COVID-19 Infection In Patients With Autoimmune Rheumatic Diseases: Patient's Perspective And Descriptive Analysis From A Lower-Middle-Income Country.

The study was conducted to determine the severity of COVID-19 in autoimmune inflammatory rheumatic disease (AIRDs) patients and knowing their perceptions. All AIRDs cases with COVID-19 infection between December 2020 and February 2021 were included. A cross-sectional telephonic survey was conducted for perceptions. Twenty- one patients were analysed for severity of illness and 16(76.2%) for perceptions. Mean age was 44.8±14.8 years, with 11(52.4%) females. Two (9.5%) patients had severe disease, 6(28.6%) required hospitalisation, and none expired. Hypertension 7(33.3%) was the commonest comorbidity. Low dose steroids were the most used drug 9 (42.9%). Regarding perceptions, 10 out of 16 (62.5%) felt that AIRD made them vulnerable to COVID-19 infection. The most common reason of delay in seeking medical advice from the rheumatologist was closure of services for chronic diseases during the pandemic. Patients with AIRDs, receiving immunosuppressive treatment seem to be at a lower risk of developing a severe form of COVID-19 pneumonia.

Combined central retinal artery and vein occlusion associated with antiphospholipid syndrome.

A female patient in early 50s presented to us several months after developing severe visual loss in her right eye. The patient was diagnosed with resolved central retinal vein occlusion (CRVO) based on the clinical picture at the time of presentation, however, retroactive evaluation of fundus imaging and further multi-disciplinary workup led to the rare diagnosis of combined central retinal artery and vein occlusion associated with antiphospholipid syndrome (APS). Only a few cases reporting retinal arterial and venous occlusions in patients with APS are found in the literature. To the best of our knowledge, no case of simultaneous CRAO and CRVO has been reported with APS. The patient was started on lifelong warfarin therapy to prevent a similar episode in the left eye. It is important to properly evaluate patients presenting with retinal vascular occlusions, as a missed diagnosis of APS can lead to recurrent and more devastating vascular events.

Diagnostic utility of anti-citrullinated protein antibody and its comparison with rheumatoid factor in rheumatoid arthritis.

OBJECTIVE: To assess the diagnostic utility of anti-citrullinated protein antibody (anti-CCP) in rheumatoid arthritis (RA) and compare it with rheumatoid factor (RF). STUDY DESIGN: Analytical study. PLACE AND DURATION OF STUDY: Section of Chemical Pathology, Department of Pathology and Microbiology and Medicine, the Aga Khan University, Karachi, from January to May 2010. METHODOLOGY: A review of medical records of patients presenting to the clinics with complaints of muscular or joint pains and who were tested for their serum anti-CCP was done. Inclusion criteria were presence of clinical synovitis in at least one joint and an absence of alternative diagnosis. Patients with arthralgia alone or with missing acute phase reactants information were excluded. Scoring and classification of RA was done using the 2010 RA Classification Criteria by the American College of Rheumatology (ACR). RESULTS: Out of the 98 charts reviewed, ACR criteria showed 54 cases with RA. The mean age of the group was 46 ± 15 years, 82.7% being females. High titers of anti-CCP corresponded with the ACR scores. The sensitivity and specificity of anti-CCP and RF reactivity for the diagnosis of RA were 54.7% and 95.5% versus 59.3% and 88.4% respectively. CONCLUSION: Anti-CCP is useful for the diagnosis of RA due to its higher specificity as compared to RF and can predict disease severity.

Transient osteoporosis of the hip.

Transient Osteoporosis of Hip (TOH) is an uncommon disorder of idiopathic nature, particularly in the Asian population. It has been described to mostly occur in middle aged men and women in their third trimester of pregnancy. A distinctive hallmark of this condition is that it is self limiting and resolves in a few months. The patient presents to the physician with pain on movement and impaired mobility of the affected joint, developing without any history of trauma. MRI is the main diagnostic tool. We report herein a case of a forty five year old male, who developed transient osteoporosis of the hip, and was managed conservatively.

Efficacy and safety of CE-224,535, an antagonist of P2X7 receptor, in treatment of patients with rheumatoid arthritis inadequately controlled by methotrexate.

OBJECTIVE: To evaluate efficacy and safety of CE-224,535, a selective P2X(7) receptor antagonist, versus placebo, in patients with active rheumatoid arthritis (RA) and inadequate response to methotrexate (MTX). METHODS: In our phase IIA study (ClinicalTrials.gov no. NCT00628095; A6341009), patients aged ≥ 18 years with active RA were randomized to receive either CE-224,535 (500 mg bid) or placebo for 12 weeks; all patients continued a stable background dose of ≥ 7.5 mg MTX. RESULTS: The American College of Rheumatology 20% (ACR20) response rate (primary efficacy endpoint) was not significantly different from placebo for CE-224,535 (34.0% vs 36.2%; p = 0.591) at Week 12, or at any timepoint over the 12-week treatment period. There was no significant difference at Week 12 for the ACR20 response rate following subgroup analyses by age, sex, baseline disease activity, baseline duration of disease, geographic region, or concomitant use of steroids. ACR50/ACR70 response rates and change from baseline in Disease Activity Score 28-joint C-reactive protein (DAS28-3-CRP) and Health Assessment Questionnaire-Disability Index for CE-224,535 were not significant at Week 12 versus placebo. Treatment-emergent adverse events (AE) were reported by 62.3% (CE-224,535) and 55.3% (placebo) of patients; the most common AE were nausea (11.3%, CE-224,535; 4.3%, placebo) and diarrhea (7.5%, CE-224,535; 4.3%, placebo). The proportion of patients discontinuing due to an AE was 9.4% (CE-224,535) and 6.4% (placebo); no deaths were reported. Serious AE occurred in 3.8% (CE-224,535) and 2.1% (placebo) of patients; none was considered treatment-related. CONCLUSION: CE-224,535 was not efficacious, compared with placebo, for the treatment of RA in patients with an inadequate response to MTX. CE-224,535 demonstrated an acceptable safety and tolerability profile.

Regression of severe Behcet's eye disease with infliximab therapy; .first two cases treated in Pakistan.

We present two cases of Behcet's Disease with severe eye problems along with oral and genital ulcerations. Both cases, initially were treated with steroids and oral immunosuppressive agents, but did not show a response and ocular disease became worse. Both the cases were kept on Infliximab therapy. an immediate positive response with improvement in vision and symptoms was seen. After initial infusions the ocular damage in both the cases stopped.

Rituximab therapy for flare-up of rheumatoid arthritis after total knee replacement surgery.

A variety of drug types are used alone or in combination to manage Rheumatoid Arthritis along with physiotherapy. We report herein the case of a 51 year old female patient with a history of Rheumatoid Arthritis whose disease remained active despite being on routinely used multiple disease modifying antirheumatic drugs. The patient underwent bilateral total knee arthroplasty with subtotal synovectomy due to the severe pain caused by her concomitant age related osteoarthritis which was only aggravated by her active rheumatoid arthritis disease. Three months following surgery, the patient's knee pain with typical rheumatoid flare and swelling reappeared for which a B cell monoclonal antibody, rituximab, was given. Her number of tender and swollen joints reduced to less than three and her C-reactive protein levels and erythrocyte sedimentation rate reduced significantly along with considerable improvement in her Global Assessment score. Her severity of pain also decreased to 3 from an initial score of 8 on the Visual Analog Scale. Thus, Rituximab helped improve our patient's symptoms from recurrence of synovitis after total knee replacement.

Chorea as an unusual presenting feature of anti-phospholipid syndrome.

Anti-phospholipid syndrome (APS) can manifest as primary disease or secondary to connective tissue diseases, such as systemic lupus erythematosus (SLE). It is characterized by recurrent arterial or venous thrombosis, thrombocytopenia, haemolytic anaemia, or positive Coombs' test, and recurrent pregnancy loss in females. Common neurological abnormalities include stroke, cognitive deficits and white matter lesions. We present an unusual case of secondary APS associated with SLE, that presented at our clinic with chorea. To the best of our knowledge this is a first such case reported from Pakistan. APS must be ruled out in any patient of SLE who presents with stroke or any other neurological abnormality regardless of the age at presentation. Moreover, unusual neurological presentations, such as chorea, should always be kept in mind in order to promptly diagnose and treat APS owing to its high morbidity and mortality.

Celecoxib-related renal papillary necrosis.

Selective cyclooxygenase 2 (COX-2) inhibitors are known to affect renal prostaglandins (epoprostenol and dinoprostone), which are at least in part COX-2 dependent. Consequently, adverse events including hypertension, peripheral edema, hypercalemia, hyponatremia, and acute renal failure have been reported to occur with the new COX-2-specific inhibitors. This case report posits celecoxib as a likely cause of renal papillary necrosis and alerts physicians to the possibility of this additional renal complication with COX-2-specific inhibitors.

Splenic rupture as the presenting manifestation of vasculitis.

BACKGROUND: Although underreported, histologic splenic involvement in Wegener's granulomatosis (WG) is not unusual. Splenic rupture in association with WG, however, is rare. Only 2 cases of nontraumatic splenic rupture have been reported as the initial feature of WG. Isolated cases of splenic rupture also have been noted in rheumatoid arthritis, systemic lupus erythematosus, and polyarteritis nodosa. OBJECTIVE: To report the third case of splenic rupture as the presenting feature of WG and review the literature concerning splenic rupture in other rheumatologic diseases to better delineate a mechanism for this rare occurrence. METHODS: Descriptive case report of 1 patient with WG with antecedent splenic rupture and a review of the relevant literature using a MEDLINE search from 1950 to 2001. RESULTS: Our patient presented with symptoms and signs of WG 2 weeks after nontraumatic splenic rupture. Two similar cases have been reported: one showed splenic vasculitis histologically and the other only a neutrophilic infiltration at the site of the splenic tear and subcapsular zone after surgery. Although splenic capsular and pulp hemorrhage alone without signs of vasculitis were noted in our patient, no other cause (ie, hematologic, infectious, neoplastic, or otherwise) for splenic rupture was found. CONCLUSIONS AND RELEVANCE: As in the 2 reported cases, WG may have been responsible for splenic rupture in our patient. Regardless, early evaluation for connective tissue disease in a patient with spontaneous splenic rupture without apparent cause merits consideration, as it may affect patient follow-up and treatment.