Improved Oral Health Is Associated with a Lower Risk of Late Onset Ankylosing Spondylitis: A Nationwide Cohort Study.

Background: The aim of this study was to evaluate the association of oral health status and habits with the occurrence of ankylosing spondylitis (AS) in a nationwide population-based cohort in a longitudinal setting. Methods: A total of 2,415,963 individuals aged 40-79 years who underwent oral health examinations were included from the National Health Insurance Service-National Health Screening (NHIS-HEALS) cohort of Korea between 2003 and 2004. The occurrence of AS was analyzed according to the oral health status and oral hygiene habits. Results: Among 2,271,221 of the participants, AS occurred in 6366 (0.3%) participants over 16.7 years. The likelihood of AS was higher in participants who had periodontitis (hazard ratio [HR]: 1.33, 95% confidence interval [CI]: 1.20-1.46, p < 0.0001) and more missing teeth (HR: 1.68, 95% CI: 1.42-1.99, p < 0.0001). However, better oral hygiene habits such as frequent tooth brushing (HR: 0.77, 95% CI: 0.71-0.83, p < 0.0001) and a history of dental scaling within the last year (HR 0.88, 95% CI 0.82-0.95, p = 0.001) were associated with a lower occurrence of AS. Conclusions: Periodontitis and an increased number of missing teeth could be related to the occurrence of late-onset AS. Improved oral hygiene care may attenuate the likelihood of late-onset AS.

Korean guidelines for the management of gout.

Gout is the most common form of arthritis, with the prevalence increasing worldwide. The present treatment guidelines provide recommendations for the appropriate treatment of acute gout, management during the inter-critical period, and prevention of chronic complications. The guidelines were developed based on evidence-based medicine and draft recommendations finalized after expert consensus. These guidelines are designed to provide clinicians with clinical evidence to enable efficient treatment of gout.

Korean guidelines for the management of gout.

Gout is the most common form of arthritis, with the prevalence increasing worldwide. The present treatment guidelines provide recommendations for the appropriate treatment of acute gout, management during the inter-critical period, and prevention of chronic complications. The guidelines were developed based on evidence-based medicine and draft recommendations finalized after expert consensus. These guidelines are designed to provide clinicians with clinical evidence to enable efficient treatment of gout.

Association of Oral Health with Risk of Rheumatoid Arthritis: A Nationwide Cohort Study.

Periodontitis and rheumatoid arthritis (RA) are inflammatory diseases that share many similarities. We aimed to investigate the associations of periodontitis and oral hygiene status and behaviors with RA in a nationwide general population cohort. Participants from the National Health Screening cohort database of Korea who underwent oral health screening by dentists between 2003 and 2004 were included. The occurrence of RA was analyzed according to the presence of periodontitis, oral health examination findings, and behaviors. Overall, 2,239,586 participants were included. During a median of 16.7 years, RA occurred in 27,029 (1.2%) participants. The risk for incident RA was higher when participants had periodontitis (hazard ratio (HR) 1.2, 95% confidence interval (CI), 1.08-1.24) and an increased number of missing teeth (HR 1.5, 95% CI, 1.38-1.69). In contrast, better oral hygiene behaviors, such as a higher frequency of daily tooth brushing (HR 0.76, 95% CI 0.73-0.79, p for trend <0.001) and a recent history of dental scaling (HR 0.96, 95% CI 0.94-0.99), were associated with a lower occurrence of RA. Periodontitis and increased missing teeth were associated with an increased risk of RA. Maintaining good oral hygiene through frequent tooth brushing and regular dental scaling may reduce the risk of RA occurrence.

Incidence and prevalence of seropositive rheumatoid arthritis among Korean women of childbearing age: a nationwide population-based study.

BACKGROUND/AIMS: Women with rheumatoid arthritis (RA) are often diagnosed with the disease during their reproductive years; however, its incidence and prevalence among women of childbearing age have not been studied. The objective of this study was to estimate the incidence and prevalence of seropositive rheumatoid arthritis (SPRA) among Korean women of childbearing age. METHODS: Women aged 20 to 44 years with SPRA were identified from National Health Insurance Service-National Health Information Database (2009 to 2016). SPRA was defined by International Classification of Diseases, 10th revision code, M05. Incidence and prevalence were calculated per 100,000 person-years and stratified by year and age. RESULTS: The average incidence and prevalence of SPRA from 2011 to 2016 among women of childbearing age was 24.1/100,000 person-years (95% confidence interval [CI], 23.7 to 24.5) and 105.2/100,000 person-years (95% CI, 100.9 to 109.5), respectively. The incidence increased annually from 21.0/100,000 person-years (95% CI, 20.1 to 21.9) in 2009 to 28.4 person-years (95% CI, 27.3 to 29.5) in 2016. Similarly, the prevalence increased annually from 95.7/100,000 person-years (95% CI, 93.7 to 97.6) in 2009 to 111.0 person-years (95% CI, 108.9 to 113.2) in 2015, with a slight decrease in 2016 (110.4 person-years; 95% CI, 108.2 to 112.6). The incidence and prevalence of SPRA increased with advancing age. The peak age for both incidence and prevalence of SPRA among women of childbearing age was 40 to 44 years. CONCLUSION: The risk of SPRA is high in women during their childbearing years; this population bears a significant disease burden. This calls for special attention to this particular population group to reduce the risk and burden of this disease.

Differential effects of periodontal microbiome on the rheumatoid factor induction during rheumatoid arthritis pathogenesis.

Association between exposure to periodontal bacteria and development of autoantibodies related to rheumatoid arthritis (RA) has been widely accepted; however, direct causal relationship between periodontal bacteria and rheumatoid factor (RF) is currently not fully understood. We investigated whether periodontal bacteria could affect RF status. Patients with preclinical, new-onset, or chronic RA underwent periodontal examination, and investigation of subgingival microbiome via 16S rRNA sequencing. Degree of arthritis and RF induction was examined in collagen-induced arthritis (CIA) mice that were orally inoculated with different periodontal bacteria species. Subsequently, single-cell RNA sequencing analysis of the mouse spleen cells was performed. Patients with preclinical RA showed an increased abundance of the Porphyromonadacae family in the subgingival microbiome compared to those with new-onset or chronic RA, despite comparable periodontitis severity among them. Notably, a distinct subgingival microbial community was found between patients with high-positive RF and those with negative or low-positive RF (p=0.022). Oral infections with the periodontal pathogens P. gingivalis and Treponema denticola in CIA mice similarly enhanced arthritis score, but resulted in different levels of RF induction. Genes related to B cell receptor signaling, B cell proliferation, activation, and differentiation, and CD4+ T cell costimulation and cytokine production were involved in the differential induction of RF in mice exposed to different bacteria. In summary, periodontal microbiome might shape RF status by affecting the humoral immune response during RA pathogenesis.

Risk of Pregnancy Complications and Low Birth Weight Offsprings in Korean Women With Rheumatic Diseases: A Nationwide Population-Based Study.

BACKGROUND: To determine the risk of pregnancy complications and adverse offspring outcomes in Korean women with rheumatic diseases (RDs). METHODS: Women aged 20-44 years with pregnancies ending in delivery were identified from the National Health Insurance Service-National Health Information Database (2009-2016). Women with RD including systemic lupus erythematosus (SLE), seropositive rheumatoid arthritis (SPRA), and ankylosing spondylitis (AS) (n = 4,284) were age-matched with controls (n = 26,023). Outcome variables included threatened abortion (TA), preterm birth (PB), preeclampsia/eclampsia (PE/E), intrauterine growth retardation (IGR), urinary tract infection, low birth weight (LBW) offsprings, and offspring death within 1 year of birth. RESULTS: Women with RDs had increased risks for cesarean section delivery (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.4-1.6), TA (OR, 1.4; 95% CI, 1.2-1.5), PB (OR, 2.4; 95% CI, 1.9-3.2), PE/E (OR, 4.4; 95% CI, 3.3-5.9), and IGR (OR, 2.4; 95% CI, 2.0-3.1) than the controls. The risk of pregnancy complications was increased in SLE and SPRA pregnancies but not in AS pregnancies. Offsprings of women with RDs had an increased risk of LBW (OR, 4.0; 95% CI, 3.2-4.9). The offspring mortality rate within 1 year of birth was higher in women with RDs (6.2/10,000 persons) than in the controls (4.9/10,000 persons). CONCLUSION: Women with RDs are at a risk of developing pregnancy complications, and the risk of LBW offsprings and offspring death within 1 year of birth is increased in these women. Therefore, this population requires special attention during their childbearing years.

Burden of comorbidities and medication use in childbearing women with rheumatic diseases: a nationwide population-based study.

BACKGROUND/AIMS: We aimed to estimate the prevalence of comorbidities and medication use in Korean women with rheumatic diseases (RDs) during their childbearing years. METHODS: We included women aged 20 to 44 years with seropositive rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS) (n = 41,547) and age-matched women without seropositive RA, SLE, and AS (n = 208,941) from the National Health Insurance Service-National Health Information Database (2009 to 2016). The prevalence of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), and cancer and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids (CSs), and disease-modifying anti-rheumatic drugs (DMARDs) were estimated. RESULTS: Women of childbearing age with RDs were more likely to have at least one of the measured comorbidities than the controls (odds ratio [OR], 3.0; 95% confidence interval [CI], 2.9 to 3.1). The OR (95% CI) was 2.9 (2.8 to 3.0) for HTN, 2.8 (2.7 to 2.9) for HLD, 1.4 (1.4 to 1.5) for DM, and 1.3 (1.3 to 1.4) for cancer. The SLE group had the highest prevalence and odds of all four measured comorbidities. Almost all (97.9%) women of childbearing age with RDs were taking RD-related medications (NSAIDs, 81.6%; CSs, 77.8%; DMARDs, 87.3%). The RD group was 13.8 times more likely to take NSAIDs and 68.2 times more likely to take CSs than the controls. Use of NSAIDs was more prevalent in RA and AS than SLE, whereas use of CSs and DMARDs was more prevalent in RA and SLE than AS. CONCLUSION: Korean women with RDs have a greater burden of comorbidities and medication use during their childbearing years than women without RDs of the same age.

Patient Perspectives and Preferences Regarding Gout and Gout Management: Impact on Adherence.

BACKGROUND: Patient-centered management is becoming increasingly important in gout, but there are limited studies exploring patients' perspectives and preferences. We aimed to investigate patients' perspectives and preferences regarding gout and gout management, and their impacts on adherence to urate lowering therapy (ULT). METHODS: A paper-based survey was performed in patients with gout seen at the rheumatology outpatient clinics of 16 tertiary hospitals. The survey included questions regarding demographics, comorbidities, gout attacks, current treatment and adherence, and patients' perspectives and preferences regarding gout and gout management. Multivariate regression analysis was performed to determine the factors associated with ULT adherence. RESULTS: Of 809 surveyed patients with gout, 755 (94.5%) were using ULT. Among those using ULT, 89.1% had ≥ 80% adherence to ULT. Majority of the patients knew management strategies to some extent (94.8%), perceived gout as a life-long disease (91.2%), and were making efforts toward practicing at least one lifestyle modification (89.2%). Most patients (71.9%) obtained information about gout management during their clinic visits. Approximately half of the patients (53.6%) preferred managing their disease with both ULT and lifestyle modification, 28.4% preferred ULT only, and 17.4% preferred lifestyle modification only. Adherence was better in patients with older age (odds ratio [OR], 1.03), those with better knowledge of gout management strategies (OR, 3.56), and those who had preference for ULT (OR, 2.07). CONCLUSION: Patients' perspectives and management preferences had high impacts on adherence to ULT in gout. Consideration of patients' perspectives and preferences is important for achieving the desired clinical outcome in gout.

Incidence and prevalence of systemic lupus erythematosus among Korean women in childbearing years: A nationwide population-based study.

BACKGROUND: Most women with systemic lupus erythematosus (SLE) are diagnosed with the disease in their reproductive years, but the incidence and prevalence of SLE among women of childbearing age have not been studied. The objective of this study was to estimate the incidence and prevalence of SLE among the Korean women of childbearing age. METHODS: Women aged 20 to 44 years with SLE were identified from National Health Insurance Service - National Health Information Database (2009-2016), which contain health information of approximately 97% of the Korean population. SLE was defined by International Classification of Diseases, 10th revision code, M32. Incidence and prevalence were calculated per 100,000 person-years and stratified by year and age. RESULTS: A total of 12,756 women with SLE were identified. The incidence of SLE from 2011 to 2016 among women in childbearing years was 8.18/100,000 person-years (95% CI 7.94-8.43), with the highest incidence in 2016 (8.56/100,000 person-years, 95% CI 7.95-9.17) and the lowest incidence in 2012 (7.85/100,000 person-years, 95% CI 7.28-8.42). The prevalence of SLE from 2009 to 2016 among women in childbearing years was 77.07/100,000 person-years (95% CI 75.76-78.39), with the highest prevalence in 2014 (79.47/100,000 person-years, 95% CI 77.64-81.30) and the lowest in 2010 (74.19/100,000 person-years, 95% CI 72.45-75.93). The peak age for SLE incidence was between 25-39 years, and lower incidence was seen in the early (20-24 years) and late (40-44 years) childbearing age periods. There was an increasing trend in prevalence according to age in women of childbearing age, with the highest prevalence occurring in the 40-44 age group. CONCLUSIONS: The risk and burden of SLE are high among women during their childbearing years. This calls for special attention to this particular population group when allocating health resources.

Effects of birth months on rheumatic diseases in South Korea: a nationwide case-control study.

OBJECTIVES: Birth month/season impacts the development of certain diseases. However, the effect of birth month/season on the development of rheumatic diseases has not been thoroughly investigated. Thus, the objective of this study was to determine whether birth month/season might affect the development of rheumatic diseases. METHODS: Birth month patterns of patients with various rheumatic diseases were compared with those of the general population. The dataset included 17,247,458 individuals from the health insurance review and assessment service database of Korea. RESULTS: Among 24 rheumatic diseases, the development of Crohn's disease, ulcerative colitis (UC), rheumatoid arthritis, Sjögren's syndrome, polymyalgia rheumatica, ankylosing spondylitis (AS), gout, and fibromyalgia (FM) was significantly associated with birth month/season. UC and AS were more prevalent in individuals born in February/winter. On the contrary, those who were born in June or July/summer were at a higher risk of gout and FM. CONCLUSIONS: Seasonal variations in infectious agents, sun exposure, and food ingestion during gestation or early infancy seem to explain the association between birth month/season and development of rheumatic diseases.

Association of periodontitis with radiographic knee osteoarthritis.

BACKGROUND: To examine whether periodontitis is associated with the presence and severity of radiographic knee osteoarthritis (OA). METHODS: Using data from the Korea National Health and Nutrition Examination Survey between 2010 and 2013, participants over the age of 50 were included in this study. Dental examinations and knee radiographs are performed in participants aged ≥50 years in this cohort. Periodontitis was defined using the community periodontal index, which was determined by measuring periodontal probing depth. The definition of radiographic knee OA was based on the Kellgren-Lawrence (K-L) grading system, which determined a K-L class ≥2 to be radiographic knee OA. The associations between periodontitis and presence and severity of radiographic knee OA were examined using logistic regression analyses. RESULTS: Among 7969 total participants, 965 men and 2078 women had radiographic knee OA. Periodontitis was observed in 1,185 (39.4%) people among those who had radiographic knee OA. Periodontitis (adjusted odds radio [aOR] 1.21, 95% confidence interval 1.05 to 1.40) was associated with radiographic knee OA after adjusting for variables including age, sex, body mass index, socioeconomic status, diabetes, and dental status. Participants were more likely to have radiographic knee OA as the severity of periodontitis increased (non-severe periodontitis, aOR 1.14 [0.98 to 1.32]; severe periodontitis, aOR 1.47 [1.17 to 1.85]). Moreover, the presence of periodontitis significantly increased with an increasing K-L class (class 1, aOR 1.30 [1.09 to 1.54]; class 2, aOR 1.32 [1.08 to 1.60]; class 3, aOR 1.39 [1.14 to 1.70]; class 4, aOR 1.45 [1.11 to 1.90]). CONCLUSION: Periodontitis is associated with the presence and severity of radiographic knee OA.

Low bone mineral density of vertebral lateral projections can predict spinal radiographic damage in patients with ankylosing spondylitis.

OBJECTIVES: To investigate the association between bone mineral status and spinal radiographic damage in patients with ankylosing spondylitis (AS) and determine whether bone mineral status can predict further spinal radiographic damage after 2 years. METHODS: Bone mineral density (BMD) of the lumbar spine (anteroposterior and lateral projections), femoral neck, and total hip and trabecular bone score (TBS) of the lumbar spine were measured in AS patients (n = 54) who fulfilled the modified New York criteria. Spinal radiographic damage was scored on cervical and lumbar spine radiographs using modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) at baseline and after 2 years. Simple and multiple linear regression analyses were performed to examine predictors of spinal radiographic damage. RESULTS: Patients with advanced AS exhibited low BMD on lumbar spine lateral projections, femoral neck, and total hip and low TBS. Low vertebral bone mass at baseline, assessed by BMD of the lateral projections or TBS, was independently associated with baseline mSASSS. After 2 years, mSASSS change from baseline was significantly associated with high baseline mSASSS, high baseline erythrocyte sedimentation rate and C-reactive protein (CRP) levels, and low baseline BMD of the lumbar spine lateral projections. The best predictive model for spinal radiographic progression consisted of baseline mSASSS, baseline CRP, and low BMD of lateral lumbar spine (area under curve = 0.826). CONCLUSIONS: BMD at vertebral lateral projections and TBS were inversely associated with baseline mSASSS in AS patients. Low BMD at vertebral lateral projections, as well as baseline mSASSS and inflammatory markers, might predict spinal radiographic damage in AS.Key Points• Vertebral bone mineral density of lateral projections and trabecular bone score are inversely associated with baseline mSASSS in patients with ankylosing spondylitis.• Baseline mSASSS, inflammatory markers, and low vertebral bone mineral density might predict spinal radiographic progression in patients with ankylosing spondylitis.

Clinical outcomes of patients with active rheumatoid arthritis with normal acute phase reactant values.

AIM: Despite high clinical disease activity, some patients with active rheumatoid arthritis (RA) have normal acute phase reactant (APR) values. This study aimed to determine the clinical outcomes of active RA patients with normal APR values. METHOD: Of 5376 patients with RA enrolled in the Korean observational study network for arthritis (KORONA) registry, 400 patients with disease duration of <2 years who had Clinical Disease Activity Index (CDAI) score of >2.8 at baseline, biologic-naïve, and erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) drawn at both baseline and 2-year follow-up visits were identified. Patients were grouped according to baseline APR levels: normal APRs, one APR elevated, and both APRs elevated. RESULTS: Baseline tender and swollen joint counts, mean CDAI and Health Assessment Questionnaire-Disability Index (HAQ-DI) scores were significantly lower in the normal APRs group compared with APR-elevated groups (P < 0.0001). At 2-year follow-up, mean CDAI scores, HAQ-DI, and percentage of the patient achieving remission were not significantly different between the normal APRs group compared with the APR-elevated groups regardless of the baseline disease activity. However, in patients with baseline CDAI moderate to high disease activity, the normal APRs group less frequently required initiation of the biologic disease-modifying anti-rheumatic drugs compared with the APR-elevated groups (P = 0.044). CONCLUSION: Active RA patients with normal APR values have milder disease presentation, but similar clinical outcomes to those with elevated APRs.

Insulin resistance is an independent predictor of erectile dysfunction in patients with gout.

BACKGROUND/AIMS: Gout is associated with metabolic disorders that are important risk factors for cardiovascular disease and erectile dysfunction (ED). We aimed to identify independent predictors of ED in patients with gout. METHODS: From August 2014 to August 2015, male outpatients who were being treated for gout in our rheumatology clinic and healthy males without any history of inflammatory disease (control group) were studied. ED was assessed in participants using the five-item version of the International Index of Erectile Function questionnaire. Insulin resistance (IR) was estimated using the homeostatic model assessment (HOMA-IR). Logistic regression analysis was performed to determine the effect of variables on ED risk in all of the study subjects and in patients with gout. RESULTS: We analyzed 80 patients with gout and 70 healthy controls. The median age of patients with gout was 52 years and median disease duration was 120 months. Gout patients were more likely to have ED than controls (55.3% vs. 41.4%, p < 0.047). After adjustment for confounding factors, only HOMA-IR was significantly associated with ED (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.05 to 3.15). Gout patients with ED were more likely to be older (p < 0.001), have higher HOMA-IR (p = 0.048), and have lower glomerular filtration rate (p = 0.038) than those without ED. Multivariate logistic regression analysis showed that HOMAIR was an independent predictor for ED (OR, 1.62; 95% CI, 1.03 to 2.82) in gout patients. CONCLUSION: IR is an independent predictor of ED in patients with gout.

Severity of Sacroiliitis and Erythrocyte Sedimentation Rate are Associated with a Low Trabecular Bone Score in Young Male Patients with Ankylosing Spondylitis.

OBJECTIVE: To examine factors related to a low trabecular bone score (TBS) and the association between TBS and vertebral fractures in patients with ankylosing spondylitis (AS). METHODS: One hundred patients (all male, aged < 50 yrs) who fulfilled the modified New York criteria for the classification of AS were enrolled. The TBS and bone mineral density (BMD) were assessed using dual-energy X-ray absorptiometry. Clinical variables, inflammatory markers, and the presence of vertebral fractures were also assessed. Sacroiliitis grade and spinal structural damage were measured using the modified New York criteria and the Stoke Ankylosing Spondylitis Spine Score (SASSS). RESULTS: The mean TBS was 1.38 ± 0.13. The TBS showed a positive correlation with BMD at the lumbar spine, femoral neck, and total hip. TBS negatively correlated with SASSS, whereas BMD at the lumbar spine showed a positive correlation. A significant decrease in TBS values was observed in patients with spinal structural damage (p = 0.001). Univariate analysis identified disease duration, erythrocyte sedimentation rate (ESR), sacroiliitis grade, and SASSS as being associated with TBS. Multivariate analysis identified ESR and sacroiliitis grade as being independently associated with TBS (p = 0.006 and p < 0.001, respectively). Ten patients had morphometric vertebral fractures. The mean TBS was lower in patients with vertebral fractures than in age-matched patients without fractures (p = 0.028). Lower TBS predicted vertebral fractures (area under curve = 0.733, cutoff = 1.311). CONCLUSION: The TBS in young male patients with AS is associated with the ESR and severity of sacroiliitis. The TBS may be useful as a tool for assessing osteoporosis in AS.

A Case of Disseminated Multidrug-Resistant Tuberculosis involving the Brain.

We report a case of a 23-year-old female immigrant from China who was diagnosed with multidrug-resistant tuberculosis affecting her lung and brain, resistant to the standard first-line therapeutics and streptomycin. She was treated with prothionamide, moxifloxacin, cycloserine, and kanamycin. However, her headache and brain lesion worsened. After the brain biopsy, the patient was confirmed with intracranial tuberculoma. Linezolid was added to intensify the treatment regimen, and steroid was added for the possibility of paradoxical response. Kanamycin was discontinued 6 months after initiation of the treatment; she was treated for 18 months with susceptible drugs and completely recovered. To our knowledge, this case is the first multidrug-resistant tuberculosis that disseminated to the brain in Korea.

Proteomics in Rheumatoid Arthritis Research.

Although rheumatoid arthritis (RA) is the most common chronic inflammatory autoimmune disease, diagnosis of RA is currently based on clinical manifestations, and there is no simple, practical assessment tool in the clinical field to assess disease activity and severity. Recently, there has been increasing interest in the discovery of new diagnostic RA biomarkers that can assist in evaluating disease activity, severity, and treatment response. Proteomics, the large-scale study of the proteome, has emerged as a powerful technique for protein identification and characterization. For the past 10 years, proteomic techniques have been applied to different biological samples (synovial tissue/fluid, blood, and urine) from RA patients and experimental animal models. In this review, we summarize the current state of the application of proteomics in RA and its importance in identifying biomarkers and treatment targets.

Acute eosinophilic pneumonia following secondhand cigarette smoke exposure.

Acute eosinophilic pneumonia (AEP) is a disease characterized by an acute febrile onset, eosinophilia in bronchoalveolar lavage fluid, and a dramatic response to corticosteroids. Although many studies have reported a close relationship between direct cigarette smoking and AEP, few studies have identified an association between passive smoking and AEP. Here, we report a case of AEP in a 19-year-old female with cough, fever, and dyspnea after 4 weeks of intense exposure to secondhand smoke for 6 to 8 hours a day in an enclosed area.