New onset of axial spondyloarthropathy in patients treated with isotretinoin for acne vulgaris: incidence, follow-up, and MRI findings.

INTRODUCTION: Oral isotretinoin is commonly prescribed for acne vulgaris. Several case reports and observational studies have reported serious musculoskeletal side effects; however, the incidence, imaging findings, and longitudinal follow-up data are limited for patients who develop inflammatory back pain (IBP). OBJECTIVE: To assess the incidence of isotretinoin-triggered axial spondyloarthropathy (SpA) in acne vulgaris patients based on clinical features and MRI findings and to examine clinical and radiological outcomes following drug withdrawal. METHODS: Five hundred thirteen acne patients receiving isotretinoin were screened for IBP; IBP patients were assessed for CRP, plain radiographs, and MRI of the sacroiliac joint. MRI-proven sacroiliitis was scored semi-quantitatively. Patients were followed longitudinally to assess SpA clinical course and longitudinal MRI sacroiliac joints, and CRP levels were reassessed 3 weeks after patients were symptom-free, following isotretinoin discontinuation. RESULTS: Of the 513 patients, 23.98% developed IBP. MRI-proven sacroiliitis was detected in 42.3% of the symptomatic patients or 10.1% of the cohort. Among MRI-proven sacroiliitis cases, 51.9% fulfilled the Assessment of Spondyloarthritis International Society criteria for axial SpA. Mean CRP level was 32.05 ± 17.23 mg/L at pain onset and 3.4 ± 2.7 mg/L after symptom resolution. MRI findings completely resolved within 9 months (mean 6.27 ± 1.7) after isotretinoin discontinuation. MRI scores positively correlated with baseline CRP levels and global acne grading system score, pain, and the Ankylosing Spondylitis Disease Activity Score. CONCLUSION: Isotretinoin-induced axial SpA is a prevalent side effect in acne vulgaris patients. Early detection and follow-up of isotretinoin-induced sacroiliitis can be facilitated by MRI. Cessation of isotretinoin resulted in complete resolution in all affected patients.Key Points• Detection of underdiagnosed isotretinoin side effects which are common but not always correctly diagnosed and managed.• Incidence, diagnosis, and management of these side effects in a real-world setting.• This is the first large prospective longitudinal cohort study to report on axial manifestations in patients treated with isotretinoin as well as the effect of drug cessation upon the clinical, laboratory, and radiological findings.

Subclinical synovitis and enthesitis in psoriasis patients and controls by ultrasonography in Saudi Arabia; incidence of psoriatic arthritis during two years.

OBJECTIVE: To evaluate ultrasonographic subclinical inflammatory synovitis and enthesitis in psoriasis patients, without clinical arthritis or enthesitis compared with healthy controls, with a 2-year follow-up to study the associated incidence of psoriatic arthritis (PsA). METHODS: A total of 109 consecutive psoriasis vulgaris patients without clinical signs of PsA and 90 healthy controls were included from two tertiary medical centers. Subjects underwent dermatological examination, PASI score evaluation for severity of psoriasis, musculoskeletal examination using 68/66 joints count for tenderness and swollen joints. Patients were assessed for CRP, musculoskeletal ultrasound (MSUS) in the form of grayscale ultrasound (GSUS), and power Doppler ultrasound (PDUS) for eight entheses and 34 joints to detect MSUS subclinical enthesitis and synovitis. All patients were followed-up for 2 years to detect evolving PsA. RESULTS: Subclinical enthesitis and synovitis were detected in 39.5% of psoriasis patients and 10% of controls (P < 0.001). CRP was significantly higher in psoriasis patients with MSUS manifestations (P < 0.01). PDUS and GSUS subclinical synovitis and/or enthesitis were detected at least in one site in psoriatic patients more than in controls (P < 0.05). During a 2-year follow-up of patients, the annual PsA incidence was 4.3%. Psoriasis patients who developed PsA showed a higher prevalence of baseline enthesitis, higher PDUS and GSUS synovitis scores, and higher baseline CRP level than those who did not develop PsA. CONCLUSIONS: MSUS subclinical synovitis and enthesitis are quite common in psoriasis patients. The incidence of PsA in Saudi's psoriasis patients was slightly higher than worldwide reports. Subclinical enthesitis, PDUS, and GSUS synovitis could predict PsA development.

Significance of Anti-C1q Antibodies in Patients with Systemic Lupus Erythematosus as A Marker of Disease Activity and Lupus Nephritis.

Anti-C1q autoantibodies have been proposed as a useful marker in SLE. This study aimed at measuring serum levels of anti-C1q antibodies in patients with SLE and investigates correlations of this level with the histopathological classes of renal biopsies and disease activity. The anti-C1q antibody level was measured in 30 females SLE patients and 20 controls. The activity of SLE disease was calculated according to the SLE disease activity index. A renal biopsy from patients with clinical manifestations of renal disease was obtained. There was a significant increase in the level of anti-C1q antibodies in SLE patients than controls and in patients with active LN than inactive LN (P<0.05). There were significant positive correlations between anti-C1q antibody level and SLEDAI & rSLEDAI scores and activity index score of renal biopsies. Anti-C1q antibodies showed higher diagnostic sensitivity and specificity than anti-dsDNA antibodies. In conclusion, anti-C1q antibodies are useful and sensitive non-invasive biomarker with high specificity in combination with anti-dsDNA antibodies for the diagnosis of renal disease activity.

Value of electroencephalographic monitoring in newborns with hypoxic-ischemic encephalopathy treated with hypothermia.

BACKGROUND: The values of electroencephalography (EEG) in neonatal hypoxic-ischemic encephalopathy (HIE) during therapeutic hypothermia (TH) are still uncertain. AIMS: The aim of this study is to detect EEG background, the prevalence of seizures during cooling, and to determine different EEG patterns that can predict brain injury in magnetic resonance imaging (MRI). PATIENTS AND METHODS: Thirty-nine newborns with HIE were subjected to TH. Continuous monitoring by video-EEG was carried out throughout cooling and during rewarming. MRI was done for all newborns after rewarming. The predictive value of EEG background for MRI brain injury was evaluated at 6-h intervals during cooling and rewarming. RESULTS: At all-time intervals, normal EEG was associated with no or mild MRI brain injury. At the beginning of cooling, normal background was more predictive of a favorable MRI outcome than at later time points. After 24 h of monitoring, diffuse burst suppression and depressed patterns had the greatest prognostic value. In most patients, a discontinuous pattern was not associated with poor prognosis. Thirty-one percent developed electrical seizures, and 8% developed status epilepticus. Seizures were subclinical in 42%. There is a significant association between duration of seizure patterns detected on the EEG and severity of brain injury on MRI. CONCLUSIONS: Continuous EEG monitoring in newborns with HIE under cooling has a prognostic value about early MRI brain injury and identifies electrographic seizures, approximately 50% of which are subclinical. Treatment of clinical and subclinical seizure results in a reduction of the total duration of seizure pattern supports the hypothesis that subclinical seizures should be treated.

Diagnostic yield of percutaneous image-guided tissue biopsy of focal hepatic lesions in cancer patients: ten percent are not metastases from the primary malignancy.

BACKGROUND: The diagnostic yield was evaluated of percutaneous image-guided tissue biopsy of hepatic lesions identified on computed tomography performed for staging of a primary malignancy, and it was determined how often the biopsy result was unexpectedly negative, benign, or secondary to a second unknown malignancy. METHODS: In a retrospective investigation from 1998 through 2008, 580 patients with primary malignancies had indeterminate focal hepatic lesions and underwent percutaneous image-guided biopsy; 369 patients had lesions in their liver at first cross-sectional imaging, performed for staging; 211 patients had a negative liver imaging study, followed by the subsequent appearance of at least 1 indeterminate suspicious lesion. The results of percutaneous image-guided tissue biopsies were compared with the histology of the primary malignancy. RESULTS: Liver biopsies were performed in 580 patients (288 men and 292 women; age, 25-92 years; mean age, 61 years). The most common primary malignancies were pancreatic (n = 96), breast (n = 85), melanoma (n = 57), esophageal (n = 51), lung (n = 47), colorectal (n = 37), and urothelial tumors (n = 26). Biopsy results were positive for malignancy in 528 (91%) cases. Among the positive biopsies, 29 (5%) cases had pathology results different from the primary tumor. Of the 52 biopsies negative for malignancy, 20 yielded a specific benign diagnosis, and 32 were nondiagnostic. CONCLUSIONS: If all liver lesions had been assumed to be metastases, as expected secondary to the known primary tumor, then the true or presumed alternate diagnosis would have been missed in 60 (10.3%) of the 580 cases. The authors did not attempt to determine whether actual clinical management changed based on these 60 liver biopsy results, so this number is an upper bound on management change. On the basis of these results, and given the minimal complication rate of liver biopsy, the authors suggest that liver biopsy should still be performed in the types of cases studied here, despite the finding that the vast majority of biopsies produced the expected result and presumably did not change patient management.