Fifty-Two-Week Results of Clinical and Imaging Assessments of a Patient with Rheumatoid Arthritis Complicated by Systemic Sclerosis with Interstitial Pneumonia and Type 1 Diabetes despite Multiple Disease-Modifying Antirheumatic Drug Therapy That Was Successfully Treated with Baricitinib: A Novel Case ReportRead the full article
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Lupus Pneumonitis Therapy Masks Coronavirus (COVID-19)
Introduction. Coronavirus pneumonitis can mimic, or present as, lupus pneumonitis. Lupus may cause inflammation of the myocardium. Lupus pneumonitis high-dose steroid therapy may mask coronavirus (COVID-19). Case Study. The patient is a 65 y/o Hispanic female with lupus pneumonitis complicated by COVID-19. Her diagnosis was confirmed by a renal biopsy. She had nephritic and nephrotic syndrome. She was hospitalized a month earlier with shortness of breath with pulmonary infiltrates and was treated with steroids. The symptoms resolved quickly with shrinking consolidations and infiltrates. The patient returned to the office for shortness of breath with a presumptive diagnosis of recurrent lupus pneumonitis from steroid taper. The patient had a CT scan of the chest that revealed upper lobe interstitial and peripheral infiltrates. The radiologist felt that this was suspicious for coronavirus pneumonitis, and the patient was placed in isolation and continued therapy for lupus pneumonitis. She deteriorated, became hypoxic, and ventilated. Conclusion. All lupus pneumonitis patients, in fact all lupus patients in general (personal experience), on high-dose steroid therapy should be tested for COVID-19 to ensure proper diagnosis and therapy planning.
Inflammatory Arthritis following Hepatitis B Vaccination in an Infant
Inflammatory arthritis in children may be idiopathic in nature or may be due to or follow infections. Rare reports identify inflammatory arthritis temporally related to vaccination in children. Herein, we describe the first reported case of an infant who developed inflammatory arthritis following hepatitis B vaccination. A 10-day-old female presented for evaluation of decreased movement of the right lower extremity and right knee swelling. Of note, the patient received a hepatitis B vaccine in her right thigh at birth. A workup found the patient to have a negative ANA but the presence of HLA B27. Findings resolved using ibuprofen. A literature review identified reports of what has been termed “reactive arthritis” in adult patients following the hepatitis B vaccine, frequently in association with HLA B27. No prior pediatric cases have been published. Healthcare providers must be aware of the rare development of postvaccination inflammatory arthritis.
Improvement of Chronic Rhinosinusitis and Reduction of the Myeloperoxidase-Antineutrophil Cytoplasmic Antibody Titer in a Patient with Eosinophilic Granulomatosis with Polyangiitis by Additional Mepolizumab
A case of eosinophilic granulomatosis with polyangiitis (EGPA) in which chronic rhinosinusitis (CRS) was improved with a reduction in the myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) titer after the addition of mepolizumab is reported. A 55-year-old woman with EGPA receiving prednisolone 5 mg/day developed CRS with increases in the eosinophil count and the MPO-ANCA titer. Although it improved with prednisolone 15 mg/day in addition to mizoribine 150 mg/day, because azathioprine could not be taken orally due to side effects, it relapsed after prednisolone was tapered to 5 mg/day. There was no exacerbation of other vasculitis symptoms such as mononeuropathy multiplex. The patient was treated with additional mepolizumab 300 mg every 4 weeks, which resulted in the improvement of CRS and marked reductions of the eosinophil count and MPO-ANCA titer, and the reduction of prednisolone to 2 mg/day. Furthermore, even after tapering mepolizumab to 200 mg every 4 weeks, her condition remained stable without relapse of EGPA and without increases in the eosinophil count and MPO-ANCA titer. The clinical course of mepolizumab treatment in this patient suggests that the IL5-dependent inflammatory cascade is one of the factors contributing to the increase in MPO-ANCA in EGPA.
From Neck Pain to Sarcoidosis: The Interesting Association
We report the case of a 31-year-old male patient, presenting to the emergency department (ED) with a 6-week history of left-sided lateral neck pain, along with a minor localized swelling. A few weeks after the beginning of his complaints, he contracted a mild coronavirus disease 2019 (COVID-19). Upon examination, his aches were defined as carotidynia; thus, proper radiologic evaluation was carried out. While ultrasound (US) and magnetic resonance imaging (MRI) scans showed evident signs of left common carotid (LCC) vasculitis, computed tomography angiography (CTA) and positron emission tomography-CT (PET-CT) scans revealed no vascular findings. Unexpected hypermetabolic hilar and mediastinal lymphadenopathy was found on PET-CT, necessitating lymph node biopsy. Pathology results displayed noncaseating granulomas. Besides, angiotensin-converting enzyme (ACE) levels in blood were high. Sarcoidosis, with concurrent LCC vasculitis, was diagnosed, and corticosteroid therapy was started. Shortly thereafter, remarkable recovery ensued.
Atypical Sjögrenʼs Syndrome Initially Presenting as Lymphocytic Interstitial Pneumonitis followed by Immune Thrombocytopenia
Background. Sjögrenʼs syndrome is an autoimmune disease characterized primarily by decreased exocrine gland function leading to eye and mouth dryness. Extraglandular manifestations occur less frequently. Case Report. A 74-year-old man with hypertension was admitted with productive cough and fever. On physical examination, he had bilateral lower lung decreased breath sounds. A chest radiograph showed bibasilar patchy infiltrate. Laboratory studies revealed hemoglobin of 11.9 g/dL, white blood cell count of 16,000/uL, and platelet count of 250,000/uL. Empiric antibiotic therapy was begun for suspected community acquired pneumonia, and then he was discharged home. However, his cough recurred. Chest computed tomography demonstrated adenopathy throughout the mediastinum and multiple ill-defined patchy groundglass opacities with a lower lobe prominence. He underwent a transbronchial biopsy to rule out malignancy; however, it showed lymphocytic interstitial pneumonitis. Antinuclear antibody was 1 : 80 homogeneous, and anti-SSA antibody was 6.3 AI (normal <1.0 AI). The patient was treated with prednisone 20 mg/day with marked improvement in his symptoms. Repeat chest computed tomography showed decreased groundglass opacities and decreased mediastinal lymph nodes. After more than a year, he was readmitted due to petechiae on his buccal mucosa and a platelet count of 2000/μL. The patient was started on prednisone 80 mg/d and intravenous immunoglobulin 80 g/d for 2 consecutive days. The platelet count eventually increased to 244,000/μL. Conclusion. We report a rare presentation of Sjogrenʼs syndrome manifesting as acute lymphocytic interstitial pneumonitis and followed by immune thrombocytopenia. Both extraglandular manifestations responded well to corticosteroid therapy.
Winning the Battle after Three Years of Suffering: A Case of a Refractory Pyoderma Gangrenosum Treatment Challenge
Pyoderma gangrenosum is an uncommon inflammatory disorder characterized by neutrophilic infiltration of the skin. It can present as skin papules or pustules that progress into painful ulcers. 30–40% of the cases are associated with other systemic diseases such as inflammatory bowel diseases, rheumatoid arthritis, and proliferative hematological disorders. Uniquely, this condition has been associated with systemic lupus erythematosus (SLE). The rarity of this disorder poses a diagnostic and therapeutic challenge. We present a case of a 55-year-old female with a history of SLE and chronic right leg ulcer, presented with increased pain from the ulcer associated with a mild flare of her cutaneous lupus; examination revealed circumferential skin ulcer measuring about 25 cm extending around the right leg above the ankle with prominent fibrinous material and surrounding erythema. Blood work showed elevated WBC with neutrophilic predominance. Serology revealed a positive ANA, elevated RNP, smith, and SSA/Ro antibodies with normal anti-CCP level. Skin biopsy was taken, and it showed a diffuse neutrophilic and lymphocytic infiltrate consistent with the diagnosis of pyoderma gangrenosum. The patient was then treated with topical and systemic steroids and sequentially with dapsone, methotrexate, mycophenolate, and cyclosporine for over a two-year period but failed to show any improvement. Therefore, a trial of intravenous immunoglobulin (IVIG) therapy was attempted and produced a dramatic response after two-month infusions characterized by shrinking in the size of the ulcer and resolving pain. We believe that refractory PG poses a therapeutic challenge, and despite a lack of specific guidelines, IVIG can be attempted if initial suppressive treatment fails to show signs of improvement.