Very Early Diagnosis of Systemic Sclerosis in Clinical Practice – Case Report and Review of the Literature

Systemic sclerosis (SSc) is a systemic autoimmune disease charac- terised by generalized microangiopathy and fibrosis of skin and internal organs. The 2013 American College of Rheumatology (ACR) / European League Against Rheumatism (EULAR) criteria have contributed considerably to classifying pa- tients with SSc in earlier stages, but they still lack sensitivity for a very early stage of the disease. Criteria for a very early diagnosis of SSc (VEDOSS) have been pro- posed by EULAR Scleroderma Trial and Research group (EUSTAR) which include three red flags: Raynaud’s phenomenon, puffy fingers and antinuclear antibody positivity, plus SSc specific antibodies positivity and/or abnormal nailfold capil- laroscopy. We report a case of a 54-year-old female patient with 6-week history of puffy fingers, Raynaud phenomenon and positive antinuclear antibodies. Further workup revealed early pathologic capillary pattern by nailfold capillaroscopy and positive anticentromere antibodies. Screening for internal organ involve- ment detected no heart, lung, or upper gastrointestinal tract involvement. The patient was started on pentoxifylline with further follow-up. The aim of the implementation of VEDOSS criteria is to diagnose SSc at the earli- est possible stage, so that subclinical internal organ involvement could be de- tected and appropriate treatment started at a potentially reversible stage

Ultrasound of the Diaphragm and Its Application in the Clinical Practice

Ultrazvuk dijafragme dijagnostička je metoda kojom se može utvrditi dijafragmalna disfunkcija ili paraliza. Dijafragmalna disfunkcija može uzrokovati otežano disanje i intoleranciju napora. Rijetko se utvrđuje u kliničkoj praksi te prava incidencija nije poznata. Javlja se u nekih neuromišićnih bolesti poput multiple skleroze, amiotrofične lateralne skleroze, poliomijelitisa, lezije N. phrenicusa te u nekih bolesti vezivnog tkiva, plućnim bolestima ili idiopatski. Za razliku od ranije upotrebljavanih metoda procjene dijafragmalne funkcije poput elektromiografije, mjerenja transdijafragmalnog tlaka i fluoroskopije, ultrazvuk je neinvazivna i jednostavna pretraga koja ne izlaže bolesnike ionizirajućem zračenju. Cilj je ovog rada opisati pregled dijafragme ultrazvučnom metodom te primjenu ultrazvuka u kliničkoj praksi uz pregled literature.Ultrasound of the diaphragm is a diagnostic method that can determine diaphragmatic dysfunction or paralysis. Diaphragmatic dysfunction can cause dyspnea and exercise intolerance. It is rarely diagnosed in clinical practice and its true incidence is unknown. It can occur in some neuromuscular diseases such as multiple sclerosis, amyotrophic lateral sclerosis, poliomyelitis, phrenic nerve lesions, and in some connective tissue diseases, lung diseases or it can be idiopathic. Unlike previously used diagnostic methods for assessing diaphragmatic function such as electromyography, transdiaphragmatic pressure measurement and fluoroscopy, ultrasound is a fast, non-invasive and simple examination, which does not expose patients to ionizing radiation. The aim of this review is to describe the examination of the diaphragm using the ultrasound method and its application in clinical practice along with a literature review

Lokulirani pneumotoraks u bolesnika s bolešću COVID-19 – prikaz slučaja

Aim: Loculated pneumothorax and multilocular cystic lung lesions are rare complications of acute respiratory distress syndrome in patients with COVID-19 infection. In this case report we wanted to emphasize that not only mechanically ventilated patients are at increased risk of pneumothorax and cystic lung lesions. Those lesions can also be found in non-ventilated patients. Case report: We present a case report of a 52-year-old man who was hospitalized because of COVID-19 pneumonia. MSCT pulmonary angiography revealed ground glass opacities, multilocular cystic lesions and loculated pneumothorax. On followup computerized tomography examination in an outpatient hospital two months later, there was a significant regression of the lung parenchymal ground glass opacities, as well as the regression of the cystic lesions with residual fluid-filled lesion in the oblique interlobar fissure. Conclusion: Only few case reports have been published on this specific lung pathology in COVID-19 disease. Increased incidence of complications such as pneumothorax in COVID-19 pneumonia is common, but physicians should also be aware of the possibility of other lung pathologies such as loculated pneumothorax and multilocular cystic lesions which can present not only in mechanically ventilated patients.Cilj: Lokulirani pneumotoraks i multilokularne cistične lezije pluća rijetke su komplikacije akutnog respiratornog distres sindroma u bolesnika s infekcijom COVID-19. U ovom prikazu slučaja željeli smo naglasiti kako nisu samo mehanički ventilirani pacijenti izloženi povećanom riziku pneumotoraksa te komplikacija potput nastanka cističnih lezija pluća, već se komplikacije mogu pojaviti i kod neventiliranih pacijenata. Prikaz slučaja: Prikazan je slučaj 52-godišnjaka koji je bio hospitaliziran zbog COVID upale pluća. MSCT plućnom angiografijom prikazale su se plućne lezije u vidu zrnatog stakla, multilokularne cistične lezije i lokulirani pneumotoraks. Na kontrolnom pregledu nakon dva mjeseca kompjutoriziranom tomografijom utvrđena je značajna regresija promjena plućnog parenhima po tipu zrnatog stakla te cističnih lezija s rezidualnom kolekcijom tekućine u interlobarnoj fisuri. Zaključak: Do sada je objavljeno samo nekoliko prikaza slučaja o ovoj specifičnoj plućnoj patologiji u pacijenata s COVID pneumonijom. Komplikacije poput pneumotoraksa kod mehanički ventiliranih bolesnika s COVID upalom pluća relativno su česte, no ovaj prikaz slučaja ukazuje na to da se komplikacije poput lokuliranog pneumotoraksa i multilokularnih cističnih lezija ne pojavljaju isključivo u pacijenata na mehaničkoj ventilaciji

Pathogenesis of Extraarticular Manifestations in Rheumatoid Arthritis—A Comprehensive Review

Rheumatoid arthritis (RA) is among the most prevalent and debilitating autoimmune inflammatory chronic diseases. Although it is primarily characterized by destructive peripheral arthritis, it is a systemic disease, and RA-related extraarticular manifestations (EAMs) can affect almost every organ, exhibit a multitude of clinical presentations, and can even be asymptomatic. Importantly, EAMs largely contribute to the quality of life and mortality of RA patients, particularly substantially increased risk of cardiovascular disease (CVD) which is the leading cause of death in RA patients. In spite of known risk factors related to EAM development, a more in-depth understanding of its pathophysiology is lacking. Improved knowledge of EAMs and their comparison to the pathogenesis of arthritis in RA could lead to a better understanding of RA inflammation overall and its initial phases. Taking into account that RA is a disorder that has many faces and that each person experiences it and responds to treatments differently, gaining a better understanding of the connections between the joint and extra-joint manifestations could help to create new treatments and improve the overall approach to the patient

A Combination of Ultrasound Characteristics with Macroscopic and Biochemical Features to Diagnose the Etiology of Lymphocytic Pleural Effusions

Objectives: The primary aim of this study was to improve the diagnosis of lymphocytic pleural effusions (LPEs) by combining their ultrasound characteristics with their macroscopic and biochemical features. Methods: This prospective, single-center, clinical observational study was conducted over a period of three years. The possible malignant etiology of LPEs was assessed using several diagnostic criteria: 1. ultrasound characteristics of the LPEs; 2. typical combinations of macroscopic and ultrasound features; and 3. the logistic regression method with three parameters—pleural nodularity, absence of fibrin, and serum protein concentration. Results: Eighty-four patients with LPEs were included in this study. Pleural nodularity (first criterion) was an ultrasound characteristic that yielded the best individual results (p < 0.001) in the differentiation of malignant and nonmalignant etiologies of LPEs (accuracy 73.81%). The combination of the second and third criteria yielded the best results in the prediction of a malignant etiology of LPEs (sensitivity 90.48%, specificity 83.33%, PPV 84.44%, NPV 89.74%, accuracy 86.90%). Based on the results of this prospective study, a protocol for the diagnostic procedure of lymphocytic pleural effusions without a definitive fluid diagnosis has been proposed. Conclusions: A combination of the ultrasound characteristics of LPEs and their macroscopic and biochemical features has improved the predictive accuracy for the malignant etiology of LPEs