Rituximab Induced Flare of Psoriatic Arthritis in a Patient with Devic's Syndrome: A Case Report.

INTRODUCTION/BACKGROUND: Devic's syndrome is a rare autoimmune disorder that occurs when the body's immune system damages and mistakenly attacks the optic nerves and the spinal cord, leading to numerous neurological. Symptoms, such as inflammation, weakness, numbness, and vision problems. Rituximab has mainly been utilized as an immunosuppressive therapy for patients with Devic's syndrome. Although evidence has shown that rituximab is efficient and well tolerated in treating patients with Devic's syndrome, there is the possibility of rituximab exacerbating severe psoriasis and psoriatic arthritis flare. CASE PRESENTATION: In this paper, we describe a case of a 58-year-old female with Devic's syndrome, blindness, and neurological involvement who responded exceptionally well to rituximab. However, she developed a severe flare of psoriatic arthritis. After withdrawing from the use of rituximab, her psoriatic arthritis symptoms had resolved. However, she did have another episode of blindness, and rituximab was started once again. Although her vision improved, her psoriatic arthritis symptoms had reoccurred. The patient was switched to eculizumab and ustekinumab, which controlled both her psoriatic arthritis and Devic's syndrome. CONCLUSION: Very few reports have identified rituximab to induce a flare-up of psoriatic arthritis, raising uncertainty regarding its potential effects on psoriatic symptoms. The precise mechanism underlying the exacerbation of psoriatic arthritis by rituximab remains uncertain. This case report highlights that rituximab can worsen psoriasis and psoriatic arthritis, and that the complexities of Devic's syndrome may require medication adjustments.

Effect of Sarcopenia on Swallowing in Patients With Head and Neck Cancer.

OBJECTIVE: Sarcopenia, characterized by decreased skeletal muscle mass, is associated with poorer oncologic outcomes in head and neck cancer (HNC) patients. The effect of sarcopenia on swallowing following HNC treatment is unknown. This study aims to investigate the association of sarcopenia and swallowing dysfunction in patients treated for HNC. STUDY DESIGN: Retrospective cohort study. SETTING: Academic medical center. METHODS: Pretreatment sarcopenia was assessed using the skeletal muscle index calculated from cross-sectional imaging at the third cervical vertebra. Feeding tube dependence, patient-reported dysphagia, and swallowing safety were assessed before and after treatment with the Functional Oral Intake Scale, Eating Assessment Tool-10, and Penetration Aspiration Scale, respectively. The association between sarcopenia and swallowing dysfunction was evaluated. RESULTS: A total of 112 patients were included, 84 males (75%) and 28 females (25%). A total of 69 (61.6%) had sarcopenia prior to initiating HNC therapy. Sarcopenia was significantly associated with an elevated risk of patient-reported dysphagia (odds ratio [OR] = 2.71 [95% confidence interval, CI, 1.12-6.79]; P < .05). Multivariate logistic regression demonstrated that sarcopenia (OR = 15.18 [95% CI, 1.50-453.53]; P < .05) is an independent predictor for aspiration following treatment for HNC. CONCLUSION: Patients with pretreatment sarcopenia had higher rates of dysphagia before treatment and were more likely to develop aspiration after completion of HNC therapy. Sarcopenia is readily measured using cross-sectional imaging and may be useful for identifying patients at risk of swallowing dysfunction and those most likely to benefit from prehabilitation efforts.

Potential Benefits of Psilocybin for Lupus Pain: A Case Report.

INTRODUCTION: Outcomes of treatment for patients with Lupus have shown overall improvement and benefit from the more aggressive use of immunosuppressants and biological agents through a treat-to-target approach. However, chronic musculoskeletal pain can be refractory to treatment despite the use of non-steroidal anti-inflammatory drugs, corticosteroids, and other analgesic agents, leading to patient dissatisfaction. The concept of new neural pathways from psilocybin usage has been proposed in a variety of pain syndromes; however, it is not trialed for patients with Lupus pain. CASE PRESENTATION: The patient was a 67-year-old male with positive anti-dsDNA antibody Lupus with a predominance of chronic polyarticular joint pain treated with hydroxychloroquine and non-steroidal anti-inflammatory drugs without pain relief. Pain dramatically improved after a one-time macro-dosing of 6 grams of Psilocybin cubensis in Oregon, which he expected would only provide a sense of enlightenment. After 12 months, he continued without debilitating joint pain. CONCLUSION: The serotonin-2A receptor's activation triggers an array of neurophysiological reactions that disrupt the functional connections in areas of the brain that are associated with chronic pain. These neuroplastic effects can generate healthy connections, resulting in long-lasting pain relief. However, this is a process that has not been fully analyzed. While there is anecdotal evidence to suggest the therapeutic benefits for autoimmune diseases, including rheumatoid arthritis and psoriasis, there is no specific research that explores its use for lupus-related pain. Since this is the first case that shows the benefit of psilocybin in a patient with Lupus, further studies on macro-dosing psilocybin to treat Lupus pain are warranted.

A Systematic Review of Primary Temporal Bone Mucosal Melanoma.

OBJECTIVE: Temporal bone mucosal melanomas (MMs) are rare, and patients may experience delays in diagnosis and treatment. Our objective was to better characterize the presentation, diagnosis, treatment modalities, and outcomes of this process. DATA SOURCES: PubMed/Medline, CINAHL (EBSCOhost), and Web of Science databases were searched in all languages without restriction of publication dates. STUDY SELECTION: Inclusion criteria included that the article was either a case report or a case series with individual case data. All non-English articles were excluded if the corresponding abstract lacked data on demographics, initial presentation, and clinical management. DATA EXTRACTION: After full-text analysis, data pertaining to demographics, diagnosis, medical and surgical management modalities, and outcomes were extracted. DATA SYNTHESIS: Data were qualitatively synthesized, and means and averages were obtained for all continuous variables. Overall survival was measured by the Kaplan-Meier method, and significance was measured through log-rank testing. CONCLUSIONS: Clinicians should suspect temporal bone MM in the differential diagnosis of patients with bloody otorrhea in the context of a chronic serous otitis media or an associated cranial nerve palsy. If suspected, physicians should not delay the acquisition of a biopsy or imaging studies. Management is highly variable and must be decided on a case-by-case basis. Outcomes remain poor because of the high propensity for MM to metastasize.

Chronic Pain in Patients with Rheumatoid Arthritis.

PURPOSE OF REVIEW: Chronic pain is highly prevalent in patients with rheumatoid arthritis (RA) and can cause various physical and psychological impairments. Unfortunately, the appropriate diagnosis of chronic pain syndromes in this population can be challenging because pain may be primary to RA-specific inflammation and/or secondary to other conditions, typically osteoarthritis (OA) and fibromyalgia (FM). This disparity further poses a clinical challenge, given that chronic pain can often be discordant or undetected with standard RA-specific surveillance strategies, including serological markers and imaging studies. In this review, we provide a robust exploration of chronic pain in the RA population with emphasis on epidemiology, mechanisms, and management strategies. RECENT FINDINGS: Chronic pain associated with RA typically occurs in patients with anxiety, female sex, and elevated inflammatory status. Up to 50% of these patients are thought to have chronic pain despite appropriate inflammatory suppression, typically due to peripheral and central sensitization as well as secondary OA and FM. In addition to the standard-of-care management for OA and FM, patients with RA and chronic pain benefit from behavioral and psychological treatment options. Moreover, early and multimodal therapies, including non-pharmacological, pharmacological, interventional, and surgical strategies, exist, albeit with varying efficacy, to help suppress inflammation, provide necessary analgesia, and optimize functional outcomes. Overall, chronic pain in RA is a difficult entity for both patients and providers. Early diagnosis, improved understanding of its mechanisms, and initiation of early, targeted approaches to pain control may help to improve outcomes in this population.

The time to offer treatments for COVID-19.

Background: COVID-19 has several overlapping phases. Treatments to date have focused on the late stage of disease in hospital. Yet, the pandemic is by propagated by the viral phase in out-patients. The current public health strategy relies solely on vaccines to prevent disease.Methods: We searched the major national registries, pubmed.org, and the preprint servers for all ongoing, completed and published trial results.Results: As of 2/15/2021, we found 111 publications reporting findings on 14 classes of agents, and 9 vaccines. There were 62 randomized controlled studies, the rest retrospective observational analyses. Only 21 publications dealt with outpatient care. Remdesivir and high titer convalescent plasma have emergency use authorization for hospitalized patients in the U.S.A. There is also support for glucocorticoid treatment of the COVID-19 respiratory distress syndrome. Monoclonal antibodies are authorized for outpatients, but supply is inadequate to treat all at time of diagnosis. Favipiravir, ivermectin, and interferons are approved in certain countries.Expert Opinion: Vaccines and antibodies are highly antigen specific, and new SARS-Cov-2 variants are appearing. We call on public health authorities to authorize treatments with known low-risk and possible benefit for outpatients in parallel with universal vaccination.

The Importance of Understanding the Stages of COVID-19 in Treatment and Trials.

COVID-19, caused by SARS-CoV-2, continues to be a major health problem since its first description in Wuhan, China, in December 2019. Multiple drugs have been tried to date in the treatment of COVID-19. Critical to treatment of COVID-19 and advancing therapeutics is an appreciation of the multiple stages of this disease and the importance of timing for investigation and use of various agents. We considered articles related to COVID-19 indexed on PubMed published January 1, 2020-November 15, 2020, and considered papers on the medRxiv preprint server. We identified relevant stages of COVID-19 including three periods: pre-exposure, incubation, and detectable viral replication; and five phases: the viral symptom phase, the early inflammatory phase, the secondary infection phase, the multisystem inflammatory phase, and the tail phase. This common terminology should serve as a framework to guide when COVID-19 therapeutics being studied or currently in use is likely to provide benefit rather than harm.

A patient with primary Sjogren's syndrome, cystic lung disease, and MALT lymphoma treated successfully with rituximab: a case-based review.

Primary Sjogren's syndrome (pSS) can have a myriad of presentations, ranging from mild xerostomia to more diffuse systemic involvement. It is well established that pSS is associated with a variety of pulmonary pathologies, and it is also known that pSS patients are at higher risk for lymphoma development. Here, we present an unusual case of a woman with primary Sjogren's syndrome who had both diffuse cystic lung disease as well as extranodal MALT lymphoma, successfully treated for both conditions with the CD-20 monoclonal antibody rituximab.

Linear Morphea With Inflammatory Myositis.

Morphea is an autoimmune disorder characterized by sclerosis and inflammation of the skin and soft tissues. Early diagnosis and treatment are essential to minimize morbidity such as joint contracture. In this report, we present the case of a 19-year-old man with linear morphea with inflammatory myositis who presented to our clinic 1 year after symptom onset with severe elbow flexion contracture. Through reviewing this rare disorder, it is hoped that early diagnosis will lead to better outcomes in the future.

Increased Cathepsin S activity associated with decreased protease inhibitory capacity contributes to altered tear proteins in Sjögren's Syndrome patients.

Cathepsin S (CTSS) activity is elevated in Sjögren's Syndrome (SS) patient tears. Here we tested whether protease inhibition and cystatin C (Cys C) levels are reduced in SS tears, which could lead to enhanced CTSS-driven degradation of tear proteins. CTSS activity against Cys C, LF and sIgA was tested in SS or healthy control tears. Tears from 156 female subjects (33, SS; 33, rheumatoid arthritis; 31, other autoimmune diseases; 35, non-autoimmune dry eye (DE); 24, healthy controls) were analyzed for CTSS activity and Cys C, LF, and sIgA levels. Cys C and LF showed enhanced degradation in SS tears supplemented with recombinant CTSS, but not supplemented healthy control tears. CTSS activity was significantly increased, while Cys C, LF and sIgA levels were significantly decreased, in SS tears compared to other groups. While tear CTSS activity remained the strongest discriminator of SS in autoimmune populations, combining LF and CTSS improved discrimination of SS beyond CTSS in DE patients. Reductions in Cys C and other endogenous proteases may enhance CTSS activity in SS tears. Tear CTSS activity is reconfirmed as a putative biomarker of SS in an independent patient cohort while combined LF and CTSS measurements may distinguish SS from DE patients.

Low Dose Naltrexone in the Treatment of Fibromyalgia.

BACKGROUND: ConclusionFibromyalgia is a chronic pain disorder characterized by diffuse musculoskeletal pain, fatigue, sleep disturbance and cognitive impairment. OBJECTIVE: A significant number of fibromyalgia patients do not respond adequately to the current drugs approved by the Food and Drug Administration (FDA) for fibromyalgia treatment including pregabalin, milnacipran, duloxetine. Thus, there is still a need for adjunctive therapies. METHOD: Naltrexone is an opioid receptor antagonist used to treat alcohol and opioid dependence. It is hypothesized that low dose naltrexone causes transient blockade of opioid receptors centrally resulting in a rebound of endorphin function which may attenuate pain in fibromyalgia. RESULTS: Two small prospective pilot studies have previously shown that treatment with low dose naltrexone may be an effective, safe, and inexpensive treatment for fibromyalgia. CONCLUSION: This prospective study lends further support to the preliminary body of evidence that naltrexone is a well tolerated and likely effective treatment option in the community setting. Further large prospective controlled trials are still needed.

Autoinflammation and Immunomodulation in Inflammatory Fibromyalgia Syndrome- A Review.

Generalized pain with tender points in specific areas accompanied by systemic symptoms such as fatigue and stiffness is characteristic of fibromyalgia (FM) syndrome. The genesis of FM is still being investigated with conflicting data on factors including autonomic dysfunction, neurotransmitters, and hormones often in combination with external stressful events. However, recent research is starting to suggest that there is a previously underappreciated subtype of fibromyalgia called inflammatory Fibromyalgia (iFM). Recent studies have described cytokines, inflammatory markers, sleep disorders, hyperalgesia, cognitive dysfunction, serum leptin levels and other inflammatory indicators as potential markers for iFM. This article will; 1) review the inflammatory markers and abnormal levels of other laboratory indicators that can help to identify the subgroup of patients that fall into the new category of Inflammatory Fibromyalgia [1-5] and 2) review all completed trials that were focused on treating this new category of disease. Through this review it is hoped that and further understanding of the complexity of the etiology of fibromyalgia can be explored.

Inflammatory Fibromyalgia: Is it Real?

Fibromyalgia (FM) is a characterized by generalized pain with widespread tender points in specific areas and is frequently accompanied by fatigue, stiffness, and a non-restorative sleep pattern. In the current retrospective study, we identified a subgroup of FM patients who had clinically important markers of inflammation. The study also explored the use of the original American College of Rheumatology (ACR) criteria in the diagnosis of FM. Our data suggested there was a distinct subset of patients with FM who had positive ESR, CRP, ANA and RF; a group that we considered representative of inflammatory FM. None of the FM patients in this study developed a documented coexisting autoimmune illness during the retrospective review period. The existence of FM subgroups further puts into question the already controversial use of either the new or old ACR classification criteria in the diagnosis of FM, as they do not address the issue of systemic inflammation which appears to be significant.

Rheumatologic manifestations of the "MonoMAC" syndrome. a systematic review.

MonoMAC syndrome is characterized by monocytopenia with susceptibility to nontuberculous mycobacterial infections. First recognized in 2011, it is caused by GATA2 mutations and can manifest as disseminated mycobacterial, fungal, and viral infections. While mortality rates for this disorder have been high, it has recently been successfully treated with haploidentical allogeneic stem cell transplant. Since approximately one third of patients may have rheumatologic symptoms, such as erythema nodosum, panniculitis, or arthralgias, rheumatologists may expect to encounter this newly described entity with increasing frequency.

Priapism after tumor necrosis factor alpha inhibitor use.

We present a possible important association of tumor necrosis factor-alpha inhibition (TNFa-i) and erectile function in a male patient with rheumatoid arthritis (RA). Long-standing, untreated RA may result in significant physical limitation and disability, however often overlooked is the association between RA and erectile and sexual dysfunction. Ischemic priapism is currently unrecognized as an adverse reaction associated with TNFa-i use and there have been no reported cases with adalimumab. Our patient, a 58-year-old Hispanic man, with sero-positive, erosive RA developed persistent priapism (17 days) despite multiple urologic interventions after initial adalimumab 40 mg administration. TNFa has recently been implicated as a potential factor in erectile dysfunction through its role in vascular reactivity. Excess TNFa, from active RA, may perturb intracavernosal smooth muscle and endothelial cell function; theoretically, TNFa inhibition may then causes excess local nitric oxide production and subsequent priapism. The potential role of TNFa-i in ED and risk for priapism is an important area for future study.