Nonischemic Dilated Cardiomyopathy in Untreated Long-Term Psoriatic Arthritis: A Newly Recognized Association: A Case Report with Mini Review.

BACKGROUND Psoriasis is a chronic inflammatory skin disease associated with multiple comorbidities including psoriatic arthritis (PsA), atherosclerotic disease, metabolic syndrome, diabetes, hypertension, obesity, and depression. Interestingly, nonischemic cardiomyopathy, especially dilated cardiomyopathy (DCM), has been associated with psoriasis and reported in only in a few cases in the literature. CASE REPORT We report the rare case of a 58-year-old man with a medical history of untreated severe psoriasis and PsA who presented with a sudden onset of shortness of breath. Laboratory and radiographic studies showed an elevated level of B-type natriuretic peptide and acute bilateral pulmonary edema. The patient had normal coronary arteries on cardiac catheterization and echocardiography showed newly diagnosed DCM with systolic and diastolic dysfunction. Cardiac magnetic resonance imaging was consistent with nonischemic DCM (NIDCM) with no evidence of hypertrophy, infiltrative process, or edema. The patient was diagnosed with acute congestive heart failure secondary to NIDCM in the setting of long-standing untreated psoriasis. He responded well to diuretics, was placed on guideline-directed medical therapy, and was discharged with a LifeVest personal cardiac defibrillator. As an outpatient, the patient was started on secukinumab, a monoclonal antibody against interleukin-17A. At his last follow-up appointment, the patient reported improvement in his cardiac symptoms and resolution of his psoriatic skin lesions; repeat echocardiography showed improvement in his ejection fraction. CONCLUSIONS Although studies have shown a higher prevalence of cardiovascular disease in patients with psoriasis, an association with NIDCM has not been studied sufficiently. We recommend further studies of the prevalence, pathogenesis, screening, and management of NIDCM in patients with psoriasis.

Mixed Cryoglobulinemia Syndrome (MCS) due to untreated hepatitis B with uncommon presentation: case report and literature review.

BACKGROUND: The mixed cryoglobulinemia (MC) syndrome is a systemic inflammatory syndrome that causes small-to-medium vessel vasculitis due to cryoglobulin-containing immune complexes most commonly caused by chronic hepatitis C virus (HCV), and rarely by chronic hepatitis B virus (HBV). Its clinical presentation is significantly varied, with manifestations ranging from purpura, arthralgia, and myalgia to more severe neurologic and renal involvement. Pulmonary involvement as organizing pneumonia, alveolar hemorrhage, and pulmonary vasculitis have been reported, but appear to be quite rare. CASE PRESENTATION: We report an uncommon case of a patient who presented with primary pulmonary syndrome without renal involvement in the setting of MC, due to untreated chronic hepatitis B infection. Early diagnosis and consequent institution of glucocorticoids, B-cell-depleting monoclonal antibody and antiviral therapy led to a favorable outcome and prevented any fatal sequelae. CONCLUSION: Pulmonary compromise in MC syndrome is very uncommon and carries a high rate of mortality. Therefore, in patients with HBV presenting with hemoptysis, physicians must carry a high clinical suspicion for alveolar hemorrhage secondary to cryoglobulinemic vasculitis.

Methimazole-Induced Pauci-Immune Glomerulonephritis and Anti-Phospholipid Syndrome: An Important Association to Be Aware of.

While methimazole (MMI) is the first line treatment for hyperthyroidism, this medication is not devoid of adverse effects. In this article, we present a 70-year-old male who admitted the hospital with right lower extremity pain and rash. The patient was recently treated with MMI for hyperthyroidism. Imaging studies revealed bilateral renal and splenic infarcts along with thrombosis of popliteal artery. Laboratory data revealed hematuria and proteinuria with positive (MPO), anti-proteinase-3 (PR3) and anti-cardiolipin IgG antibodies. Renal biopsy revealed pauci-immune glomerulonephritis and features with anti-phospholipid antibody syndrome (APS). MMI was discontinued and the patient was treated successfully with steroid therapy and anti-coagulation with resolution of proteinuria, hematuria and normalization of laboratory parameters. While MMI-induced pauci-immune glomerulonephritis has been previously reported, its association with APS has never been described before. Our case demonstrates that this rare diagnosis can be treated by early withdrawal of MMI and initiation of steroids along with anticoagulation.

Discoid lupus erythematosus following herpes zoster.

The isomorphic response is the appearance of new lesions from a preexisting skin condition at a site of trauma. Discoid lupus erythematosus (DLE) may develop on traumatized skin and also may arise at sites of a prior cutaneous eruption. We report the case of a 20-year-old woman with a history of systemic lupus erythematosus (SLE) and DLE who developed a painful, multidermatomal, vesicular rash on the left breast and back consistent with herpes zoster (HZ) during treatment with systemic immunosuppression. Four months after the HZ resolved, the patient developed new-onset DLE lesions within the prior HZ-affected dermatomes. Our case is one of few reports of an isomorphic response in an immunosuppressed young woman with a history of SLE and DLE. When HZ presents in this patient population, close monitoring of the HZ-affected sites for any evidence of DLE is recommended. Topical corticosteroids should be applied to the involved areas at the earliest appearance of such lesions to further prevent potentially scarring DLE lesions.

Subcutaneous oedema of upper limbs heralding an aggressive form of dermatomyositis.

Subcutaneous oedema is a rare presenting clinical manifestation of dermatomyositis. In this case, we report a 44-year-old man presenting with bilateral upper extremity predominant swelling and weakness. The proximal muscle weakness, dysphagia and presence of Gottron's papules as well poikiloderma like skin changes led to the clinical diagnosis of dermatomyositis. He received aggressive treatment with high-dose glucocorticoids and required intravenous immunoglobulin with improvement in his symptoms.

A Unique Case of Systemic Lupus Erythematosus Pelvic Vasculitis.

The clinical presentation of Systemic Lupus Erythematosus (SLE) is diverse and vasculitis can be a potential manifestation. Cutaneous lesions involving small vessels are the most frequent presentation. However, medium and large vessel vasculitis may present with life-threatening visceral manifestations. We present a unique case of pelvic vasculitis mimicking a pelvic mass as an initial presentation of SLE. There are case reports of systemic vasculitis involving the female genital tract with giant cell arteritis (GCA), polyarteritis nodosa (PAN), and granulomatous with polyangiitis and microscopic polyangiitis (GPA/MPA), among others, but only a few cases attributed to SLE. Awareness of this condition and a prompt diagnosis are warranted as this is a severe and potentially life-threatening condition.

Osseous sarcoidosis: a case series.

Sarcoidosis is an inflammatory disorder characterized by noncaseating granulomas infiltrating affected organs. Any organ system can be involved, and more than 90 % of patients have a primary pulmonary manifestation. The incidence of radiographically evident bone involvement has been reported over a wide range: from 3 to 39 % depending on the population studied and imaging modalities used. Any bone may be affected in osseous sarcoidosis. Bilateral involvement of the phalanges of the hand and feet is most common. However, reports of long bone, skull, rib and vertebral involvement have appeared. To date, there are no specific tools for the assessment of skeletal disease activity in sarcoidosis. Plain radiograph picks lesions in the small bones of hands and feet greater than does in other bones. Bone scan is useful for defining the extent of the skeletal disease and bone marrow involvement. Magnetic resonance imaging usually demonstrates multifocal lesions within the vertebrae that are hypointense on T1-weighted images and hyperintense on T2-weighted images. In cases of multifocal bone lesions and an established diagnosis of sarcoidosis, a diagnosis of bone sarcoidosis should be considered in the differential diagnosis. Optimal treatment of osseous sarcoidosis remains controversial. We present five cases of multisystem sarcoidosis with skeletal involvement including long bones and vertebrae and a description of immunosuppressive therapies used in our patients. A literature review highlighting the diagnostic approach using radiographic imaging, as well as treatment strategies, is provided.