Vasculitis Leading to Gangrene: An Early Presentation in a Rheumatoid Arthritis Patient.

Vasculitis is a late complication in rheumatoid arthritis (RA) and is seen in RA patients with long-standing disease. Rheumatoid vasculitis affects small-to-medium-sized vessels. In a few patients, vasculitis develops early in the course of the disease. Here, we report the case of a 32-year-old female who presented with gangrene in the second and third digits of the right foot and gangrene in the second digit of the left foot. She was on hydroxychloroquine and methotrexate for one year since the diagnosis of RA. The patient then developed Raynaud's phenomenon and blackish discoloration of toes. She was started on pulse methylprednisolone, aspirin, nifedipine, and pentoxifylline. As no improvement was seen, intravenous cyclophosphamide was started. There was no improvement even after starting cyclophosphamide, and the gangrene further worsened. Eventually, after consulting the surgical team, it was decided to amputate the digits. The second digits in both feet were subsequently amputated. Hence, a physician should always be careful in checking for signs of vasculitis in RA patients early in the course of the disease as well.

Mortality and Complications of COVID-19 Among Adult Congenital Heart Disease Patients: A Retrospective Cohort Study Using the National Inpatient Sample Database.

This study examines in-hospital mortality and complicated COVID-19 infection among adult congenital heart disease (ACHD) patients admitted with COVID-19, using the National Inpatient Sample (NIS). A total of 4219 COVID-19 patients with ACHD were included. We demonstrated that COVID-19 patients with ACHD were more likely to experience in-hospital mortality (OR 1.04, 95% CI 1.04-1.04, P < 0.01) and complicated COVID-19 infection (OR: 1.30, 95% CI: 1.11-1.53, P < 0.01). In our sub-group analysis, COVID-19 patients with tetralogy of Fallot (TOF) had higher mortality and COVID-19 patients with atrial septal defects (ASD) had a higher incidence of complicated infection when compared to COVID-19 patients with all other ACHDs. Risk factors for mortality among COVID-19 patients with ACHD include advanced age, lower income, unrepaired ACHD, malnutrition, and chronic liver disease. Accordingly, we recommend aggressive preventive care with vaccination and non-pharmacologic measures in order to improve survival for ACHD patients.

Population Risk Factors for Severe Disease and Mortality in COVID-19 in the United States during the Pre-Vaccine Era: A Retrospective Cohort Study of National Inpatient Sample.

Background-Previous studies on coronavirus disease 2019 (COVID-19) were limited to specific geographical locations and small sample sizes. Therefore, we used the National Inpatient Sample (NIS) 2020 database to determine the risk factors for severe outcomes and mortality in COVID-19. Methods-We included adult patients with COVID-19. Univariate and multivariate logistic regression was performed to determine the predictors of severe outcomes and mortality in COVID-19. Results-1,608,980 (95% CI 1,570,803-1,647,156) hospitalizations with COVID-19 were included. Severe complications occurred in 78.3% of COVID-19 acute respiratory distress syndrome (ARDS) and 25% of COVID-19 pneumonia patients. The mortality rate for COVID-19 ARDS was 54% and for COVID-19 pneumonia was 16.6%. On multivariate analysis, age > 65 years, male sex, government insurance or no insurance, residence in low-income areas, non-white races, stroke, chronic kidney disease, heart failure, malnutrition, primary immunodeficiency, long-term steroid/immunomodulatory use, complicated diabetes mellitus, and liver disease were associated with COVID-19 related complications and mortality. Cardiac arrest, septic shock, and intubation had the highest odds of mortality. Conclusions-Socioeconomic disparities and medical comorbidities were significant determinants of mortality in the US in the pre-vaccine era. Therefore, aggressive vaccination of high-risk patients and healthcare policies to address socioeconomic disparities are necessary to reduce death rates in future pandemics.

Giant cell arteritis and its mimics: A comparison of three patient cohorts.

OBJECTIVE: To compare temporal artery biopsy (TAB)-positive giant cell arteritis (GCA) to TAB-negative GCA and patients with GCA mimics METHODS: PATIENTS DIAGNOSED WITH TAB-POSITIVE AND TAB-NEGATIVE GCA BETWEEN 1/1/1998 AND 12/31/2013 WERE: retrospectively identified. These two groups were compared to a cohort of patients with TAB performed between 1/1/2009 and 12/31/2010 in which the TAB was negative and alternative diagnosis was provided after a minimum of 6-months of follow-up. Baseline characteristics were compared between groups using chi-square and rank sum tests. RESULTS: 591 study subjects were identified (286 TAB-positive, 110 TAB-negative GCA and 195 TAB-negative GCA mimics) during the respective study periods. Compared to TAB-negative GCA, GCA mimics had similar rates of headache and vision loss but significantly less frequent jaw/limb claudication, arterial bruits and constitutional symptoms, as well as lower platelet levels. Compared to TAB-positive GCA patients, TAB-negative GCA were younger, had shorter time to diagnosis, met fewer 1990 ACR classification criteria and had lower frequencies of polymyalgia rheumatica, jaw claudication and temporal artery abnormalities; but, higher frequency of arm claudication and constitutional symptoms. Among 61 TAB-negative patients with advanced arterial imaging, 43 (69%) had at least one abnormality consistent with GCA. CONCLUSION: Consideration of alternative diagnoses is requisite in evaluating patients with negative TAB. Advanced imaging assists in identifying occult large-vessel vasculitis and should be employed in all TAB-negative patients with suspicion for GCA.

Efficacy of Methotrexate in Real-world Management of Giant Cell Arteritis: A Case-control Study.

OBJECTIVE: To determine the effect of methotrexate (MTX) on relapse risk and glucocorticoid (GC) use in a large single-institution cohort of patients with giant cell arteritis (GCA). METHODS: Patients diagnosed with GCA from 1998 to 2013 with confirmed evidence of temporal artery biopsy and/or radiographic evidence of large vessel vasculitis were identified. Each patient with GCA treated with adjunct MTX (case) was matched to a similar patient with GCA treated only with GC (control). GC requirements and relapse events before and after MTX initiation (or corresponding index date) were compared using rate ratios (RR). RESULTS: Eighty-three cases and 83 controls were identified and compared. No significant differences in age, demographics, laboratory variables, baseline disease characteristics, or mean initial prednisone doses were observed. Median [interquartile range (IQR)] time from GCA diagnosis to MTX initiation in cases was 39 (13-80) weeks and the median (IQR) starting dose was 13.5 (10-15) mg/week. RR comparing relapse rates before and after MTX initiation/index date were significantly reduced in both cases (RR 0.32, 95% CI 0.24-0.41) and controls (RR 0.60, 95% CI 0.43-0.86). The decrease in relapse rate was significantly greater in patients taking MTX than in those taking GC alone (p = 0.004). Rates of GC discontinuation did not differ between groups. CONCLUSION: In this large single-institution cohort, the addition of MTX to GC decreased the rate of subsequent relapse by nearly 2-fold compared to patients taking GC alone. MTX may be considered as adjunct therapy in patients with GCA to decrease the risk of further relapse events.