Chronic use of hydroxychloroquine did not protect against COVID-19 in a large cohort of patients with rheumatic diseases in Brazil.

BACKGROUND: There is a lack of information on the role of chronic use of hydroxychloroquine during the SARS-CoV-2 outbreak. Our aim was to compare the occurrence of COVID-19 between rheumatic disease patients on hydroxychloroquine with individuals from the same household not taking the drug during the first 8 weeks of community viral transmission in Brazil. METHODS: This baseline cross-sectional analysis is part of a 24-week observational multi-center study involving 22 Brazilian academic outpatient centers. All information regarding COVID-19 symptoms, epidemiological, clinical, and demographic data were recorded on a specific web-based platform using telephone calls from physicians and medical students. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. Mann-Whitney, Chi-square and Exact Fisher tests were used for statistical analysis and two binary Final Logistic Regression Model by Wald test were developed using a backward-stepwise method for the presence of COVID-19. RESULTS: From March 29th to May 17st, 2020, a total of 10,443 participants were enrolled, including 5166 (53.9%) rheumatic disease patients, of whom 82.5% had systemic erythematosus lupus, 7.8% rheumatoid arthritis, 3.7% Sjögren's syndrome and 0.8% systemic sclerosis. In total, 1822 (19.1%) participants reported flu symptoms within the 30 days prior to enrollment, of which 3.1% fulfilled the BMH criteria, but with no significant difference between rheumatic disease patients (4.03%) and controls (3.25%). After adjustments for multiple confounders, the main risk factor significantly associated with a COVID-19 diagnosis was lung disease (OR 1.63; 95% CI 1.03-2.58); and for rheumatic disease patients were diagnosis of systemic sclerosis (OR 2.8; 95% CI 1.19-6.63) and glucocorticoids above 10 mg/ day (OR 2.05; 95% CI 1.31-3.19). In addition, a recent influenza vaccination had a protective effect (OR 0.674; 95% CI 0.46-0.98). CONCLUSION: Patients with rheumatic disease on hydroxychloroquine presented a similar occurrence of COVID-19 to household cohabitants, suggesting a lack of any protective role against SARS-CoV-2 infection. Trial registration Brazilian Registry of Clinical Trials (ReBEC; RBR - 9KTWX6).

Chronic use of hydroxychloroquine did not protect against COVID-19 in a large cohort of patients with rheumatic diseases in Brazil

Abstract Background: There is a lack of information on the role of chronic use of hydroxychloroquine during the SARS-CoV-2 outbreak. Our aim was to compare the occurrence of COVID-19 between rheumatic disease patients on hydroxychloroquine with individuals from the same household not taking the drug during the first 8 weeks of community viral transmission in Brazil. Methods: This baseline cross-sectional analysis is part of a 24-week observational multi-center study involving 22 Brazilian academic outpatient centers. All information regarding COVID-19 symptoms, epidemiological, clinical, and demographic data were recorded on a specific web-based platform using telephone calls from physicians and medical students. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. Mann-Whitney, Chi-square and Exact Fisher tests were used for statistical analysis and two binary Final Logistic Regression Model by Wald test were developed using a backward-stepwise method for the presence of COVID-19. Results: From March 29th to May 17st, 2020, a total of 10,443 participants were enrolled, including 5166 (53.9%) rheumatic disease patients, of whom 82.5% had systemic erythematosus lupus, 7.8% rheumatoid arthritis, 3.7% Sjögren's syndrome and 0.8% systemic sclerosis. In total, 1822 (19.1%) participants reported flu symptoms within the 30 days prior to enrollment, of which 3.1% fulfilled the BMH criteria, but with no significant difference between rheumatic disease patients (4.03%) and controls (3.25%). After adjustments for multiple confounders, the main risk factor significantly associated with a COVID-19 diagnosis was lung disease (OR 1.63; 95% CI 1.03-2.58); and for rheumatic disease patients were diagnosis of systemic sclerosis (OR 2.8; 95% CI 1.19-6.63) and glucocorticoids above 10 mg/ day (OR 2.05; 95% CI 1.31-3.19). In addition, a recent influenza vaccination had a protective effect (OR 0.674; 95% CI 0.46-0.98). Conclusion: Patients with rheumatic disease on hydroxychloroquine presented a similar occurrence of COVID-19 to household cohabitants, suggesting a lack of any protective role against SARS-CoV-2 infection. Trial registration Brazilian Registry of Clinical Trials (ReBEC; RBR - 9KTWX6).

Hemofilia adquirida A: relato de caso / Acquired hemophilia A: case report

Hemofilia adquirida A (HAA) é uma doença rara ? incidênciade 1/1.000.000 ao ano -, com maior prevalência em pessoas de65 a 85 anos. A doença caracteriza-se pela presença de autoanticorposcontra fator VIII (FVIII), o que induz a inibição daligação entre este com fator de Von Willebrand e consequenteinativação de sua função anticoagulante. O objetivo deste trabalhofoi apresentar um caso de Hemofilia adquirida A e destacar anecessidade do médico generalista para o reconhecimento destadoença, visto que sua alta taxa de mortalidade - aproximadamentemais de 20% - a torna um importante diagnóstico diferencialde coagulopatias graves. Paciente do sexo masculino, 59anos, com quadro de dor no ombro esquerdo e evolução parahematomas em diversas partes do corpo. Confirmado o diagnósticode hemofilia adquirida A, iniciou-se o tratamento suportivoe de supressão de inibidor de fator VIII, entretanto, houve novossangramentos. Após terapêutica com ciclofosfamida, foi obtidaa supressão das recorrências dos casos hemorrágicos. Devido aposterior desenvolvimento de anemia, o quimioterápico foi suspenso.Um mês após a retirada do fármaco, o paciente segue semreincidência do quadro. O diagnóstico de hemofilia adquirida Aé evidente caso haja o conhecimento prévio dos achados semiológicose sua rotina de investigação laboratorial, mas frequentementeé atrasado devido à falta de familiaridade com a doençapelos médicos generalistas, fator que interfere diretamente nocurso da Hemofilia adquirida A, pois o diagnóstico precoce éum fator determinante para a redução da taxa de mortalidade.(AU)

Acquired hemophilia A (AHA) is a rare disease ? incidence of1/1.000.000 per year - with a higher prevalence in the elderly.The condition is characterized by the presence of autoantibodiesagainst factor VIII, which induces inhibition of its binding tovon Willebrand factor and consequent inactivation of theiranticoagulant function. The objective of this paper was topresent a case of Acquired hemophilia A and emphasize theneed of primary care physicians to recognize this disease, animportant differential diagnosis of severe coagulopathy, withhigh mortality rate. A fifty-nine years old male patient, withleft shoulder pain and development of hematomas in severalareas of the body. The diagnosis of Acquired hemophilia Awas confirmed and supportive treatment and suppression offactor VIII inhibitor was initiated. However, there was furtherbleeding. After therapy with cyclophosphamide, suppressionof recurrent bleeding cases was obtained. Due to furtherdevelopment of anemia, chemotherapy was discontinued.One month after withdrawal of treatment the patient remainswithout recurrence. The diagnosis of Acquired hemophilia Acan be easier done if there is prior knowledge of the clinicalfindings and interpretation of laboratory investigation. Delayeddiagnosis due to lack of familiarity with the disease by generaldoctors directly interferes in the course of Acquired hemophiliaA, because the early diagnosis is a key factor in reducing themortality rate.(AU)

Use of infliximab in a patient with rheumatoid arthritis and chronic hepatitis B.

Anti-TNF-α agents have emerged as a potent treatment for patients with rheumatoid arthritis unresponsive to conventional disease-modifying antirheumatic drugs. Increased susceptibility to infections induced by these drugs is the main complication of their use. Reactivation of hepatitis B virus (HBV) is one of the most worrisome side effects in patients with HBV infection receiving anti-TNF-α. We report the case of a 56-year-old male patient with stable hepatitis B and good response to the antiviral combination of lamivudine and tenofovir when infliximab was started. The patient went into remission. During the 30-month treatment with the biologic, his liver function remained stable, with no HBV reactivation.

Uso de infliximabe em paciente com artrite reumatoide e hepatite B crônica / Use of infliximab in a patient with rheumatoid arthritis and chronic hepatitis B

Os agentes anti-TNF-α emergiram como potente tratamento para os pacientes com artrite reumatoide que não respondem às drogas modificadoras de doença convencionais. Por induzir à imunossupressão, essas drogas têm como principal complicação o aumento da suscetibilidade a várias infecções. A reativação do vírus da hepatite B (HBV) é um dos efeitos colaterais mais preocupantes em pacientes recebendo agentes anti-TNF-α com infecção pelo HBV. Descrevemos o caso de um paciente de 56 anos com quadro de hepatite B estável, com boa resposta à associação dos antivirais lamivudina e tenofovir quando iniciou infliximabe. O paciente obteve boa resposta ao anti-TNF-α , atingindo remissão da doença. Durante os 30 meses de tratamento com o biológico, manteve função hepática estável, sem reativação do HBV.

Anti-TNF-α agents have emerged as a potent treatment for patients with rheumatoid arthritis unresponsive to conventional disease-modifying antirheumatic drugs. Increased susceptibility to infections induced by these drugs is the main complication of their use. Reactivation of hepatitis B virus (HBV) is one of the most worrisome side effects in patients with HBV infection receiving anti-TNF-α. We report the case of a 56-year-old male patient with stable hepatitis B and good response to the antiviral combination of lamivudine and tenofovir when infliximab was started. The patient went into remission. During the 30-month treatment with the biologic, his liver function remained stable, with no HBV reactivation.

Manifestações clínicas e laboratoriais de polimiosite em um caso de leptospirose / Clinical and laboratorial features of polymyositis in a case of leptospirosis

Nem sempre é possível estabelecer uma clara distinção entre as doenças musculares de causa infecciosa e as miosites idiopáticas. Há situações, inclusive, em que se considera existir uma relação causal entre ambas as doenças. Descrevemos o caso de uma paciente com manifestações clínicas e laboratoriais de polimiosite que apresentou infecção precedente de leptospirose, em que se considera a hipótese de ação de "gatilho" do agente infeccioso no quadro muscular inflamatório.

Sometimes, it is not possible to establish an obvious distinction between the muscular manifestations due to infectious diseases and the idiopathic myositis. In fact, in some situations it is believed there is a causal relationship between those diseases. We describe the case of a patient with clinical and laboratorial features of polymyositis who had developed leptospirosis previously. The hypothesis of the infectious agent acting as a "trigger" to the muscular disease is discussed.

Hipertensão arterial pulmonar e acidente vascular encefálico em paciente com Arterite de Takayasu / Pulmonary arterial hypertension and cerebrovascular disease in patient with Takayasu Arteritis

Arterite de Takayasu (AT) é uma doença rara caracterizada por vasculite dos grandes vasos, principalmente aorta e seus ramos. A inflamação vascular leva a irregularidades na parede do vaso, causando estenoses e aneurismas. O envolvimento da artéria pulmonar (AP) é freqüente na AT. Apesar disso, o desenvolvimento de hipertensão arterial pulmonar (HAP) é menos comum, alterando o tratamento e o prognóstico dos pacientes. Descrevemos um caso de uma paciente com AT com estenoses múltiplas em artérias pulmonares, HAP e doença cerebrovascular, além de revisão de literatura sobre o assunto.

Takayasu arteritis (TA) is a rare illness characterized by vasculitis of great vessels, mainly of aorta and its branches. The vascular inflammation leads to irregularities of the vessel wall causing stenosis and aneurysms. The pulmonary artery (PA) involvement is frequent in TA. Despite this, the development of pulmonary arterial hypertension is less common, modifying the treatment and the prognosis of the patients. We describe a case of a patient with TA with multiple stenosis in pulmonary arteries, pulmonary arterial hypertension and cerebrovascular disease, as well as review of the literature on the subject.

Osteoesclerose difusa associada com o vírus da hepatite C e com o uso de drogas endovenosas / Diffuse osteosclerosis associated with hepatitis C virus and intravenous drug abuse

A esclerose difusa adquirida é uma entidade em que se observa neoformação óssea. Foram observados casos de osteoesclerose em usuários de drogas endovenosas e portadores do vírus da hepatite C, o que permite que este vírus seja apontado como o provável fator etiológico. existe considerável aumento da densidade óssea, sendo o osso neoformado estruturalmente normal e não-suscetível a fraturas patológicas. Tal achado indica que o entendimento da fisiopatologia da osteoesclerose pode fornecer novas alternativas para o tratamento da osteoporose. Um caso de osteoesclerose em um homem de 36 anos com vírus da hepatite C adquirido pelo uso de drogas endovenosas é descrito

Vasculite necrotizante cutânea em paciente com artrite de Takayasu / Takayasu’s arteritis associated with cutaneous manifestations

O fato de a arterite de Takayasu ser um protótipo de doença de grandes vasos pode fazer com que as manifestações cutâneas, atribuídas ao acometimento de pequenos vasos, passem despercebidas. Descrevemos um caso de arterite de Takayasu associada a manifestações cutâneas decorrentes de vasculite necrotizante. Neste caso, correlacionamos os achados clínicos e laboratoriais com os da biópsia cutânea, estabelecendo o diagnóstico. A paciente respondeu prontamente ao regime terapêutico de prednisona e metotrexate.