Beyond the Rash: Exploring the Symptoms and Diagnosis of Dermatomyositis

Dermatomyositis represents a rare autoimmune disorder characterized by the concurrent presentation of inflammatory myopathy and distinctive cutaneous manifestations. Herein, we present a comprehensive case report involving a 62-year-old male patient exhibiting a complex array of symptoms encompassing progressive muscle weakness, characteristic dermatological findings, and systemic involvement. This case report serves to illuminate the diagnostic intricacies inherent to dermatomyositis and underscore the imperative for a multidisciplinary approach to its effective management. The clinical presentation of the patient featured hallmark signs such as the classic heliotrope rash, Gottron's papules, and proximal muscle weakness, all indicative of dermatomyositis. Laboratory investigations revealed elevated muscle enzyme levels and the presence of positive autoantibodies, thereby reinforcing the diagnostic framework. Imaging modalities substantiated muscular involvement, while electromyography provided definitive evidence of myopathic alterations. Notably, a muscle biopsy further corroborated the diagnostic findings. In response to these diagnostic cues, the patient was expeditiously initiated on a therapeutic regimen encompassing corticosteroids, immunosuppressants, calcium channel blockers, and a tailored physical therapy program. This case underscores the pivotal significance of timely recognition and intervention for the treatment of dermatomyositis, thus mitigating the risk of long-term complications and enhancing the patient's overall quality of life. Moreover, it highlights the indispensability of interdisciplinary collaboration, uniting the expertise of dermatologists, rheumatologists, and neurologists, in navigating the intricacies of this intricate autoimmune disorder. We emphasize the pressing need for a comprehensive evaluation and an individualized therapeutic approach, thereby amplifying the prospects for superior patient outcomes and an improved quality of life.

Shrinking Lung Syndrome in a Systemic Lupus Erythematous Patient Improved by Rituximab: A Case Report With Literature Review

Shrinking lung syndrome (SLS) is a rare complication of autoimmune and connective tissue diseases like systemic lupus erythematosus (SLE). A 35-year-old female patient, diagnosed with SLE, came to the hospital complaining of severe dyspnea and pleuritic pain for several months that was worsening on exertion. Imaging (X-ray and CT scan) of the chest at the time of presentation showed bilateral basal atelectasis with elevated diaphragm. Pulmonary function test (PFT) showed restrictive findings including forced expiratory volume in the first second (FEV1) of 37%, total lung capacity of 40%, and vital capacity of 32% predicted with a restrictive pattern on flow volume loop confirming the diagnosis of SLS. The treatment focused on methotrexate and rituximab. Patients with a known history of SLE who start respiratory symptoms like cough and dyspnea should be ruled out of SLS at the earliest as it can be deadly in the later stages.

The Comorbidity of Endometriosis and Systemic Lupus Erythematosus: A Systematic Review

Autoimmune diseases manifest in genetically predisposed individuals exposed to certain triggers that aggravate immune dysfunction and result in an exacerbated immune response in the form of hyperactivity to both the humoral and cell-mediated response. The devastating reality apart from the severity of the disease is that multiple immune diseases could co-occur, increasing the patient's physical, psychological, and financial burden. Autoimmune diseases are utterly deranging. One of the dreadful autoimmune diseases is systemic lupus erythematosus (SLE). SLE is a rheumatological disease that affects multiple systems, and there are no predictors to know which system will be affected in the future. It could affect the mucocutaneous system. It could also present with hematological, rheumatological, neuronal, renal, pulmonary, and cardiac manifestations. SLE is prevalent in females, predominantly in the childbearing age group. The pharmacological therapy and bombarding pathophysiology of the disease lead to obstetrical and gynecological complications such as infertility, abortion, miscarriage, and stillbirth. Over the past decade, the autoimmune disease comorbidity increased eminently. One of the common associations is rheumatological diseases (like rheumatoid arthritis, Sjogren syndrome, and SLE) with gynecological diseases (e.g., endometriosis and uterine fibroids). SLE and endometriosis have strong associations, and the prevalence of each condition is relatively high among the female population. Endometriosis is a chronic disease triggered by inflammation, hormonal milieu, and other predisposing factors that lead to the fibrous tissue that lines the uterus (endometrial tissue) to be implanted at sites other than the uterus, commonly in the peritoneum and mesentery. The pathogenesis of this association remains unexplained. The approved theory is that their immune dysfunction is summarized by the elevated humoral and cell-mediated response, which leads to an attack to the epithelium, mesothelium, and Serosa and leads to fibrous tissue deposition in different sites other than the uterus. Statistical evaluations have shown a remarkable association between autoimmune diseases and both gynecological and nongynecological diseases.

Noninfectious Uveitis in Rheumatology: Patterns, Treatment, and Outcomes

OBJECTIVES

The present study aimed to determine the pattern and cause of noninfectious uveitis in rheumatology practice. The secondary objective was to identify the pattern of treatment and outcomes.

MATERIALS AND METHODS

This retrospective cross-sectional study was conducted in the Department of Rheumatology, National Hospital and Medical Centre, Lahore, Pakistan. After receiving consent, electronic medical records (EMRs) of all patients with a diagnosis of noninfectious uveitis (NIU) from November 2019 to January 2023 were reviewed, and a total of 52 patients labeled as having noninfectious uveitis were identified. The collected data included age at diagnosis, anatomical location of uveitis, associated systemic disease, used medications, and outcomes. All cases had been diagnosed and assessed mutually by a rheumatologist and an ophthalmologist using the International Uveitis Study Group classification system to classify the pattern of uveitis by location, clinical course, and laterality and rule out the possibility of other ophthalmologic diseases. Disease activity was defined using the Standardization of Uveitis Nomenclature (SUN) guidelines. Data was analyzed on SPSS Statistics version 23 (IBM Corp, Armonk, NY, USA).

RESULTS

The mean age of the patients in this study was 36.02 ± 43.31 years, with 31 (59.6%) male patients. Anterior uveitis was the most common type observed among the patients at 55.8%, panuveitis was found in 25%, intermediate uveitis and posterior uveitis were seen in 9.6% each. Based on laterality, unilateral eye involvement was identified in 53.8% of patients. Spondyloarthritis (SpA) and idiopathic uveitis were observed in 34.6% and 28.8%, respectively. In this study, 28 (54.9%) patients were on conventional disease-modifying antirheumatic drugs (cDMARDDs), and 23 (45.1%) were on biological DMARDs. In the biologics group, 82% of patients were in remission in comparison to 60% in the cDMARDs group.

CONCLUSION

To the best of our knowledge, this is the first report on noninfectious uveitis in the Pakistani population. The study concluded that anterior uveitis is the most common type of uveitis and is more common in males. Spondyloarthropathy is one of the most common underlying systemic diseases. Human leukocyte antigen (HLA)-B27 is associated more with uveitis. Biologics are more effective than cDMARDs in controlling the disease. Collaborative work between different specialties resulted in early diagnosis of underlying systemic disease, better management plans, and disease outcomes. To obtain further details on noninfectious uveitis, a population-based study is needed in Pakistan.

Association Between Vitamin D and Minor Salivary Gland Inflammation

Objective There has been increasing research regarding the effects of vitamin D on autoimmune disorders. There is some evidence of a correlation between vitamin D levels and sicca symptoms. We attempted to evaluate the correlation between vitamin D levels and inflammation of the minor salivary gland (MSG). Methods Data for 214 patients who had undergone MSG biopsy were reviewed. Eighteen patients with other autoimmune/neoplastic processes were excluded. Seventy-seven of 196 patients had serum Vitamin D levels available and were selected for this retrospective study. Demographic, clinical, and immunological features, extra-glandular manifestations, autoantibodies, and clinical laboratory tests were collected and compared between patient groups with a focus score (FS) of 0 and 1 or more. Results Out of 77, 29 patients had an FS of 0 while 48 had an FS of 1 or more. Mean vitamin D levels were noted to be lower in patients with an FS of 1 when compared to patients with an FS of 1 or more. Conclusion In this study, patients with an FS of 1 were noted to have low vitamin D levels but this association was not seen at a higher FS.

Lupus Nephritis Associated With Renal Cell Carcinoma

A 43-year-old man was found to have hematuria and proteinuria during a regular checkup. Workup revealed a renal mass on a CT scan. He continued to have worsening proteinuria and hematuria, with declining renal function, so a renal biopsy was performed, which revealed lupus nephritis class IV. He underwent partial nephrectomy, which confirmed the diagnosis of renal cell carcinoma on pathology. He was started on glucocorticoids, hydroxychloroquine, and cyclophosphamide for lupus nephritis.

The Role of Belimumab in Systemic Lupus Erythematosis: A Systematic Review

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease involving multiple systems with a range of clinical presentations caused by the production of antibodies, activation of complements, and deposition of immune complexes. The exact cause of SLE is still unknown. The effectiveness of traditional treatment methods for SLE is very little. Nowadays, resistance to conventional therapy, steroids, and immunosuppressants is common among SLE patients. Patients with refractory disease and nephritis generally have severe drug-induced toxicity which contributes to organ dysfunction, despite available therapies. Different biologic agents and therapeutic antibodies have become an alternative and have been under experiment in clinical trials, enrolling patients whose disease is inadequately controlled by conventional treatment. Belimumab is the only targeted therapy approved for SLE treatment. This systematic review discusses one such biological agent for treating systemic lupus erythematosus, namely, belimumab. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included randomized clinical trials (RCTs) from 2005 to 2021 on adult SLE. patients treated with monoclonal antibodies to assess the efficacy and safety. Methodological quality was assessed using PubMed, PMC, the Cochrane Risk of Bias tool, and the QUality In Prognosis Studies Tool (QUIPS) for RCTs. Two independent reviewers performed an electronic search on MEDLINE, Cochrane Library, SCIELO, Scopus, and ResearchGate. Based on a systematic review of articles we found that belimumab appears to be efficacious and generally well-tolerated in the treatment of SLE as compared to other drugs. The long-term use of belimumab combined with standard therapy showed a low incidence of organ damage. A lower incidence of organ damage was seen after initiating treatment in patients with a high risk for organ dysfunction. Patients who test for antinuclear antibody or anti-dsDNA-positive SLE, with moderate symptoms in the skin and musculoskeletal systems despite immunosuppressants, are treated with belimumab as an adjunct therapy. Patients with severe lupus nephritis or active CNS lupus cannot be treated with belimumab. Belimumab is effective in most races, as a clinical trial done in North-East Asia showed improvement in SLE symptoms and decreased dependence on prednisone. Belimumab also decreased disease activity and severe flares. Belimumab had greater efficacy in children.

Infective Endocarditis-Like Presentation of Felty Syndrome: A Case Report

Felty syndrome (FS) and infective endocarditis (IE) can present with similar signs and symptoms. FS is a diagnosis of exclusion, which poses a challenge for the clinician since accurate diagnosis is required to treat this condition effectively.

A 52-year-old woman with a 15-year history of rheumatoid arthritis (RA) was admitted due to dyspnea and pain in the right ankle and left arm for two weeks. She was hemodynamically stable and afebrile. Physical examination revealed right ankle swelling and tenderness, left forearm tenderness, abdominal distension, and swan-neck finger deformities. Laboratory tests were notable for pancytopenia with a white blood cell (WBC) count of 2900 × 10³/μL (absolute neutrophil count (ANC) of 1800/μL). Rheumatoid factor and anti-cyclic citrullinated peptide tests were positive. Synovial fluid analysis of the right ankle showed no crystals or bacteria, and a WBC count of 192 × 10³/μL. Left upper extremity computed tomography (CT) revealed two abscesses, in the forearm and elbow, respectively. CT chest and abdomen revealed a wedge-shaped consolidation in the left upper lobe, multiple bilateral pulmonary nodules, and splenomegaly. Abdominal ultrasonography showed portal hypertension with no clear findings of cirrhosis. Blood cultures were negative. Transthoracic echocardiography (TTE) and transesophageal echocardiography showed no vegetation. Incision and drainage were performed for the right ankle swelling, and left forearm and elbow abscesses. Left forearm abscess culture revealed Staphylococcus hemolyticus. Transbronchial needle aspiration and culture of the left upper lobe lesion showed acute and chronic inflammation with no signs of malignancy or microbial growth. Repeat TTE and blood cultures were negative. Bone marrow biopsy and flow cytometry showed no evidence of large granular lymphocytic (LGL) leukemia. The patient was diagnosed with FS complicated by disseminated infections and pulmonary necrobiotic nodules. Empiric ceftriaxone and vancomycin were initiated. The patient was discharged after the resolution of her symptoms.

FS is a rare extra-articular presentation of RA with a triad of a > 10-year history of RA, neutropenia (ANC < 2000/μL), and splenomegaly. IE can also present with disseminated infections and splenomegaly. Repeat TTE and blood cultures were performed due to concerns regarding the high mortality rate of IE and the possibility of false-negative echocardiography results. LGL leukemia also presents with RA and neutropenia, which was deemed less likely in our patient based on unremarkable bone marrow biopsy and flow cytometry results.

FS is a rare condition. Therefore, it is important to keep its possibility in mind in the setting of RA while performing workup for the most likely conditions.

Role of Direct Oral Anticoagulation Agents as Thromboprophylaxis in Antiphospholipid Syndrome

Antiphospholipid syndrome (APS) is an autoimmune disorder that causes venous, arterial and small-vessel thrombosis, pregnancy loss, and premature birth. Cardiac valvular disease, renal thrombotic microangiopathy, thrombocytopenia, hemolytic anemia, and cognitive impairment are some of its other clinical symptoms. Antiphospholipid antibodies cause endothelial cells, monocytes, and platelets to become activated, as well as an increase in tissue factor and thromboxane A2. Complement activation might play a key function in pathogenesis. Long-term oral anticoagulation is used to treat thrombosis, and individuals having arterial episodes should be treated quickly. Patients with systemic lupus erythematosus (SLE), as well as those with solely obstetric antiphospholipid syndrome, should get primary thromboprophylaxis. Obstetric care is based on a combination of medical and obstetric high-risk management, as well as aspirin and heparin therapy. Possible supplementary therapy for this condition is hydroxychloroquine. Statins, rituximab, and novel anticoagulant medicines are all potential future treatments for non-pregnant individuals with antiphospholipid syndrome. We aim to review the role of direct-acting oral anticoagulants (DOACs) as thromboprophylactic drugs in the treatment of APS in this article. The treatment of venous thromboembolism has been transformed by a new class of DOACs. These drugs, such as rivaroxaban, function by inhibiting factor Xa directly. Not only do they have known anticoagulant actions, but they also obviate the need for dosage monitoring and modification, in contrast to warfarin. We conducted an exhaustive literature search of PubMed/MEDLINE and Google Scholar Indexes using the keywords "Antiphospholipid syndrome," "thromboprophylaxis," and "oral anticoagulants" up to September 2021. We found that DOACs have been shown to be non-inferior to warfarin in a variety of anticoagulation situations in a number of high-powered clinical studies. In many hypercoagulable conditions such as APS, DOACs are quickly establishing themselves as first-line therapy. This article is focused on comprehensively reviewing the mechanism of action of DOACs, their role as thromboprophylactic drugs, risks and complications of DOACs, and comparing their efficacy with the standard treatment protocol and warfarin.

Recurrent Unprovoked Deep Vein Thromboses in the Setting of Sarcoidosis

Sarcoidosis is described as a state of immune-mediated chronic systemic inflammatory disease that is typically characterized by non-caseating granulomas. It involves multiple organs like the lungs, lymph nodes, eyes, skin, and liver. Besides the solid organ involvement, it is also known to be associated with various pro-thrombotic states leading to pulmonary embolism and deep vein thrombosis. Mechanical factors causing the venous stasis were considered the major contributing factors. However, based on recent studies, chronic inflammation from macrophages and activated leukocytes are also hypothesized to further activate thrombin and fibrin formation. Regardless of the etiology, the management focuses on life-long anticoagulation to prevent further episodes of thrombosis. Herein we present a case of a 38-year-old male with a history of sarcoidosis who was admitted after having recurrent deep vein thromboses. Further investigations revealed a negative hypercoagulable workup or other auto-immune processes and the absence of any granulomas causing mechanical compression on large vessel venous vasculature. He was adequately managed with anticoagulation therapy and followed up outpatient with no further similar episodes. This case adds to the growing understanding that the mechanisms by which sarcoidosis induces thromboembolism is primarily pro-inflammatory rather than mechanical in nature.

Impact of Change in Lifestyle and Exercise on Cognitive Function in Patients With Rheumatoid Arthritis: A Systematic Review

Rheumatoid arthritis (RA) is a chronic destructive type of arthritis. It has a high prevalence in females as compared to the male population globally. It mainly affects the synovium of peripheral joints and leads to the destruction of joints with time. Patients with RA usually have a high burden of inflammation which may lead to certain physical disabilities and debilitating effects on mental health and cognitive ability. The question we investigated here in this systematic review is how changing lifestyles and increasing exercise or physical activities affects one's cognitive abilities. This article adheres to preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. We used different databases such as PubMed, MEDLINE, and ScienceDirect to find relevant articles. To ensure the quality of the finally selected 12 studies, we followed different quality appraisal tools.  Based on our review, we found out that increasing physical activities and aerobic exercises positively increase overall well-being and decrease the inflammatory load, which will ultimately positively impact cognitive function in this subgroup of patients. We also discover certain key players affecting motivation, perception, and adherence to physical activities. We encourage future studies to be done on this topic to help in increasing quality of life and increasing independence in this group of patients. Counseling and addressing patient concerns are very important and keep disease activity well controlled so that physical activities become feasible.