Treatment of Vasculitis: Beyond the Basics

Vasculitis is the inflammation of blood vessels in the human body. It causes changes and remodeling in the walls of the vessels that include thickening, narrowing and scarring. As a result, the blood flow to the organs and tissues gets restricted leading to organ damage. The cause of primary vasculitis is not known; however, most cases are thought to be autoimmune. In the present era, it is getting difficult to treat vasculitis with conventional therapies, which includes cyclophosphamide, methotrexate, azathioprine and mycophenolate mofetil, with increasing rates of relapses. Since ever, corticosteroids and cytotoxic agents or immunosuppressants have been the mainstay for treating systemic vasculitis. However, the introduction of newer biological agents have bring about a revolution in the treatment of relapses and in cases where there is failure to induce and sustain remission

Visual and treatment outcomes of tubercular uveitis: a prospective case series from a referral hospital in Pakistan

Objective: Pakistan is the fifth highest TB burden country. Tuberculous uveitis (TbU) is a form of extrapulmonary TB, that is not uncommon in high burden country but very limited data is available on its outcome. The aim of the study is to assess the outcome of TbU with anti-tuberculous treatment (ATT). Results: A prospective study was conducted at Jinnah Medical College Hospital (JMCH) Karachi, Pakistan from July to December 2017. Patients with suspected TbU were started on standard ATT chemotherapy for 12 months. Their response was assessed via slit lamp examination and visual acuity at 1, 3, 6 and 12 months of treatment. Forty patients with probable TbU were treated with ATT, mean age was 36 ± 3 years and 24 (60%) were females. Around 26 (65%) had Monteux test of 15 mm or more. History of TB contact was positive in 24 (60%) and 12 (30%) had previous history of TB. All patients complained for blurring of vision and floaters. Posterior uveitis seen in 36 (90%) of patients. Complete response achieved in 32 (80%) after ATT while 6 (14%) had changed in inflammation and 2 (6%) had no benefit

Assessment of Clinical Outcomes in Patients Presenting with Transverse Myelitis: A Tertiary Care Experience from a Developing Country

Background: Transverse myelitis (TM) is an inflammatory disorder of spinal cord, characterized by acute or sub-acute dysfunction of spinal cord affecting the motor, sensory, and autonomic systems. It may be idiopathic or related to other diseases. Although some patients recover from TM with minor or no residual problems, others suffer permanent impairments that affect their ability to perform ordinary tasks of daily living. Our objective was to determine the frequency of different clinical outcomes in patients presenting with TM. Methods: It was a prospective cohort clinical study conducted from May 2018 till October 2018. Study was conducted in the Department of Neurology at Jinnah Medical College Hospital (JMCH), Karachi. In total 131 patients of TM were enrolled and treated as per standard protocol, and re-evaluated after eight weeks for assessment of clinical outcomes. Results: The average age of patients was 51.15 ± 6.56 years. Out of 131 cases, 36.6% of patients had full recovery and 63.4% had poor recovery while recurrence occurred in 66.7% cases. Urinary frequency was observed in 12.2% cases and incontinence in 6.9% cases. Conclusion: Acute TM has become transformed with recent developments, especially the advent of the MRI and the discovery of biomarkers

Clinical patterns of seronegative spondyloarthropathies in a tertiary centre in Pakistan

الملخص: أهداف البحث: لالتهاب الفقرات والمفاصل أنماط مختلفة في مناطق مختلفة من العالم. وتعتبر معرفة النمط الإقليمي مهمة للتشخيص الصحيح. تهدف هذه الدراسة لتقييم الأعراض والنمط السريري لالتهاب الفقرات والمفاصل بين شريحة المجتمع المنخفضة اقتصاديا واجتماعيا في الباكستان. طرق البحث: خلال الفترة من يوليو ٢٠١٦ إلى يونيو ٢٠١٧، تم إجراء دراسة ملاحظة سريرية في مستشفى تعليمي جامعي للرعاية الثالثة. وكانت العينة التي تم الاختيار منها ٥٠٠٠ شخص في البداية من عيادة الروماتيزم. وتم اختيار ١١٤ شخص وإدراجهم في هذه الدراسة على النحو المحدد في معايير الاشتمال. كما تم تسجيل جميع المتغيرات الديموغرافية وعمل الفحوصات السريرية الأساسية. وتم تجميع معلومات المريض بناء على المشاهدات الدارجة لالتهاب الفقرات والمفاصل. واستخدمت معايير تشخيص مجموعة الدراسة الأوروبية لالتهاب الفقرات والمفاصل لتشخيص وتصنيف المشاركين بالدراسة. النتائج: من بين ١١٤ حالة تم تشخيصها في هذه الدراسة، ضمت الدراسة ٣٦٪ (٤١) من الإناث و٦٤٪ (٧٣) من الذكور. وكان متوسط العمر للمرضى بين ٢٥-٦٥ عاما. وكان الذكور أكثر تضررا بمرتين تقريبا عن الإناث بمعدل ٢: ١.٤. وكان الذكور في العمر ٣٠-٦٠ عاما الأكثر ضررا. وكانت الأنواع الفرعية الأكثر تشخيصا في كثير من الأحيان التهاب الفقار اللاصق، والتهاب المفاصل التفاعلي والتهاب المفاصل الصدفي. وكانت أكثر الأعراض انتشارا هي التهاب المفصل العجزي الحرقفي، وألم التهاب العمود الفقري والتهاب المفصل الزليلي. الاستنتاجات: وجدت الدراسة الهيمنة الذكورية لالتهاب الفقرات والمفاصل، ومن بين جميع المرضى الذين شملتهم هذه الدراسة؛ تم تشخيص التهاب الفقار اللاصق، والتهاب المفاصل الصدفي والتهاب المفاصل التفاعلي مع الأنواع الفرعية السائدة -لالتهاب الفقرات والمفاصل. Abstract: Objectives: The patterns of spondyloarthropathies (SpA) differ across regions globally, and an understanding of these patterns is important for the correct diagnosis of this condition. The aim of this study was to evaluate the presenting symptoms and clinical patterns of SpA in a community of low socioeconomic status in Pakistan. Methods: This clinical observational study was conducted in a tertiary care teaching hospital from July 2016 to June 2017. Five thousand patients were initially recruited in the rheumatology clinic. A total of 114 patients were finally selected and enrolled in this study, as defined by the inclusion criteria. All demographic variables were recorded and baseline clinical investigations were performed. The European Spondyloarthropathy Study Group (ESSG) diagnostic criteria were used to diagnose the condition and classify the study participants. Results: Of the 114 patients, 64% (73 patients) were men and 36% (41 patients) were women. The mean age of the patients ranged 25–65 years. The men were affected twice as much as women with a ratio of 2:1.4. Men in the age group of 30–60 years constituted a large proportion of the study population. The most frequently diagnosed subtypes were ankylosing spondylitis, reactive arthritis, and psoriatic arthritis. The most common presenting symptoms were sacroiliitis, inflammatory spinal pain, and synovitis. Conclusion: Males had a higher prevalence of SpA. Ankylosing spondylitis, psoriatic arthritis, and reactive arthritis were the most commonly diagnosed subtypes. الكلمات المفتاحية: التهاب الفقرات والمفاصل, التهاب المفاصل الروماتويدي, التهاب المفاصل الصدفي, التهاب الفقار اللاصق, التهاب المفاصل التفاعلي, Keywords: Ankylosing spondylitis, Psoriatic arthritis, Reactive arthritis, Rheumatoid arthritis, Spondyloarthropathie

COVID-19: An Emerging Culprit of Inflammatory Arthritis

Arthralgia is one of the most common symptoms that occur in patients with COVID-19. About 15% of patients present with arthralgia at some point. Although COVID-19 seems to attack the musculoskeletal system (muscles and joints) in its infective and postinfective stage causing inflammatory arthritis, not much is known about the rheumatic manifestations of this infection. In this case series of 5 patients, we discuss the occurrence of bilaterally symmetrical polyarthritis in patients, previously free from any rheumatic disease, after encountering COVID-19 infection. The musculoskeletal manifestations in these patients phenotypically resembled rheumatoid arthritis. These patients were treated successfully with low-dose glucocorticoids and disease-modifying antirheumatic drugs (DMARDs)

Redundancy Is of No Good; Iatrogenic Hypervitaminosis D: A Rare Case of Persistent Vomiting Due to Hypercalcemia

Introduction: Iatrogenic or physician-induced hypervitaminosis D is a rare cause of persistent vomiting. To the best of our knowledge, this is the first case report on iatrogenic hypervitaminosis D presenting with persistent vomiting in Pakistan. Case Report: We report a rare case of continual vomiting for 15 days in a 48-year-old woman of Pakistani descent. She was a known case of diabetes mellitus for 8 years, which was well controlled at the time of presentation. Conclusions: The correct diagnosis of our patient was based on clinical suspicion, appropriate lab tests, and deliberation of the differential diagnosis. It is important to consider hypervitaminosis D as a cause of persistent vomiting if no other obvious is apparent

Dry eye disease and high disease activity score (DAS-28) in rheumatoid arthritis: an underrated combination

Objective: To determine the association of dryness of eyes with rheumatoid arthritis severity. Method: The cross-sectional, observational study was conducted at the Jinnah Medical College Hospital, Karachi, from December 2020 to May 2021, and comprised adult patients of either gender with rheumatoid arthritis who were diagnosed on the basis of clinical and serological investigations. Data was collected using a structured pre-tested questionnaire. Ocular Surface Disease Index questionnaires with Tear Film Breakup Time were used to assess the severity of dry eyes. Disease Activity Score-28 with erythrocyte sedimentation rate was used to assess the severity of rheumatoid arthritis. Association between the two was explored. Data was analysed using SPSS 22. Results: Of the 61 patients, 52(85.2%) were females and 9(14.8%) were males. The overall mean age was 41.7±12.8 years, with 4(6.6%) aged 60years. Further, 46(75.4%) subjects had sero-positive rheumatoid arthritis, 25(41%) had high severity, 30(49.2%) had severe Occular Surface Density Index score and 36(59%) had decreased Tear Film Breakup Time. Logistic Regression analysis showed there were 5.45 times higher odds of having severe disease among the people with Occular Surface Density Index score >33 (p=0.003). In patients with positive Tear Film Breakup Time, there were 6.25 higher odds of having increased disease activity score (p=0.001). Conclusion: Disease activity scores of rheumatoid arthritis were found to have strong association with dryness of eyes, high Ocular Surface Disease Index score and increased erythrocyte sedimentation rate. Key Words: Rheumatoid arthritis, Tear film breakup time, Disease activity score-28, Dry eye, Ocular surface disease index

Scleromalacia perforans: a case report

Abstract Background Scleromalacia perforans is a rare ocular manifestation of rheumatoid arthritis which can potentially lead to blindness and is a late consequence in the course of the disease. It is an unusual finding for it to be present in a patient with joint pain without any rheumatologic progression of disease. Case presentation We describe a rare case of scleromalacia perforans and orbital inflammatory disease in a 40-year-old Pakistani woman with apparently no associated rheumatologic deformity. It is rare in the sense that we usually see scleromalacia perforans with fixed deformities of rheumatoid arthritis in the hands or progressed systemic complications but not as a starting landmark of disease. She presented to us with pronounced eye manifestation which on further inquiry and investigation was found to be associated with rheumatoid arthritis. There was perforation of left globe on presentation and the right one was preserved. She visited various physicians and ophthalmologists and was treated with topical and systemic antibiotics but ended up losing sight in her left eye. Conclusion We conclude that ocular manifestations, however rare they are, should be foreseen, investigated, and treated in patients with suspected arthritis as the complication is grave and sight threatening