Sinonasal immunoglobulin G4-related disease: a case report of an atypical and rare entity.

BACKGROUND: Immunoglobulin G4-related disease is marked by extensive inflammation and fibrosis of an unknown autoimmune component, with an overall incidence ranging from 0.78 to 1.39 per 105 person-years. Sinonasal immunoglobulin G4-related disease is atypical and exceedingly uncommon in the existing literature, frequently manifesting clinically as chronic rhinosinusitis, epistaxis, and facial pain. CASE PRESENTATION: This report describes a 25-year-old Iraqi female who has been suffering from symptoms of chronic rhinosinusitis for 8 years. Despite undergoing several surgeries, there has been no improvement in her symptoms. A tissue biopsy that revealed dense lymphoplasmocytosis with noticeable plasma cell infiltration, storiform fibrosis, and obliterative angitis, along with positive immunohistochemical staining for Immunoglobulin G4 plasma cells, finally confirmed the diagnosis of sinonasal immunoglobulin G4-related disease. The patient responded well to oral prednisolone and methotrexate treatments. CONCLUSIONS: The main objective of the current report is to raise awareness among physicians about the significance of promptly identifying and diagnosing this rarity, thus preventing the adverse consequences linked to delayed diagnosis and treatment initiation.

Safety of COVID-19 Vaccine in Patients with Rheumatic and Musculoskeletal Diseases.

Objectives: The main purpose of this study was to determine the frequency of COVID-19 vaccine side effects in patients with rheumatic diseases and to examine any potential associations with medications, disease type, or comorbidities. Methods: A multicentre cross-sectional study from rheumatology units in different hospitals in Iraq was carried out between 8th of August 2021 and 4th of August 2022. Patients were eligible for inclusion if they have a rheumatic disease and have taken one or more doses of any COVID-19 vaccine. Results: A total of 661 (57.8% female, mean age 46.51± 12.97 years) patients with rheumatic illnesses who received the "COVID-19" vaccination were included in this study. Rheumatoid arthritis was the most frequent diagnostic group. The Pfizer vaccine was given to the majority of patients (74.6%), followed by Sinopharm (16.2%), and AstraZeneca (9.2%). Side effects were detected in 661(100%) and 528 (100%) patients following the first and second vaccination doses, respectively; among which the most frequent were injection site pain in 57.8% following the first dose and 47.6% after the second dose, followed by fatigue and fever. According to multivariate logistic regression models, age (B=-0.204, p = 0.000), had a significantly inverse correlation coefficient with the experience of greater side effects. Rheumatic disease flares reported in 9.9%, 10.3%, and 8.2% of patients who received the Pfizer, Sinopharm, and AstraZeneca vaccines, respectively. Conclusion: The "COVID-19" vaccination has a reassuring safety profile with no greater risk of adverse events in any specific illness or pharmacological therapy.

Unusual cause of inflammatory backache: SAPHO syndrome.

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) is a rare chronic inflammatory disease that develops in adults. We present a case of SAPHO syndrome in a 37-year-old male presenting with gradually worsening back and neck pain for a 7-year period. The episodes were preceded by a history of pustular skin eruptions, which first appeared on the upper trunk and then involved his face and were pustular and scarring. The purpose of presenting this case report from Iraq is to raise awareness about this rare condition, which is frequently misdiagnosed and under-recognized.

Azathioprine-induced lymphoma in a patient with Takayasu arteritis: A case report from Iraq.

Key Clinical Message: Azathioprine, used for vasculitis and connective tissue diseases, carries long-term cancer risks. This case report raises awareness among healthcare providers about such risks and emphasizes the need for taking necessary precautions to avoid them while treating such diseases. Abstract: We present an Azathioprine-induced lymphoma case in a 51-year-old male patient with Takayasu arteritis who presented with painless cervical swelling, itching, weight loss, and decreased appetite. This case report aims to increase awareness of the potential long-term cancer risks associated with azathioprine use in the treatment of chronic diseases.

A case report of an extremely rare association of ankylosing spondylitis with pachydermoperiostosis.

Key Clinical Message: We describe a case of a young man with features of pachydermoperiostosis and spondyloarthropathy. By describing this rarity, we aim to help build a database for future studies and construct a management plan that rheumatologists and clinicians can use. Abstract: This is the first case report in Iraq describing the combination of pachydermoperiostosis and ankylosing spondylitis. We report this interesting association in a 23-year-old male who presented with inflammatory back pain, coarse facial features, clubbing, signs of enthesitis, limitation of spine movement, and clinical and radiographic signs of sacroiliitis.

Unusual presentation of rheumatoid arthritis in a 106-year-old woman: A rare case report.

By reporting this case, we hope to encourage medical professionals to concentrate on diagnosing old patients with unusual presentation of rheumatoid arthritis.

A 5 item version of the Workplace Activity Limitation Scale successfully identifies impaired work productivity in rheumatoid arthritis patients: A split-sample factor analysis approach.

BACKGROUND: There is a growing interest in studying the effects of arthritis on a person's work productivity using a growing variety of outcome indicators. OBJECTIVES: To develop a valid and reliable shortened version of the Workplace Activity Limitation Scale 12 (WALS-12) for assessing work productivity limitations in rheumatoid arthritis (RA) patients. METHODS: A cross-sectional study involving 277 RA patients was conducted. An exploratory factor analysis on WALS-12 was used for item reduction on the first sample. Then confirmatory factor analysis (CFA) was run to establish the best fit indices of the reduced version. On the second sample, CFA and linear discriminant analysis were performed to assess the diagnostic performance and discriminant ability of the reduced form. A Bland-Altman method was used to find the agreement between the WALS-12 and the reduced one. RESULTS: The WALS-12 was reduced to 5 items. The Cronbach α was 0.817, with a composite reliability of 0.715. The Spearman rho correlation coefficient ranged between 0.675 and 0.795 for WALS-5, which was higher for the scale items with their domains than the correlation of WALS-5 with the domains of Work Limitations Questionnaire-25. Also, the root square of the average variant extracted from WALS-5 was 0.802. WALS-5 showed excellent discriminant ability with an area under the curve of 0.98 (P < .001), sensitivity of 97%, specificity of 82%, and accuracy of 94%. The reduced version WALS-5 was in agreement with the original version WALS-12. CONCLUSIONS: WALS-5 is a valid and reliable tool to assess the work productivity limitations in RA patients.

A case report of H-syndrome from Baghdad Medical City treated with tocilizumab.

This case report presents the first H-syndrome rarity in Iraq, a 12-year-old female patient who was attending the Rheumatology out clinic for progressive hands joint deformities. She has a history of a multi-systemic collection of diseases with various clinical features that include beta thalassemia minor, sensorineural deafness, and celiac disease.

Mean platelet volume to lymphocyte ratio and platelet distribution width to lymphocyte ratio in Iraqi patients diagnosed with systemic lupus erythematosus.

Introduction: The mean platelet volume to lymphocyte ratio (MPVLR) and platelet distribution width to lymphocyte ratio (PDWLR) have the potential to serve as markers of inflammation which may indicate disease activity. The mean platelet volume to lymphocyte ratio and PDWLR were assessed in patients with systemic lupus erythematosus (SLE) in this study. Material and methods: Sixty-two patients with systemic lupus erythematosus and 79 controls who were age and gender matched were included. Their sociodemographic information, as well as disease activity scores based on the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), disease duration, current medications, lymphocytes, platelets, platelet distribution width (PDW), and mean platelet volume (MPV), anti-nuclear antibody (ANA), anti-double stranded deoxyribonucleic acid (anti-dsDNA), and complement components (C3, C4) were recorded. The correlations of MPVLR and PDWLR with disease activity and some laboratory parameters were analyzed. Results: Lupus patients had significantly higher median (interquartile range) values for MPVLR and PDWLR than controls (5.69 [1.16-23.67] vs. 4.40 [2.78-11.93], p = 0.009) and 10.51 (2.87-79.37) vs. 5.21 (2.88-14.66), p < 0.001] respectively. According to the ROC curve, > 7.53 was the best PDWLR cut-off value for predicting SLE with a sensitivity of 71%, a specificity of 87% and an accuracy of 82.6%, whereas the optimum MPVLR cut-off value was > 6.46 with a sensitivity of 45.2%, a specificity of 88.9% and an accuracy of 76.8%. In addition, MPVLR had a significant positive correlation with SLEDAI (r = 0.34, p = 0.008). However, there was no significant correlation between PDWLR and SLEDAI (r = 0.23, p = 0.067). Furthermore, PDWLR had a significant positive correlation with PDW (r = 0.482, p < 0.001), while MPVLR had a significant negative correlation with C3 level (r = -0.260, p = 0.042). Both PDWLR and MPVLR were positively correlated with nephritis (r = 0.388, p = 0.002; r = 0.246, p = 0.038, respectively). Conclusions: The platelet distribution width to lymphocyte ratio can be considered as an assisting biomarker in the diagnosis of SLE with the other clinical and serological parameters. The mean platelet volume to lymphocyte ratio may be used in the evaluation of disease activity in SLE patients.

Neutrophil/lymphocyte and platelet/lymphocyte ratios as potential markers of disease activity in patients with Ankylosing spondylitis: a case-control study.

BACKGROUND: The neutrophil/ lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) have the potential to be inflammatory markers that reflect the activity of many inflammatory diseases. The aim of this study was to evaluate the NLR and PLR as potential markers of disease activity in patients with ankylosing spondylitis. METHODS: The study involved 132 patients with ankylosing spondylitis and 81 healthy controls matched in terms of age and gender. Their sociodemographic data, disease activity scores using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), erythrocyte sedimentation rate (ESR), and white blood cell, neutrophil, lymphocyte and platelet counts were recorded. The patients with ankylosing spondylitis were further divided according to their BASDAI scores into patients with inactive disease (BASDAI < 4) and patients with active disease (BASDAI ≥4). The correlations between the NLR, PLR and disease activity were analysed. RESULTS: There was a statistically significant difference in the NLR and PLR between the active and inactive ankylosing spondylitis patients (2.31 ± 1.23 vs. 1.77 ± 0.73, p = 0.002), (142.04 ± 70.98 vs. 119.24 ± 32.49, p <  0.001, respectively). However, there was no significant difference in both the NLR and PLR between the healthy control group and ankylosing spondylitis patients (p > 0.05). In addition, the PLR was significantly higher in both the active and inactive groups compared to those in the healthy control group (142.04 ± 70.98 vs. 99.32 ± 33.97, p = 0.014), (119.24 ± 32.49 vs. 99.32 ± 33.97, p = 0.019). The BASDAI scores were positively correlated with the PLR (r = 0.219, p = 0.012) and the NLR, but they were not statistically significant with the later (r = 0.170, p = 0.051). Based on the ROC curve, the best NLR cut-off value for predicting severe disease activity in ankylosing spondylitis patients was 1.66, with a sensitivity of 61.8% and a specificity of 50.6%, whereas the best PLR cut-off value was 95.9, with a sensitivity of 70.9% and a specificity of 55.5%. CONCLUSION: The PLR may be used as a useful marker in the assessment and monitoring of disease activity in AS together with acute phase reactants such as the ESR.

Neutrophil/lymphocyte and platelet/lymphocyte ratios as potential markers of disease activity in patients with Ankylosing spondylitis: a case-control study

Abstract Background: The neutrophil/ lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) have the potential to be inflammatory markers that reflect the activity of many inflammatory diseases. The aim of this study was to evaluate the NLR and PLR as potential markers of disease activity in patients with ankylosing spondylitis. Methods: The study involved 132 patients with ankylosing spondylitis and 81 healthy controls matched in terms of age and gender. Their sociodemographic data, disease activity scores using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), erythrocyte sedimentation rate (ESR), and white blood cell, neutrophil, lymphocyte and platelet counts were recorded. The patients with ankylosing spondylitis were further divided according to their BASDAI scores into patients with inactive disease (BASDAI < 4) and patients with active disease (BASDAI ≥4). The correlations between the NLR, PLR and disease activity were analysed. Results: There was a statistically significant difference in the NLR and PLR between the active and inactive ankylosing spondylitis patients (2.31 ± 1.23 vs. 1.77 ± 0.73, p = 0.002), (142.04 ± 70.98 vs. 119.24 ± 32.49, p < 0.001, respectively). However, there was no significant difference in both the NLR and PLR between the healthy control group and ankylosing spondylitis patients (p > 0.05). In addition, the PLR was significantly higher in both the active and inactive groups compared to those in the healthy control group (142.04 ± 70.98 vs. 99.32 ± 33.97, p = 0.014), (119.24 ± 32.49 vs. 99.32 ± 33.97, p = 0.019). The BASDAI scores were positively correlated with the PLR (r = 0.219, p = 0.012) and the NLR, but they were not statistically significant with the later (r = 0.170, p = 0.051). Based on the ROC curve, the best NLR cut-off value for predicting severe disease activity in ankylosing spondylitis patients was 1.66, with a sensitivity of 61.8% and a specificity of 50.6%, whereas the best PLR cut-off value was 95.9, with a sensitivity of 70.9% and a specificity of 55.5%. Conclusion: The PLR may be used as a useful marker in the assessment and monitoring of disease activity in AS together with acute phase reactants such as the ESR.

Review of biologics, biosimilars, and intended copies in rheumatology, and current practice in Iraq.

Biologic therapies are an important option in the treatment of patients with rheumatic disease. As the development of potential biosimilars increases, many countries are following the guidelines developed by the WHO, European Medicines Agency, or US Food and Drug Administration to create country-specific regulations for the review and approval of these products. Iraq does not yet have such regulations, and this presents a potential safety concern for patients. The analytical, nonclinical, and clinical data requirements for approval of a potential biosimilar are specific and scientifically rigorous. In some countries, products are available that have not met the stringent criteria for biosimilars; they are usually referred to as "intended copies". Frequently, the available data are not sufficient to demonstrate that they are similar in efficacy and safety to the reference product. Thus, safety issues may arise once the product is in use, as was the case with Kikuzubam, an intended copy of rituximab that was withdrawn from the market in Mexico following reports of severe adverse reactions. It is important to implement scientific, evidence-based guidelines for the review, approval, therapeutic use, and monitoring of biosimilars, and to provide training on this topic to healthcare professionals and patients. In this review, we discuss issues related to the use and regulation of biosimilars, and the differences between biosimilars and intended copies. We also provide suggestions for including biosimilars as a treatment option in Iraq.