All-Cause and Cause-Specific Mortality in Psoriatic Arthritis and Ankylosing Spondylitis: A Systematic Review and Meta-Analysis.

OBJECTIVE: Psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are chronic inflammatory diseases associated with a higher risk of cardiometabolic comorbidities compared to the general population. Individual studies examining mortality in these patients have produced conflicting results. The present study was undertaken to perform a systematic review and meta-analysis to analyze the all-cause and cause-specific mortality in PsA and AS from the available literature. METHODS: A comprehensive database search was performed for studies reporting all-cause or cause-specific mortality in patients with PsA and AS compared with the general population. Pooled relative risks (RRs) were calculated using a random-effects model. RESULTS: We included 19 studies (11 of PsA, 7 of AS, 1 of both). In PsA studies, there was no increased mortality compared to the general population (RR 1.12 [95% confidence interval (95% CI) 0.96-1.30]; n = 10 studies). We found a higher all-cause mortality in female (RR 1.19 [95% CI 1.04-1.36]) but not in male (RR 1.02 [95% CI 0.66-1.59]) PsA patients. Cardiovascular-, respiratory-, and infection-specific mortality risks were significantly higher for PsA patients (RR 1.21 [95% CI 1.06-1.38], RR 3.37 [95% CI 1.30-8.72], and RR 2.43 [95% CI 1.01-5.84], respectively), but not cancer-related mortality (RR 1.01 [95% CI 0.91-1.11]). In AS, we found a higher risk of death from all causes (RR 1.64 [95% CI 1.49-1.80]; n = 6 studies) and cardiovascular causes (RR 1.35 [95% CI 1.01-1.81]; n = 3 studies) compared to the general population. All-cause mortality was high in both male (RR 1.56 [95% CI 1.43-1.71]) and female (RR 1.85 [95% CI 1.56-2.18]) AS patients. The included AS studies did not report mortality data for non-cardiovascular causes. CONCLUSION: This systematic review and meta-analysis showed a significantly increased risk of overall mortality in AS but not PsA. Cardiovascular-specific mortality was higher for both PsA and AS, which emphasizes the importance of early screening and management of cardiovascular risk factors.

Urine in the lung: An uncommon cause of transudative pleural effusion.

Urinothorax [UT], the accumulation of urine in the pleural space, is an uncommon cause of pleural effusions resulting from trauma, obstruction, or iatrogenic causes. Thoracentesis with pleural fluid analysis and evaluation of biochemical characteristics, such as pleural fluid creatinine (PCr) to serum creatinine ratio (Scr), is necessary to establish this diagnosis. This case illustrates a 93 year old man with a complicated past medical history including chronic kidney disease stage 4, adenocarcinoma of the prostate status post brachytherapy complicated by proctitis, high grade transitional cell carcinoma of the right kidney with right hydronephrosis, and recurrent hematuria who was hospitalized for worsening hematuria and suprapubic pain. The patients CXR showed a large right pleural effusion. A repeat thoracentesis was performed removing 1.85L clear yellow fluid. PCr and SCr were 4.1 mg/dl and 3.94 mg/dL respectively. This confirmed the diagnosis of UT with a PCr to SCr ratio of 1.04. Again, diagnosis requires pleural fluid analysis and is associated with a paucicellular, transudative effusion with an ammonia-like odor, acidotic pH less than 7.4, and a PCr to SCr ratio greater than 1.0. Management is dependent on correcting the underlying pathology, such as repairing traumatic GU injury or obstruction.

The Use of Pleural Fluid to Serum Glucose Ratio in Establishing the Diagnosis of a Not So Sweet PD-Related Hydrothorax: Case Report and Literature Review.

Hydrothorax is a well-known but rare complication of peritoneal dialysis (PD), with an average incidence of 2% mainly in cases of continuous ambulatory peritoneal dialysis (CAPD). In more than 80% of these cases, the hydrothorax is attributed to an abnormal pleuroperitoneal communication. It commonly manifests as unilateral effusion, predominantly on the right. A thoracentesis to determine pleural glucose has been a diagnostic aid well relied on, as the dextrose rich dialysate raises the pleural fluid glucose. A pleural fluid glucose to serum glucose gradient greater than 50 mg/dL is suggestive of a leak with a specificity of 100% according to some studies; however, its sensitivity is variable. Our case illustrates a diagnostic dilemma due to a relatively low pleural fluid to serum glucose gradient of 21 mg/dL that caused a delay in diagnosis. A pleural fluid to serum glucose ratio >1.0 was used as a diagnostic marker that pointed toward a peritoneal leak. For confirmation, a peritoneal scintigraphy with nuclear technetium 99 scan was performed that revealed a pleuroperitoneal fistula as the source of the recurring hydrothorax in the setting of automated peritoneal dialysis (APD). The hydrothorax completely resolved with termination of APD on follow-up as the patient was transitioned to intermittent hemodialysis (HD).

Herbaspirillum Infection in Humans: A Case Report and Review of Literature.

Introduction. Herbaspirillum seropedicae are Gram-negative oxidase-positive nonfermenting rods of Betaproteobacteria class, commonly found in rhizosphere. More recently, some Herbaspirillium species have transitioned from environment to human hosts, mostly as opportunistic (pathogenic) bacteria. We present a 58-year-old female with non-small-cell lung cancer (NSCLC) who presented with pneumonia and was found to have Herbaspirillum seropedicae bacteremia. Case History. A 58-year-old woman with NSCLC on Pralsetinib presented with fevers and rigors for 2 days. Coarse breath sounds were auscultated on the right upper lung field. Labs revealed leukopenia and mild neutropenia. CT chest revealed right upper lobe pneumonia. She was admitted for sepsis secondary to pneumonia and placed on broad spectrum antibiotics with intravenous piperacillin-tazobactam and vancomycin. The patient continued to have fever 2 days after admission (max: 102.8°F). Preliminary blood cultures grew Gram-negative rods. The patient continued to have temperature spikes on the 3rd day of antibiotics (T max 101.5°F). Blood cultures revealed oxidase-positive nonfermenting rods. The patient's antibiotic was changed to IV meropenem on the 4th day of hospitalization. Ultimately, on the seventh day of hospitalization, the blood culture was confirmed from outside lab as Herbaspirillum seropedicae. The patient started feeling better and defervesced after about 24 hours. Discussion. More recently, Herbaspirillum spp. have been recovered from humans. Our patient had Herbaspirillum bacteremia, and reported regularly cleaning her pond and weeding her garden with possible exposure to this environmental proteobacterium. Herbaspirillum may be more prevalent than earlier thought owing to misidentification. With the institution of appropriate antimicrobial therapy, the outcomes seem mostly favorable.

Diffuse exanthematous drug eruption associated with intravenous immunoglobulin.

Diffuse exanthematous drug eruption due to intravenous immunoglobulin (IVIg) is a rare adverse event reported only in case reports. We present a case of a 71-year-old woman with a diffuse maculopapular rash 5 days after receiving an IVIg infusion for treatment of chronic inflammatory demyelinating polyneuropathy. She was managed conservatively with antihistamines; she was already receiving prednisone 25 mg daily as part of treatment for the neuropathy. The rash resolved over 2 weeks.