Mohamed Osama Hegazi

Effective control of polymyalgia rheumatica with tocilizumab.

AbstractDespite their disadvantages, glucocorticoids (GCs) remain a mainstay of therapy for polymyalgia rheumatica (PMR). Second-line antirheumatic and immune-modulatory drugs are not infrequently required because of disease relapses during GC tapering and GC adverse effects. Therapy with methotrexate or with an anti–tumor necrosis factor drug showed modest efficacy in this situation. Tocilizumab (TCZ) is an anti–interleukin 6 receptor antibody that is being recently studied in the treatment of PMR patients who are intolerant or refractory to GCs, especially after failure of a second-line agent. We report a case of PMR in which GCs were stopped because of adverse effects despite good response. The condition responded to neither methotrexate nor etanercept. Treatment with TCZ has led to significant improvement of the patient’s clinical and biochemical PMR activity parameters, and she was kept in a solid remission for 1 year without any TCZ-related adverse effects. Tocilizumab is a promising drug in the management of PMR. Further studies are required to clearly define the indications and duration of TCZ therapy in the management of PMR.

Pulmonary hypertension responding to hyperthyroidism treatment

Abstract:  Pulmonary hypertension in adults with hyperthyroidism is increasingly being reported. Although the mechanism is uncertain, the reversal of pulmonary hypertension following restoration to an euthyroid state supports a causal relationship. This case report is of a 43‐year‐old woman who presented with Graves disease and right ventricular failure. Echocardiography showed severe pulmonary hypertension, moderate to severe tricuspid regurgitation, normal left heart function and a negative bubble contrast study. Carbimazole therapy was instituted along with diuretics and captopril. The patient was followed for a period of 14 months. Clinical and biochemical euthyroidism was attained after 4 months of treatment. Resolution of right ventricular failure and normalization of pulmonary artery pressure occurred 11 and 14 months after initiation of therapy, respectively. Investigating thyroid status in patients with pulmonary hypertension is recommended. In patients with hyperthyroidism and (otherwise unexplained) pulmonary hypertension, restoration of euthyroidism may cure right ventricular failure and restore normal pulmonary artery pressure.

Mycophenolate mofetil as a maintenance therapy for lupus-related diffuse alveolar hemorrhage: a case report.

Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of systemic lupus erythematosus (SLE). Cases complicated with DAH often have active SLE with multi-organ involvement, especially lupus nephritis. We describe a rare case of DAH as the first presenting manifestation of SLE in the absence of lupus nephritis. Remission was induced by IV methylprednisolone, IV cyclophosphamide, and plasmapheresis. Further cycles of cyclophosphamide were prevented by recurrent infections. Maintenance of remission was successfully achieved with oral mycophenolate mofetil 1 g twice daily, with a good control of SLE and without further DAH episodes.

Anticoagulation for cerebral venous thrombosis with subarachnoid hemorrhage: a case report.

Objectives: To report the success of anticoagulation (AC) treatment in a case of cerebral venous thrombosis (CVT) with subarachnoid hemorrhage (SAH) in view of the limited evidence seen in the literature supporting such a treatment option. Clinical Presentation and Intervention: A 38-year-old lady with CVT and SAH presented 12 h after the onset of symptoms. AC with low-molecular-weight heparin was started 4 days later, when the repeated brain CT showed regression of the SAH. Heparin was changed to warfarin, and she was asymptomatic over a 12-month follow-up period. Discussion: In a limited number of small studies, AC has been found to be beneficial for cases of CVT with hemorrhagic complications. The proper time to start AC in such cases was not clearly defined, and a delay of 4–33 days was observed after the onset of symptoms. In cases of spontaneous intracranial hemorrhage (ICH) in general, active bleeding is usually confined to the first 6 h, and chances of hematoma enlargement are higher in the first 24 h. On the other hand, it has been advised to rule out a coincidental vascular malformation and to radiologically confirm regression (or at least non-progression) of the ICH before starting AC. Conclusion: AC for cases of CVT may remain beneficial in the presence of SAH. The time to start AC for CVT with hemorrhagic complications is unclear; however, AC was successful when given 4 days after the onset of symptoms in our case. It may be wise to repeat CT after at least 24 h from the onset of symptoms (to confirm regression or at least non-progression of the ICH) before starting AC. It may also be prudent to perform magnetic resonance angiography, or digital subtraction angiography to rule out a coincidental intracranial aneurysm before AC.

Central Pontine Myelinolysis in the Hyperosmolar Hyperglycaemic State

Objective: To report a rare association of central pontine myelinolysis (CPM) with hyperosmolar hyperglycaemic state (HHS). Clinical Presentation and Intervention: A diabetic female presented with HHS and prolonged severe hypernatraemia. The metabolic derangement was adequately treated with proper correction of both hyperglycaemia and hypernatraemia. Lack of improvement in the presenting confusional state and the development of a fresh neurological deterioration led to the suspicion of CPM that was confirmed with magnetic resonance imaging. She fully recovered after 4 weeks with no specific medical treatment. Conclusion: This case report showed that osmotic demyelination was linked to hypernatraemia and that CPM could result from severe hypernatraemia of HHS.

Can a change in policy reduce emergency hospital admissions? Effect of admission avoidance team, guideline implementation and maximising the observation unit.

Background: Reduction in admissions is an important aim of emergency department working policy to overcome the problems of a shortage of inpatient beds, overcrowding, rising costs and exhausted resources. A new policy was instituted in the emergency department of a hospital in Kuwait with the following components: (1) an admission avoidance team of emergency department doctors; (2) implementation of disease management guidelines; and (3) maximising the use of an emergency department observation unit. Methods: The effects of this policy on reduction in admission rates for total medical admissions and for chest pain, bronchial asthma, heart failure, pneumonia and pyelonephritis as selected samples of common medical conditions were prospectively studied over a period of 3 years from institution of the policy and compared with the 3-year period before the policy was instituted. Results: There was a significant reduction in admission rates after institution of the new policy, with a relative reduction of 35.9% for total medical admissions, 52.7% for chest pain, 49.2% for bronchial asthma, 34.7% for heart failure, 59.1% for pneumonia and 43.3% for pyelonephritis compared with the period before the policy was instituted. Conclusion: A multidisciplinary emergency department policy, using as much available evidence as possible, was successful in significantly reducing medical hospital admissions in spite of the rising numbers of patients visiting the emergency department and observation unit.

Hypothermia with pneumonia: a rare presentation of brucellosis.

Objective: To report a very rare form of brucellosis presenting with hypothermia and pneumonia. Clinical Presentation and Intervention: A 41-year-old male shepherd presented with a depressed level of consciousness. Clinically, his rectal temperature was 29.5°C, and he was cold, apathetic, hyporeflexic, and hypotensive, with atrial fibrillation. He had clinical and radiological evidence of bilateral bronchopneumonia. Blood culture and serologic testing were positive for Brucella melitensis. The patient recovered completely after proper management of the hypothermia and treatment of the brucellosis with antibiotics (doxycycline 100 mg orally twice daily for 6 weeks and streptomycin 1 g i.m. daily for 21 days). Conclusion: This case shows that brucellosis should be considered in the differential diagnosis of septicemic patients presenting with hypothermia.

Synovitis with pitting edema as the presenting manifestation of systemic lupus erythematosus

Rheumatologists are increasingly aware of the entity synovitis with pitting edema. The remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome has been reported with an array of conditions that include polymyalgia rheumatica, rheumatoid arthritis, Sjögren’s syndrome and psoriatic arthropathy. Synovitis with pitting edema is now being increasingly recognized with systemic lupus erythematosus (SLE). We report a patient who presented with edema of hands and feet and was diagnosed eventually with definite SLE. With magnetic resonance imaging, joint effusions and tenosynovitis were confirmed to be associated with the otherwise-unexplained extremity edema.

Junctional bradycardia with verapamil in renal failure – care required even with mild hyperkalaemia

SUMMARY What is known and objective:  Treatment for hypertension with verapamil has a favourable renoprotective effect and is generally considered safe in patients with mild to moderate renal failure. In this report, we highlight the vulnerability of patients with mild to moderate renal failure to verapamil side effects especially in the presence of hyperkalaemia. Case summary and what is new:  We report two cases of junctional bradycardia with slow release (SR) verapamil therapy in the presence of mild hyperkalaemia in patients with mild to moderate chronic renal failure. Verapamil and hyperkalaemia may synergistically increase the vulnerability to atrioventricular conduction delay. Conclusion:  Renal failure patients with baseline mild hyperkalaemia are particularly liable to bradyarrhythmias with SR verapamil. In such cases, we would recommend verapamil dose reduction and avoidance of SR formulation. In cases of verapamil toxicity, actively treating any level of hyperkalaemia is recommended.What is known and objective:  Treatment for hypertension with verapamil has a favourable renoprotective effect and is generally considered safe in patients with mild to moderate renal failure. In this report, we highlight the vulnerability of patients with mild to moderate renal failure to verapamil side effects especially in the presence of hyperkalaemia.

Psoriatic arthritis comorbidity index: development and validation of a new specific tool for classifying prognostic comorbidity in psoriasis and psoriatic arthritis patients

Objective: 1. identify comorbidities with greatest impact on PsA patients’ health status. 2.develop and validate a prospectively applicable comorbidity index for classifying PsA patients according to their comorbid conditions. Methods: This was a retrospective multicenter cohort analysis of PsA patients in a rheumatology clinical registry, assessing the effect of different comorbidities measured at patients’ visits over 10-years period. Outcomes of interest included functional ability, quality of life, medications induced complications, hospitalization/ death. A weighted index that was developed in a cohort of 1707 PsA patients. Internal and external validation were carried out. Results: PsA patients who had higher incidence of comorbid condition and were at high risk of hospitalization were men, with older age at disease onset, high BMI (p < 0.05). Multivariate regression analysis identified 29 comorbidities. A comorbidity index weighted according to the regression coefficient of the variables was developed (the score range: 0-37). A cut off point of 8 was associated with a sensitivity of 97.5% and a specificity of 87%. The developed PsACI correlated significantly with the 4 tested comorbidity indices: Charlson comorbidity index, Functional comorbidity index, Rheumatic Diseases comorbidity index, and Multimorbidity index at 1-, 3-, 5and 10-years. Similar significant correlation was seen on external validation assessment. Conclusion: The PsA-comorbidity index is a valid method for estimating comorbidity risk in PsA patients. It enables the clinicians to include comorbidities assessment and management in their practice. It can be used to predict resource utilization, identify targets for reducing costs, by prospectively identifying PsA patients at high risk. Correspondence to: Y. El Miedany, Rheumatology, Darent Valley Hospital, Dartford, United Kingdom, E-mail: drelmiedany@rheumatology4u.com Received: March 14, 2017; Accepted: April 10, 2017; Published: April 13, 2017 Introduction Rheumatic diseases are chronic progressive conditions which may result in significant physical disability and, in several cases, accelerated mortality [1-3]. While the primary disease accounts for much of the heightened death risk and the majority of morbidity, other factors such as comorbid conditions play a major contributing role [4, 5]. A widely accepted definition of comorbidity is “the existence or occurrence of any distinct additional entity during the clinical course of a patient who has the index disease under study” [6]. These additional entities are categorized according to the comorbidity ‘three Cs’ classification scheme: causality, complication, and coincidence. Causality is when an inflammatory disease like rheumatoid (RA), psoriatic arthritis (PsA) or systemic lupus erythematosus (SLE) is followed by patho-physiologically linked abnormalities, such as cardiovascular disorders; complications are comorbidities therapeutically linked to illnesses such as diabetes mellitus or osteoporosis (glucocorticoid-induced) or peptic ulcer (NSAIDinduced). Coincidence means that comorbidities occur independently and are unrelated to the index disease (for example, inflammatory arthritis and appendicitis) [7,8]. Separate patterns of comorbidity have been identified in patients with rheumatic diseases whether they have inflammatory arthritic conditions (such as RA, PsA, and SLE); or those with non-inflammatory rheumatic disorders such as fibromyalgia or osteoarthritis [9]. As these comorbidities contribute to increased early mortality, affect disease activity, response to treatments, and generate costs in these populations, they should be considered when managing patients with inflammatory arthritic conditions [10-12]. Furthermore, medications used to manage the underlying inflammatory condition, including diseasemodifying antirheumatic drugs (whether synthetic (sDMARD), or biologic therapy (bDMARD), corticosteroids, and NSAID, may also increase or, conversely, decrease the likelihood of comorbidities. People with psoriasis (PsO) and PsA were reported to have an elevated risk of developing comorbidities. A recent review noted that over half of the PsA patients have more than one comorbidity; which had a significant negative impact on their functional ability as well as quality of life [13]. There is currently no standardized, and validated instrument for recording and collecting comorbidity data in patients with PsO and PsA, which is relevant to contemporary and routine rheumatology practice. El Miedany Y (2017) Psoriatic arthritis comorbidity index: development and validation of a new specific tool for classifying prognostic comorbidity in psoriasis and psoriatic arthritis patients Volume 2(2): 2-7 Rheumatol Orthop Med, 2017 doi: 10.15761/ROM.1000117 The purpose of the study is to identify comorbidities with greatest impact on PsO and PsA patients’ health status. Also, to develop and validate a prospectively applicable comorbidity index for classifying these patients according to their comorbid conditions which might alter their risk of hospitalization and mortality.