiology for the shock. Antimicrobials were discontinued and systemic corticosteroids were maintained, achieving remission of the symptoms. Shock as an unusual adverse reaction to Rituximab was suspected.

Reactivation of cutaneous and mucocutaneous tegumentary leishmaniasis in rheumatoid arthritis patients: an emerging problem?

ABSTRACT Rheumatoid arthritis (RA) is a chronic condition that is frequent in patients living in tropical areas exposed to leishmaniasis. RA therapy involves immunosuppressant drugs such as methotrexate (MTX), monoclonal antibodies (mAbs) and prednisone. We report an unusual presentation of cutaneous (CL) or mucocutaneous leishmaniasis (ML) in RA patients from an endemic area of leishmaniasis. A 51-year-old woman noted a cutaneous ulcer on her left ankle during MTX and prednisone RA therapy. Initially diagnosed as a venous stasis ulcer, the aspirate of the injury revealed the presence of Leishmania DNA. A 73-year-old woman presenting non-ulcerated, infiltrated and painful erythematous nodules inside her nostrils while receiving MTX, anti-TNF mAb, and prednisone for RA, had also the aspirate of injuries showing the presence of Leishmania DNA. Both patients healed after the therapy with liposomal amphotericin. The RA therapy has changed to low-dose prednisone, without further reactivation episodes. Both cases suggest that CL or ML can reactivate after administration of an immunosuppressant for RA treatment. Therefore, immunosuppressive treatments for RA should be carefully prescribed in patients from endemic areas or with a history of CL and ML.