Mohammed Ruzieh

The role of autoantibodies in the syndromes of orthostatic intolerance: a systematic review

Abstract Orthostatic intolerance is defined as the provocation of symptoms upon standing, commonly caused by neurogenic orthostatic hypotension (OH) and postural tachycardia syndrome (POTS), the etiology for which has not been fully uncovered yet. Many reports have described the occurrence of dysautonomia, orthostatic intolerance and POTS following febrile illness, presumably viral and post-vaccine. Furthermore, patients with dysautonomia have higher rates of autoimmune disorders such as Hashimoto thyroiditis and SLE. Recent evidence has shown the presence of adrenergic and cholinergic receptor antibodies in patients with POTS and orthostatic hypotension. In patients with cholinergic receptor antibodies, higher titers correlate with the disease severity. Few reports have shown that immunomodulation therapy resulted in significant improvement in symptoms. In this article, we review the available literature correlating autoimmunity with orthostatic intolerance syndromes. Future studies are warranted to evaluate the prevalence of such antibodies and examine different treatment modalities in this sub group of patients.

Ivabradine in the treatment of postural tachycardia syndrome (POTS), a single center experience: RUZIEH et al.

Ivabradine is a selective If channel blocker that reduces heart rate without affecting other cardiovascular functions. In case reports and case series, it was shown to improve symptoms in patients with postural tachycardia syndrome (POTS).

Successful Treatment of Life-Threatening Interstitial Lung Disease Secondary to Antisynthetase Syndrome Using Rituximab: A Case Report and Review of the Literature.

We are presenting a case of antisynthetase syndrome (ASS) that manifested with severe interstitial pneumonitis in the presence of anti-Jo-1 and Ro (SSA) antibodies. Our patient developed respiratory failure with high oxygen requirements despite treatment by high-dose steroids. The patient was then treated with rituximab. This treatment led to significant improvement in the patient condition, with resolution of the ground glass opacities on high-resolution computerized tomography and near normalization of pulmonary function tests. In this communication, we performed a literature review and summarized previous reports pertinent to using of rituximab to treat interstitial lung disease (ILD) secondary to ASS by searching the PubMed database from 1980 to 2014. We were able to find 14 reports that included total of 45 patients with ILD secondary to ASS. A significant improvement in ILD was reported in the majority of reported patients who received rituximab, while there was only 1 mortality-related to Pneumocystis jirovecii pneumonia. Rituximab treatment was tolerated well in the majority of cases. It is our conclusion that rituximab can be considered a therapeutic option in ILD secondary to ASS based on our experience with this case and the currently available evidence in the literature. Nevertheless, there is a need for additional controlled studies to assess the efficacy and safety of rituximab in ILD secondary to ASS compared with other immunosuppressive regimens.

Orthostatic intolerance and postural tachycardia syndrome: new insights into pathophysiology and treatment

Orthostatic intolerance is characterized by symptoms of light-headedness or syncope that is provoked upon standing or in an upright posture. It is most commonly caused by postural orthostatic tachycardia syndrome (POTS) or orthostatic hypotension (OH). Its pathophysiology is complex and commonly involves abnormal autonomic nervous system regulation, autoimmunity, a hyperadrenergic state, and hypovolemia. This article reviews the pathophysiology underlying orthostatic intolerance, as well as the current treatment available.ZusammenfassungOrthostatische Intoleranz ist durch Symptome der Benommenheit oder Synkope charakterisiert, die durch Aufstehen oder aufrechtes Stehen provoziert werden. Ursache ist meist das posturale orthostatische Tachykardiesyndrom oder eine orthostatische Hypotonie. Die Pathophysiologie ist komplex und bezieht üblicherweise eine abnorme Regulation des autonomen Nervensystems, Autoimmunreaktionen, einen hyperadrenergen Zustand und Hypovolämie ein. In dieser Übersicht werden die Pathophysiologie, die der orthostatischen Intoleranz zugrunde liegt, und derzeit verfügbare Behandlungsmöglichkeiten zusammengefasst.

Role of closed loop stimulation pacing (CLS) in vasovagal syncope: RUZIEH et al.

Vasovagal syncope (VVS) or neurocardiogenic syncope is defined by transient loss of consciousness with spontaneous and rapid recovery. Recently, a closed loop stimulation (CLS) pacing system has emerged as a new strategy which appears superior to conventional pacing for patients with refractory syncope. However, its efficacy remains of considerable debate and large randomized controlled clinical trials are needed. Between 2002 and 2017, 12 total studies evaluated the use of CLS pacing in patients with refractory VVS, and are summarized in this article.

Endobronchial Cartilage Rupture: A Rare Cause of Lobar Collapse.

Endobronchial cartilage rupture is a rare clinical condition, which can present in patients with severe emphysema with sudden onset shortness of breath. We present a case of a 62-year-old male who presented to our emergency department with sudden onset shortness of breath. Chest X-ray showed lung hyperinflation and a right lung field vague small density. Chest Computed Tomography confirmed the presence of right middle lobe collapse. Bronchoscopy revealed partial right middle lobe atelectasis and an endobronchial cartilage rupture. Endobronchial cartilage rupture is a rare condition that can present as sudden onset shortness of breath due to lobar collapse in patients with emphysema and can be triggered by cough. Bronchoscopic findings include finding a collapsed lung lobe and a visible ruptured endobronchial cartilage. A high index of suspicion, chest imaging, and early bronchoscopy can aid in the diagnosis and help prevent complications.

Posttransplant Tacrolimus-Induced Diabetic Ketoacidosis: Review of the Literature

Diabetic ketoacidosis (DKA) in patients receiving tacrolimus as part of their immunosuppressive regimen is a rarely reported adverse event. We report a patient with autosomal dominant polycystic kidney disease (ADPKD) and no known history of diabetes mellitus who presented with DKA, 3 months after kidney transplantation.

Correlation between the severity of chronic inflammatory respiratory disorders and the frequency of venous thromboembolism: meta-analysis

The present study aims to integrate the growing body of evidence on the possible association between the severity of chronic inflammatory respiratory disorders (CIRDs) and the frequency of venous thromboembolism (VTE). Eight studies were analyzed to assess the correlation between the severity of CIRDs and the incidence of VTE. Our results suggest that there is no significant increased risk of VTE in patients with severe CIRD compared to mild or moderate CIRD, OR=0.92 (95% CI 0.59 – 1.43; I = 74%). Further studies are indicated to explore this possible association. Gaining a better understanding of the VTE risk for patients with CIRDs will enable clinicians to provide better individualized risk management and preventive care.

Clinical Efficacy of Cardiac Resynchronization Therapy in Patients with Ischemic and Non-ischemic Cardiomyopathy

We evaluated the response of cardiac resynchronization therapy (CRT) in ischemic cardiomyopathy (ICMP) and non-ischemic cardiomyopathy (NICMP). We determined if the cause of cardiomyopathy, ischemic versus non-ischemic, affects CRT outcomes in regard to New York Heart Association (NYHA) category and ejection fraction. We used a retrospective chart review for adult patients who underwent biventricular device placement between January 2005 and July 2015 at the university of Toledo medication center as part of their standard of care. NYHA category and ejection fraction were compared before and after CRT in both ICMP and NICMP patients. The NYHA category improved by 0.39±0.90 and 0.81±0.79 (p1⁄4 0.001) in ICMP and NICMP, respectively. The NYHA category worsened on follow-up in 11 (11.2%) patients in the ICMP group and five (5.2%) patients in the NICMP group (p1⁄4 0.12). A total of 50 (51%) patients in the ICMP group and 26 (26.8%) in the NICMP had no improvement in their NYHA category (po0.001). Thirty-seven (37.8%) patients in the ICMP group and 66 (68%) in the NICMP group showed improvement by one or more in their NYHA categories (po0.001). NICMP remained a significant predictor of response to CRT independent of other variables after controlling it using logistic regression analysis. The ejection fraction increased by 5.58±11.41 in ICMP compared with 12.86±14.55 in NICMP (p1⁄4 0.001). Our study shows an improvement in NYHA functional class and ejection fraction after CRT therapy in heart failure patients regardless of etiology. However, a more favorable outcome was noticed in the NICMP subgroup. A future randomized control trial with a control group that specifically addresses this question and investigates possible etiologies is warranted.