Proton pump inhibitor induced subacute cutaneous lupus erythematosus: Clinical characteristics and outcomes.

BACKGROUND: There is a growing literature reporting the association between proton pump inhibitor (PPI) use and subacute cutaneous lupus erythematosus (SCLE). AIMS: To compare the clinical characteristics of a cohort of patients with PPI-induced SCLE, their clinical course and treatment with a control group of primary SCLE patients not exposed to PPI. METHODS: We conducted a matched case-control study in a tertiary referral setting at the Louise Coote Lupus Unit. There were 64 SCLE patients: 36 with PPI-induced SCLE and 28 patients with primary SCLE. RESULTS: Twenty-six patients (72%) had pre-existing SLE in the PPI-induced SCLE group. Lower limb skin lesions were significantly more prevalent in the PPI group (p < 0.0001). The prevalence of anti-Ro and anti-Ro-52 antibodies was numerically higher in the PPI group (64% and 60%), respectively, compared with 46% and 42% in the primary SCLE group. Peripheral blood eosinophils were normal in all patients in the PPI group. Thirteen patients underwent skin biopsy in the PPI group and 12 had histology in keeping with SCLE. The median time to presentation was 8 months with a median resolution period of 6 weeks. PPIs were stopped in 34 patients, while 2 patients continued treatment for other clinical indications. Twelve patients received concurrent oral corticosteroids. Two patients had severe SCLE in the form of Toxic Epidermal Necrolysis requiring critical care admission and were managed with corticosteroids, IV immunoglobulin and/or belimumab. CONCLUSION: Lower limb involvement is a pointer to PPI-induced SCLE which is likely a class effect with all PPI.

Prevalence of Cardiovascular Risk Factors in Saudi Patients With Psoriatic Arthritis: A Single-Center Retrospective Cohort Study.

Background Psoriatic arthritis (PsA) is an extremely heterogeneous disease with numerous articular phenotypes and extra-articular manifestations. It is common for patients with PsA to have coexisting medical conditions. In recent studies, PsA patients were found to have a greater prevalence of cardiovascular risk factors when compared to non-PsA groups. Objectives This study aimed to describe the prevalence of cardiovascular risk factors among Saudi psoriatic arthritis patients treated at King Abdulaziz Medical City (KAMC), Riyadh. Methods A hundred and twenty-six patients with psoriatic arthritis diagnoses were enrolled in this study. Patients who were 18-years-old or older, had PsA diagnosed by a rheumatologist, and met the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria were included in the study population. Patients were excluded from the study if they were younger than 18, did not fulfill the CASPAR criteria, did not have a documented diagnosis by a rheumatologist, or had been diagnosed with any type of joint arthritis in the past. In this retrospective cohort article, we investigated the frequency of risk factors for cardiovascular disease such as [hypertension (HTN), dyslipidemia (DLP), diabetes mellitus (DM), obesity, and coronary heart disease (CHD)] and non-established risk factors such as [HbA1C, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)]. SPSS version 12.0 for Windows (SPSS Inc.) was used for statistical analysis. The threshold for statistical significance was set at 5%. Results A hundred and twenty-six PsA patients were enrolled in this study, 30 (24%) had PsA for less than two years (early), and 96 (76%) had PsA for more than two years (established). When the analysis was performed, the mean age was 47.5 years, and the mean age at diagnosis of PsA was 42.4 years. Of them, 89 (71%) were female while 37 (29%) were male. Established PsA patients were significantly older at the time of analysis than early PsA patients (49.2 vs. 41.8 years; P= 0.007). Furthermore, established PsA patients had a longer duration of PsA than those with early PsA (6.3 vs. 1.5 years; P= <0.001). The most frequently reported comorbidity was obesity (61%) followed by DLP (43%), HTN (34%), DM (30%), and CHD (11%). CV comorbidities did not differ between subgroups. However, patients with established PsA had a higher prevalence of DLP, especially females. Additionally, patients with early PsA had greater rates of HTN than those with established PsA, and patients with early PsA were more likely to have CHD. Conclusion This study confirms that PsA is linked with cardiovascular (CV) morbidity. When evaluating PsA, future studies should take these CV conditions into consideration.

Pregnancy and Inflammatory Rheumatological Diseases: A Single-Center Retrospective Cohort Study.

Background Rheumatic diseases pose risks to pregnant women, leading to complications like preterm birth, congenital heart block, and pregnancy loss. These diseases are expected to deteriorate during pregnancy and further in the postpartum period. The impact of these diseases on the pregnancy will add further burden on the patient, fetus, physician, and healthcare system. Advances in diagnosis and treatment have improved outcomes making them similar to that of healthy women, but close follow-up in a multidisciplinary clinic is essential. The objective of this study is to study the outcome of pregnancy in women with rheumatological disease and the behavior of the disease during pregnancy. Methods A retrospective cohort study was conducted in King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia, to compare the outcomes of pregnancy across three rheumatological diseases: Sjogren syndrome (SS), systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA) from 2016 to 2021. A total of 128 pregnancies in 107 women with rheumatological diseases were included in this study. Pregnancy measures and outcomes were investigated by assessing maternal health, fetal health, and pregnancy complications, specifically maternal disease activity, medications to control the disease, infection, preterm birth, birth weight, abortions/stillbirths, mode of delivery, bleeding, preeclampsia, congenital heart block, and neonatal lupus. Results There were 55 patients with RA (63 RA pregnancies), 44 with SLE (54 SLE pregnancies), and eight with primary SS (11 SS pregnancies). In most of the pregnancies (n= 108; 95.58%), the patients were in clinical remission before pregnancy. Lupus nephritis, which was in remission before pregnancy, has been reported in nine (16.67%) out of 54 SLE pregnancies. Vaginal delivery was the most common mode of delivery (n=87; 67.97%). On the other hand, there were 38 cesarean sections (29.69%). Rheumatological disease flares occurred in 10 pregnancies (7.87%). One hundred and twenty-two live births were delivered. Preterm infants were born in 25 pregnancies (20.16%), and 16 (13.22%) of the newborns needed neonatal intensive care unit (NICU) care. Interestingly, congenital heart block (CHB) was found in five (12.2%) neonates out of 41 anti-SS-related antigen A (anti-SSA) positive mothers; one of those five died from heart block. Eleven neonates were delivered with positive serology, and five were diagnosed with neonatal lupus. Conclusion The outcome of pregnancy in patients with rheumatological disease is favorable. A multidisciplinary team approach and close clinical follow-up are the cornerstone for such success. A small dose of prednisolone (5 mg or less) is safe and will not have a negative impact on maternal or fetal health. CHB is a concern for pregnant women with positive anti-SSA.

Infection Risk, Mortality, and Hypogammaglobulinemia Prevalence and Associated Factors in Adults Treated with Rituximab: A Tertiary Care Center Experience.

BACKGROUND: Rituximab is a human monoclonal antibody directed against the B-cell transmembrane protein CD20. Although well-tolerated, given its mechanism of action, rituximab can induce a state of severe immunosuppression, increasing the risk of opportunistic and fulminant infection and mortality. AIM: To evaluate the risk of infection, mortality, and hypogammaglobulinemia and their associated factors among rituximab receivers. METHOD: This was a single-center retrospective cohort study of adults treated with rituximab for various indications. Hypogammaglobulinemia was defined by a cut-off value below the normal limit (an IgG level of <7.51 g/L, an IgM level of <0.46 g/L, and/or an IgA level of <0.82 g/L). Patients who met the definition of hypogammaglobinemia solely based on IgA were excluded. Severe infection was defined as any infection that required intensive care unit admission. RESULTS: A total of 137 adults with a mean age of 47.69 ± 18.86 years and an average BMI of 28.57 ± 6.55 kg/m2 were included. Hematological malignancies and connective tissue diseases were the most common primary diagnoses for which rituximab was used. More than half of the patients received the 375 mg/m2 dose. Rituximab's mean cumulative dose was 3216 ± 2282 mg, and the overall mortality rate was 22.6%. Hypogammaglobulinemia was diagnosed in 43.8% of the patients, and it was significantly more prevalent among males and the 375 mg/m2 and 500 mg doses. Hematological malignancy was the only predictor for infection. Patients with blood type AB or B, hematological malignancies, and corticosteroids had a significantly higher mortality rate. Receiving the 1000 mg dose and having a low CD19 were associated with a significantly lower risk of infection and mortality, respectively. CONCLUSIONS: Hypogammaglobulinemia was diagnosed in 43.8% of the patients, and it was significantly more common among males and the 375 mg/m2 and 500 mg doses. Hematological malignancies were significantly associated with higher infection and mortality rates, while corticosteroids were significantly associated with a higher mortality. Since the culprit of mortality was infection, these findings highlight the critical need for more frequent immunological monitoring during rituximab treatment period to mitigate the burden of infection and identify candidates for immunoglobulin replacement.

Clinical Course and Outcomes of COVID-19 Infection in Patients Treated with Rituximab: A Tertiary Care Center Experience.

Introduction: Patients receiving rituximab (RTX) may be at increased risk for severe Coronavirus infections and worse outcomes compared with the general population. Because of the conflicting results concerning the effect of RTX on the clinical course and outcomes of COVID-19 infection, we aimed to share our experience with 35 patients infected with COVID-19 while treated with RTX for a variety of clinical indications. Methods: This was a single-centre retrospective cohort study that included 35 patients. All patients aged ≥14 years who were treated with RTX for various conditions and were found to have COVID-19 infection were included. Patients with poor outcomes or patients with suspected COVID-19 infection were excluded. Results: The patients' mean age was 42.8 ± 16.3 years with an average BMI of 29.9 ± 11.4 kg/m2. Over half (51.4%, n = 18) of the patients received RTX at a dose of 375 mg/m2 with a median frequency of 4 doses. More than a third (37.1%, n = 13) of the patients had hypogammaglobulinemia and 25.7% had low CD19. Over a third (42.9%, n= 15) of the patients required hospitalization and almost a third (25.7%, n = 9) required treatment in the intensive care unit. There was a statistically significant association between intensive care unit admission and age, steroid use, and low CD19. The mortality rate was 25.7%, and it was significantly higher in elderly, diabetics, corticosteroid users, patients who were hospitalized, treated in the intensive care unit, and had low immunoglobin or CD19. Conclusion: Treatment with RTX seems to be a potential risk factor for unfavorable outcomes in COVID-19 patients. RTX should be used with caution or avoided unless the benefit clearly outweighs the risk.

Prevalence and Clinical Predictors of Psoriatic Arthritis in Saudi Patients With Psoriasis: A Single-Center Retrospective Cohort Study.

Background Among psoriatic patients, psoriatic arthritis is the most common and most impactful comorbidity. In most cases, it occurs after the onset of psoriasis. Detecting and treating it early is crucial for rheumatologists and dermatologists. Objectives The study aimed to determine the prevalence of psoriatic arthritis among recognized cases of psoriasis, as well as to determine the clinical features of psoriasis that are linked to a greater prevalence of psoriatic arthritis at King Abdulaziz Medical City (KAMC), Riyadh. Methods A retrospective cohort study of 487 psoriatic patients diagnosed between 2015 and 2023 was conducted at KAMC, Riyadh. The study included subjects aged 18 years or older with a psoriasis diagnosis documented by a dermatologist and a psoriatic arthritis diagnosis documented by a rheumatologist based on the Classification Criteria for Psoriatic Arthritis (CASPAR). Patients younger than 18 years, diagnosed with psoriatic arthritis concurrently with psoriasis, or within 90 days of psoriasis diagnosis, or who lack a documented diagnosis of psoriasis by a dermatologist were excluded. The study evaluated demographic data and medical variables concerning psoriasis (age at onset, type of psoriasis, site of psoriasis, and nail dystrophy) and psoriatic arthritis. SPSS Statistics version 25 (IBM Corp., Armonk, NY) was used to conduct statistical analysis. The p-value of 0.05 was used to evaluate statistical significance. Results Overall, 487 patients had psoriasis in this study. Of these, 49 (10%) were diagnosed with psoriatic arthritis. The mean ± standard deviation of the age of the psoriasis group was 41.7 ± 15.6 years, with 264 (54.2%) females and 223 (44.8%) males. The clinical features of psoriasis that were linked to a greater frequency of psoriatic arthritis in our study included female gender (71.4%), plaque psoriasis (95.9%), psoriatic lesions involving the extremities (75%), scalp (42.9%), and trunk (36.7%), nail dystrophy (28.6%), as well as the involvement of three or more sites (40.8%) at the time of their initial diagnosis of psoriasis. Conclusion Our study indicated that 10% of Saudi patients with psoriasis had psoriatic arthritis. Moreover, the present study shows that patients with greater psoriatic lesions at initial presentation are more likely to develop psoriatic arthritis.

Outcomes of COVID-19 in Inflammatory Rheumatic Diseases: A Retrospective Cohort Study.

Background Similar to coronavirus disease 2019 (COVID-19), the pathogenesis of inflammatory rheumatic diseases includes cytokines dysregulation and increased expression of pro-inflammatory cytokines. Although current data from international studies suggest that rheumatic diseases are associated with a higher risk of COVID-19 infection and worse outcomes, there is limited literature in Saudi Arabia. This study aims to evaluate the outcomes and length of hospital stay of COVID-19 patients with inflammatory rheumatic diseases in Saudi Arabia. Method This was a single-center retrospective cohort study that included 122 patients with inflammatory rheumatic diseases and documented coronavirus disease 2019 (COVID-19) infection from 2019 to 2021. Patients with suspected COVID-19 infection, non-inflammatory diseases, such as osteoarthritis, or inflammatory diseases but without or with weak systemic involvement, such as gout, were excluded. Results The vast majority (81.1%) of the patients were females. Rheumatoid arthritis was the most common primary rheumatological diagnosis. The admission rate was 34.5% with an overall mortality rate of 11.5%. Number of episodes of COVID-19 infection, mechanical ventilation, cytokine storm syndrome, secondary bacterial infection, number of comorbidities, rituximab, diabetes mellitus, hypertension, chronic kidney disease, and heart failure were significantly associated with a longer hospital stay. Additionally, hypertension, heart failure, rituximab, mechanical ventilation, cytokine storm syndrome, and secondary bacterial infection were significantly associated with higher mortality. Predictors of longer hospitalization were obesity, number of episodes of COVID-19 infection, mechanical ventilation, number of comorbidities, and chronic kidney disease, whereas, hypertension was the only predictor of mortality. Conclusion Obesity, number of episodes of COVID-19 infection, mechanical ventilation, number of comorbidities, and chronic kidney disease were significantly associated with higher odds of longer hospitalization, whereas, hypertension was significantly associated with higher odds of mortality. We recommend that these patients should be prioritized for the COVID-19 vaccine booster doses, and rituximab should be avoided unless its benefit clearly outweighs its risk.

Isolated Cardiac Sarcoidosis Presenting as Torsades de Pointes in a Patient With Non-ischemic Cardiomyopathy: A Case Report.

Sarcoidosis is an immune-mediated, inflammatory, non-caseating-granulomatous disease that can virtually infiltrate any organ. Cardiac sarcoidosis is a leading cause of death in patients with sarcoidosis. Its clinical presentation is highly heterogenous and unpredictable, ranging from asymptomatic to life-threatening conduction disturbances, such as ventricular arrhythmias, and heart failure. Herein, we report a case of isolated cardiac sarcoidosis presenting as sinus bradycardia with first-degree atrioventricular block and an episode of non-sustained polymorphic ventricular tachycardia in a 42-year-old male with non-ischemic cardiomyopathy. He was diagnosed by cardiac magnetic resonance imaging and positron emission tomography with fluorodeoxyglucose and treated with oral prednisone.

The prevalence, clinical features, predictive factors and investigations to screen for cancer in patients with inflammatory myositis. A case series from two tertiary care centers in Riyadh, Saudi Arabia.

OBJECTIVES: To describes the epidemiology of cancer in patients with idiopathic inflammatory myopathies (IIM) treated at 2 tertiary centers in Riyadh, Saudi Arabia. METHODS: This was a retrospective multi-center study evaluating the prevalence and the type of malignancy in an IIM population in King Saud University Medical City and King Abdulaziz Medical City between August 2017 to August 2018. RESULTS: In total, 60 patients were included. Four had neoplasms (6.7%), 2 men had lymphoma, a woman had breast cancer and a second, ovarian cancer. Two patients died due to cancer or its complications. Older age (age greater than 40 years), dysphagia, necrotic rash, absence of interstitial lung disease, high erythrocyte sedimentation rate and a negative anti Jo-1 antibody were potentially predictive risk factors for neoplasm. All patients diagnosed with cancer-associated myositis were investigated with routine and invasive modalities. Three of the 4 patients had abnormal findings in both modalities. One patient, the routine investigations were unremarkable, but a computed tomography of the pelvis revealed an ovarian mass that was subsequently diagnosed as malignant.  Conclusion: An individualized approach might be more appropriate for high risk patients. Larger prospective studies are required to confirm the findings of the current study.