Clinical Course of Patients with Rheumatoid Arthritis Who Continue or Discontinue Biologic Therapy After Hospitalization for Infection: A Retrospective Observational Study

Background: To analyse the subsequent clinical course of patients with rheumatoid arthritis (RA) who either continued or discontinued biologic agents after hospitalization for infections. Methods: We retrospectively reviewed the clinical records of 230 RA patients with 307 hospitalizations for infections under biologic therapy between September 2008 and May 2014 in 15 institutions for up to 18 months after discharge. The risks of RA flares and subsequent hospitalizations for infections from 61 days to 18 months after discharge were evaluated. Results: Survival analyses indicated that patients who continued biologic therapy had a significantly lower risk of RA flares (31.4% vs. 60.6%, P < 0.01), and a slightly lower risk of subsequent infections (28.7% vs. 34.5%, P = 0.37). Multivariate analysis showed that discontinuation of biologic therapy, diabetes, and a history of hospitalization for infection under biologic therapy were associated with RA flares. Oral steroid therapy equivalent to prednisolone 5 mg/day or more and chronic renal dysfunction were independent risk factors for subsequent hospitalizations for infections. Conclusions: Discontinuation of biologic therapy after hospitalization for infections may result in RA flares. Continuation of biologic therapy is preferable, particularly in patients without immunodeficiency.

The effects of oral steroid therapy on prolidase enzyme activity in patients with nasal polyps

Objective To compare prolidase enzyme activity (PEA) in serum and polyp specimens of patients with nasal polyps obtained before and after the oral steroid therapy. Materials and methods Thirty three patients with nasal polyps (39 ± 13 years) received 1 mg/kg of oral steroids. Serum samples were collected from each patient, but nasal polyp specimens could be obtained only from 23 patients (38 ± 13 years) before and after the oral steroid therapy. PEA was measured by ELISA method. Results Serum PEA values were 210 (176–242) U/L and 184 (147–217) U/L before and after the oral steroid therapy, respectively (p = 0.015). Polyp tissue PEA was 1337 (738–2130) U/g and 871 (590–1663) U/g before and after the oral steroid therapy, respectively (p = 0.429). Conclusion In patients with nasal polyps, significantly lower serum PEA after the oral steroid therapy may be a consequence of the role of prolidase enzyme in inflammatory processes which are important for the development of nasal polyps. More comprehensive studies with larger sample sizes are needed to elucidate the role of PEA in the pathogenesis of nasal polyps.

Clarification of Eosinophilic Esophagitis Treatment in the DoD Retention Standards

ABSTRACT The DoD Instruction 6130.03, Volume 2, outlines the retention standards for the U.S. Military, providing guidance on medical conditions and treatments that are disqualifying for all branches of the military. This document states that patients with conditions requiring immunomodulating or immunosuppressant medications do not meet retention standards. Eosinophilic esophagitis is a common, chronic inflammatory disease of the esophagus that typically presents with dysphagia. Although proton pump inhibitors are effective at treating this disease in some cases, swallowed topical steroids are the most frequently used therapy within the DoD. These medications act locally in the esophagus and do not cause systemic side effects typical of oral steroid therapy, including immunosuppression. They are effective at inducing and maintaining disease remission and are generally well tolerated, with minimal side effects. We propose a brief amendment to this document to clarify the language used and avoid inappropriate Medical Evaluation Board referrals.

Purpuric Skin Rash in a Patient Undergoing Pfizer-BioNTech COVID-19 Vaccination: Histological Evaluation and Perspectives

The COVID-19 pandemic has affected the entire planet, and within about a year and a half, has led to 174,502,686 confirmed cases of COVID-19 worldwide, with 3,770,361 deaths. Although it is now clear that SARS-CoV-2 can affect various different organs, including the lungs, brain, skin, vessels, placenta and others, less is yet known about adverse reactions from vaccines, although more and more reports are starting to emerge. Among the adverse events, we focused particularly on skin rashes. In this short report, we describe the case of a patient vaccinated with Comirnaty, who developed a purpuric rash resistant to oral steroid therapy after 2 weeks. To date, this is one of the very few cases in which skin biopsy was performed to better characterize the histopathological picture of this rash. Finally, we conduct a literature review of the cases of rashes from SARS-CoV-2 vaccines described in the literature, with the aim of laying foundations for future, larger case studies.

Interessamento genitale della porpora di Schönlein-Henoch

Henoch-Schönlein purpura (HSP) is a paediatric vasculitis, affecting several organs. Purpura is typically found on posterior surface of lower limbs and is more often associated with joint, abdominal and kidney involvement. The paper reports a case of HSP with mild cutaneous and abdominal manifestations, with genital involvement (haemorrhagic oedema of the penis that is more rarely described in literature), which was treated with oral steroid therapy that led to an optimal clinical response.

Focal vasculitic myositis as a primary manifestation of Behçet’s disease: a case series of 10 Korean patients in a locomotive medicine clinic

Objectives Muscle involvement in Behçet’s disease (BD) is rare, and several cases have been reported in the literature. Therefore, this study aimed to describe the clinical, laboratory and imaging findings in adult patients presenting with BD-associated myositis before the diagnosis of BD. Methods We retrospectively screened patients who visited a locomotive medicine clinic presenting with myalgia, local swelling, or tenderness of extremities without an established diagnosis of BD. We enrolled patients whose pain in the extremities was proven to be suggestive of focal vasculitic myositis and who were eventually diagnosed as having BD at the initial visit or during follow-up. We thoroughly reviewed the clinical, histological and imaging findings and treatment outcomes in patients who presented with focal vasculitic myositis as the primary manifestation of BD. Results Ten adult patients with focal vasculitic myositis as the primary manifestation of BD were enrolled. The lower and upper extremities were affected in eight and two patients, respectively. The affected lower extremities were the calf (n = 6) and thigh muscles (n = 2). The common findings of MRI included high signal intensity of the affected muscles and intermuscular fascia on fat-suppressed images, suggestive of myofascitis and oedematous changes in the subcutaneous layer. The results of skin or muscle biopsy were suggestive of vasculitis. All the patients were pain-free at the short-term follow-up (1–3 weeks) after oral steroid therapy. Conclusion Focal vasculitic myositis can be a primary manifestation of BD warranting medical attention. BD-associated myositis responds well to oral steroid therapy.

Update on Clinical Manifestation in Acute Low-Tone Hearing Loss

Background and Objectives Acute low-tone hearing loss (ALHL) is gaining attention as an independent disease identity with close association with endolymphatic hydrops and early stage Meniere’s disease (MD). This study aims to compare patients of ALHL with patients exhibiting low-tone hearing loss and ear fullness without vertigo in various audio-vestibular assessments and in progression to overt MD.Subjects and Method A total of 249 patients with low-tone hearing loss with ear fullness without vertigo was enrolled in this study. Of these patients, 58 patients met criteria for ALHL, which was defined as having an average hearing loss of ≥30 dB at 125, 250, and 500 Hz and ≤20 dB at 2, 4, and 8 kHz. Demographics, electrocochleography (ECoG) abnormality, rate of hearing improvement, vestibular functions, and progression to MD were analyzed.Results An average low-tone hearing loss of ALHL patients was 42.8 dB, which recovered to 18.9 dB following a combined treatment of diuretics and oral steroid therapy. The hearing recovery rate of this group was 87.9% and the ECoG abnormality ratio was 42.5%. Also, 15.5% of ALHL patients eventually progressed to MD.Conclusion This study described demographics and characteristics of ALHL, demonstrating a successful response to the combined treatment of diuretics and oral steroid. Also, this report demonstrated a close relationship between the degree of low-tone hearing loss and ECoG abnormality and observed the progression to MD in ALHL patients. These data can be usefully applied in clinical setting to explain clinical outcomes of ALHL.

Differential response to biologics in a patient with severe asthma and ABPA: a role for dupilumab?

Background Allergic bronchopulmonary aspergillosis (ABPA) is a severe hypersensitivity reaction to aspergillus species colonizing the airways of patients with asthma or cystic fibrosis. Biologics including anti-IgE and anti-IL5 antibodies have strongly changed the treatment of severe asthmatics and have partly been reported to be effective in the treatment of ABPA. Recently, dupilumab, an anti-IL4-Rα antibody which inhibits signaling by the Th2-cytokines IL4 and IL13, has been approved for the treatment of severe asthma. Case presentation Here, we report the case of a 49-year-old woman with severe asthma and ABPA, who was uncontrolled despite maximum inhalative therapy, anti-IL5-Rα antibody and continuous oral steroid therapy. Moreover, trials of itraconazole as well as omalizumab showed insufficient efficacy. Lung function revealed peripheral obstruction. FeNO and IgE were increased, eosinophils were suppressed under treatment while marked increases had been documented previously. Switching to dupilumab led to a complete resolution of pulmonary symptoms, resolution of exacerbations and complete withdrawal of oral steroids. A drastic improvement in lung function was noted, with an increase in FEV1 of almost 1 l. FeNO was normalized and IgE strongly reduced. Conclusion Our case highlights that a patient may exhibit differential treatment responses to the currently available asthma biologics and suggests switching treatment if outcome is insufficient. A potential role for dupilumab in the treatment of ABPA warrants future studies.

The dreaded osteonecrosis of femur following chronic steroid therapy: a case series from a dermatologist’s eye

<p>Corticosteroids, undoubtedly, is the saving grace of many patients ailing from a variety of inflammatory and autoimmune dermatoses. But it is not free of side effects, some being crippling enough to subject the patient to huge amounts of morbidity. Here we report a series of cases – Vesiculobullous diseases and Lupus Erythematosus - with prolonged oral steroid therapy that lead to osteopenia and osteonecrosis of the femur.</p>