Role of Anifrolumab in Refractory Cutaneous Manifestations of Lupus Erythematosus: A Case Series and Literature Review.

Lupus erythematosus (LE) is an autoimmune disease that presents either as a systemic (SLE) or an isolated skin disease (CLE). Currently, there is no FDA-approved medication specifically for CLE, and is treated with the same approach as SLE. We present two refractory cases of SLE with severe cutaneous manifestations unresponsive to the first-line therapy treated with anifrolumab. First, a 39-year-old Caucasian female with a known history of SLE with severe subacute CLE presented to the clinic for her refractory cutaneous symptoms. Her current regimen was hydroxychloroquine (HCQ), mycophenolate mofetil (MMF), and s/c belimumab with no improvement. Belimumab was discontinued, and she was started on anifrolumab with significant improvement. Another, a 28-year-old female with no known medical history was referred to a rheumatology clinic for elevated anti-nuclear antibody (ANA) and ribonucleoprotein (RNP) titers. She was diagnosed with SLE, and was treated with HCQ, belimumab, and MMF but failed to produce a reasonably good outcome. Hence belimumab was discontinued and anifrolumab was added instead with significant cutaneous improvement. The treatment spectrum for SLE is wide, which includes antimalarial (HCQ), oral corticosteroids (OCS), and immunosuppressants (Methotrexate-MTX, MMF, azathioprine-AZT). Anifrolumab, a type 1 IFNα receptor subunit 1 (IFNAR1) inhibitor, has been recently approved by the FDA for moderate to severe SLE while on standard therapy in August 2021. Early use of anifrolumab in moderate to severe cutaneous manifestations of SLE or CLE may result in significant improvement in patients.

Marijuana as a Cause of Diffuse Coronary Vasospasm Leading to Cardiac Arrest.

Marijuana is considered as the most popular illicit drug around the world. It has numerous cardiovascular effects with myocardial infarction (MI) being a lethal one. The negative physiological effects of marijuana are well-studied, including tachycardia, nausea, memory impairment, anxiety, panic, and arrhythmia. We present a case of cardiac arrest following marijuana use in a patient who had a normal electrocardiogram (EKG) on presentation but diffuse coronary vasospasm on left heart catheterization (LHC) with no obstructive lesion. The patient had a transient episode of ST elevation on EKG following the procedure which resolved with an increased dose of nitroglycerine drip. Synthetic cannabinoids are more potent and not detected on a regular urine drug screen (UDS). In patients with low risk for cardiovascular events, particularly young adults, presenting with symptoms of MI/cardiac arrest, marijuana-induced MI should be suspected due to the severe adverse effects of its synthetic component.