Year : 2022 | Volume
: 2 | Issue : 1 | Page : 22--26
The 8th Annual Saudi society for rheumatology conference: The abstracts oral
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. The 8th Annual Saudi society for rheumatology conference: The abstracts oral.Ann Rheumatol Autoimmun 2022;2:22-26
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. The 8th Annual Saudi society for rheumatology conference: The abstracts oral. Ann Rheumatol Autoimmun [serial online] 2022 [cited 2022 Aug 19 ];2:22-26
Available from: http://www.ara.ssr.com/text.asp?2022/2/1/22/345954
A Case Report of 22sits of Multifocal Osteonecrosis in a 26-Year-Old Female Sickle Cell Disease Patient
Albadr Hussein, Khalid Alkhleel, Lujain Alharbi
Multifocal osteonecrosis is caused by avascular necrosis (AVN), which is a serious disorder characterized by bone tissue death (MFON). The shoulder, knee, and hip, or the shoulder, ankle, and knee, are three successive anatomical places where MFON occurs. All of these anatomical areas are affected by osteonecrosis. Corticosteroid use has been linked to an increased risk of MFON. Other risk factors include HIV infection, systemic lupus erythematosus, coagulation problems, renal failure, multiple sclerosis, inflammatory bowel illnesses, Sjogren's syndrome, leukemia, lymphoma, antiphospholipid syndrome, and sickle cell disease one of the most common causes of osteonecrosis in people living in Africa and the Mediterranean. Because most patients do not show symptoms, diagnosing MFON is difficult, making it impossible to determine the disease's prevalence in individuals with other underlying disorders. Our patient, a 26-year-old Saudi woman who has had sickle cell anemia since childhood, was hospitalized to our hospital with a diagnosis of vaso-occlusive crisis caused by an upper respiratory tract infection, which was treated with several drugs. After 3 days in the hospital, the patient began to improve; but, on day 6, she had acute, severe bilateral foot pain that make her unable to stand. Over the last 2 years, the patient had several AVN attacks in bilateral pelvic bone, bilateral femoral head, shoulders, and knees in a symmetrical pattern. Over the last 2 years, a total of twenty AVN attacks have been happened in a symmetrical manner. For this new symptom, she had a rheumatology consultation. The patient appeared to be in a lot of discomforts during the examination. With a normal ankle joint look and range of motion, both the distal tibias and the heel revealed severe local tenderness. Following that, an magnetic resonance imaging of the bilateral distal tibia revealed AVN. The patient was diagnosed with MFON and was treated conservatively with a positive outcome. The present case highlights the importance of conducting a careful investigation of patients with sickle cell disease who present with multiple joint involvements, and the choice of the appropriate investigation according to the presentation.
Antiphospholipid AntiBodies-Hypoprothrombinemia Syndrome Associated with Systemic Lupus Erythematosus
Khalid Alkhalil, Ahmad Abdulshkour, Albadr Hussein
We describe a case of patients who initial presentation of systemic lupus erythematosus (SLE) was accompanied by hemorrhagic episodes and significant coagulopathy. Further investigation demonstrated positive antiphospholipids, (anticardiolipin and anti-beta-2 glycoprotein and lupus anticoagulants) associated with significative decreased Factor II (prothrombin) activity. The patient was diagnosed with systemic lupus with secondary antiphospholipid (APL) associated-hypoprothrombinemia syndrome as a result of APLs antibodies directed against Factor II. It is a rare clinical entity that can occur in association with SLE, transient viral infections, drug reactions, or even in healthy individuals. Bleeding stopped promptly, and coagulation studies improved significantly with high-dose corticosteroids and hydroxychloroquine treatment.
Hypoprothrombinemia syndrome associated with systemic lupus erythematosus, lupus factor II deficiency, systemic lupus erythematosus, and bleeding
Cardiovascular Risk Factors among Patients with Rheumatoid Arthritis: A Cohort Study
Mazen Al Zo'ubi
Background: To investigate the factors affecting the modifiable risk factors of cardiovascular disease (CVD) among patients with rheumatoid arthritis (RA). Methods: During this study, 316 patients with RA were enlisted from the outpatient rheumatology clinic at King Hussein Hospital of the Jordanian Medical Services, from June 1, 2021, to December 31, 2021. Demographic data and disease duration were recorded. After 14 h of fasting, venous blood samples were drawn to determine the levels of cholesterol, triglyceride, high-density lipoprotein, and low-density lipoprotein. History of smoking, diabetes mellitus (DM), and hypertension was recorded. Body mass index and Framingham's 10-year risk score of each patient were calculated. Disease duration was noted. Results: The mean age of the male population was 49.29 and that of females was 46.06 years old. The female gender was more common (78.5%). About 27.2% of the study population had one modifiable risk factor. The most frequent risk factor observed in the study was obesity (38%) and dyslipidemia (38%). DM was the least frequent risk factor, with a frequency of 14.6%. Framingham's cardiovascular risk score differed significantly between the sexes, with the risk score of males being 9.80, whereas that of females was 5.34 (P < 0.00). Regression analysis revealed that age increased the odds ratio of DM, hypertension, obesity, and high-moderate FRS 0.7%, 10.9%, 0.33, and 10.3%, respectively. Conclusion: Patients with RA have a high frequency of modifiable CVD risk factors. Male gender and aging represent a major player in developing multiple CVD risk factors.
Nailfold Capillaroscopy in Early stages of Mixed Connective Tissue Disease
Yasser A. Elmotaleb Gazar1, Hesham S Hamoud1, Sherif M. Ismail2
1Department of Rheumatology and Rehabilitation, Faculty of Medicine, Al-Azhar University, 2National Research Center, Cairo, Egypt
Introduction: Mixed connective tissue disease (MCTD) is a systemic autoimmune disease with high titer of anti-U1RNP and number of clinical pictures mainly Raynaud's phenomenon. Nailfold capillaroscopy (NFC) is a noninvasive diagnostic tool for patients with different connective tissue diseases that permit the detection of local microvascular changes that correlate with systemic vascular involvement. Aim of the Study: The aim of this study was to comparing the results of NFC in patients with systemic sclerosis (SSc) to determine the chief characteristics of skin microangiopathy in early MCTD and trying to describe a characteristic MCTD pattern. Methodology: This cross-sectional study included forty patients diagnosed with MCTD according to Alarcón-Segovia and Villareal criteria and twenty patients with confirmed SSc according to the American College of Rheumatology and the European League Against Rheumatism classification criteria for SSc. Nailfold examination for study subjects was done describing architectural, derangement, capillary density changes, megacapillary and enlarged loops, microhemorrhages, and angiogenesis. Results: Of the 60 patients studied, 49 (81.7%) patients were females and 11 were males with a mean age of 31 years with a median of 29.5 and range (16–52 years). Three of the 20 patients diagnosed with SSc had arthritis. Out of 60 patients, 53.3% had thickened skin, 19 patients exhibited puffy fingers, 6 patients showed rash, and none had swollen joints. The skin was significantly thicker in SSc patients (85%) compared to 37.5% in the MCTD population. Patients presented with various features, the most common of which was fatigue (26.7%) and myositis (23% of patients) (these are not classified as comorbidities features would be a more appropriate word). There is a significant negative correlation of −0.508 (P = 0.022) between the enlargement scores and illness duration in SSc patients. Those patients also exhibited a statistically significant positive correlation of 0.520 (P = 0.019) between hemorrhage score and the number of tender joints. Alternatively, patients diagnosed with MCTD exhibited a significant positive correlation between the architectural changes scores of their joints and both the duration of their illness (0.347; P = 0.028) and the number of swollen joints (0.424 P = 0.006). MCTD patients also showed a significant correlation of 0.423 (P = 0.007) between their hemorrhage scores and their age at the time of the study. Conclusion: In this study, the results obtained were qualitatively satisfactory for clear delineation of the nailfold capillaries features in MCTD. Therefore, it aids in the recognition of alternations in nailfold capillaries making early prediction of course of illness in MCTD patients possible and thus preventing morbidities and sequelae of the disease.
Keywords Mixed connective tissue disease, nailfold capillaroscopy, Raynaud's phenomenon, systemic sclerosis
National Guidelines for Management of Lupus Nephritis in Saudi Arabia
Huda Alfaris1, Mohammad Alkhowaiter2, Khawla Alghanim3, Mohammad Alkhowaiter2, Roa'a Aljohani4, Abdulaziz Alkhalaf2, Sultana Abdulaziz5, Tariq Aljohani6, Hanan Al Rayes1
1Department of Medicine, Prince Sultan Military Medical City, 2Department of Medicine, King Saud University, 6Department of Pathology and Laboratory Medicine, King Saud University, Riyadh, 3King Fahad Military Medical Complex, Dammam, 4Department of Medicine, Taiba University, Medina, 5Department of Medicine, King Fahad Hospital, Jeddah, Saudi Arabia
Introduction: Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease that can affect all organs and cause a significant morbidity and mortality. The estimated prevalence of SLE in the central region of Saudi Arabia is around 19.28/100,000 population. About half of them will eventually develop clinically significant renal disease. Therefore, screening for renal involvement is essential for early diagnosis and management. Objective: The objective of this study was to develop a pathway to facilitate early diagnosis and management of lupus glomerulonephritis at the Kingdom of Saudi Arabia. Methods: The Saudi Society of Rheumatology in collaboration with the Saudi Society of Nephrology and Transplantation and under supervision of the Saudi Commission for Health Specialties organized a committee of rheumatologists, nephrologists, and a renal pathologist. Multiple workshops were conducted to adapt the 2019 Update of the Joint European League Against Rheumatism (EULAR) and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA–EDTA) recommendations for the management of lupus nephritis as well as The Kidney Disease: Improving Global Outcome 2020 using the ADAPTE process. Results: This article includes recommendations for the screening of renal involvement, renal pathology and classification, initial and subsequent therapy of lupus nephritis, treatment of refractory and relapsing lupus nephritis, and management of advanced renal disease. Recommendations about pregnancy and postpartum care are also included. Conclusion: We developed a guideline for the management of adults with lupus nephritis, adapted to the local context of our health-care system, using guidelines developed elsewhere.
New-Onset Rheumatic Disease after Coronavirus Disease 2019 Vaccination 3 Cases from the Practice
Coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented setback for global economy and health. Vaccination is one of the most effective interventions to substantially reduce severe disease and death due to SARS-CoV-2 infection. Vaccination programs are being rolled out globally, but most of these vaccines have been approved without extensive studies on their side effects and efficacy. Recently, new-onset autoimmune diseases after COVID-19 vaccination have been reported increasingly (e.g., immune thrombotic thrombocytopenia, autoimmune liver diseases, Guillain–Barré syndrome, IgA nephropathy, rheumatoid arthritis, and systemic lupus erythematosus). Molecular mimicry, the production of particular autoantibodies, and the role of certain vaccine adjuvants seem to be substantial contributors to autoimmune phenomena. However, whether the association between the COVID-19 vaccine and autoimmune manifestations is coincidental or causal remains to be elucidated. Here, I prescribed three cases of healthy patients without a known history of any rheumatic diseases that developing new onset of extensive psoriatic arthritis (skin and joints), one case of typical ankylosing spondylitis and typical case of polymyalgia rheumatica. These reports could help guide clinical assessment and management of autoimmune manifestations after COVID-19 vaccination.
Outcome of Coronavirus Disease 2019 Infected Patient with Rheumatic Disease and Exposed to Coronavirus Disease 2019 Confirmed Patient Single Clinic Experience from Saudi
Albadr Hussein, Alaa Ahmed, Basim Samman
Objective: The aim of the study was to detect the effect of coronavirus disease 2019 (COVID-19) infection on patient with rheumatic disease and effect of exposure to COVID-19 patient with patient with rheumatic disease among our rheumatology outpatients and to investigate clinical presentation, course of the disease, and outcome in each group. Patients and Methods: Patients with inflammatory rheumatic diseases (IRDs) registered in our rheumatology clinic were assessed during their routine outpatient follow between January 2021 and December 2021. Patients' demographics, diagnosis, medication, comorbidities, treatment changes, access to drugs during the pandemic, and the incidence of COVID-19 infection were collected by the direct questioner. Results: Total includes 1227 patients. The total visit is 2185, 81 patients had no show, total infected cases were 55, and total exposed to COVID-infected patients was 37. Eighty-one patients had no show contacted by phone (six of them get infected and involved to our study, one patient died because a cardiac issue (not infected), and twenty patients had wrong contact information. Conclusions: There was no increased risk of severe COVID-19 infection among patients with IRD.
Pachydermoperiostosis as Mimic of Rheumatoid Arthritis
Marwa Abo Almauty1, Adel Abd El Salam1
1Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
Introduction: Pachydermoperiostosis (PDP) is a rare hereditary disorder characterized by digital clubbing, subperiosteal new bone formation with pain, polyarthritis, and hyperhidrosis. Case Report: A 19-year-old male, presented to our outpatient clinic complained of aching pain along the shaft of tibia, swelling of both knee 3 years ago that progressed with bilateral swelling in both ankle and wrist. The pain was insidious in onset, throbbing in character, not relieved with the over counter medications. The patient also complained of profuse sweating, progressive enlargement of hands and feet and gradual coarsening of facial features and tingling sensation of both hands and feet, and impaired sensation to hot and cold temperature. On examination, skin folds in the forehead, clubbing and arthralgia of both knee, ankle, and wrist, reduced sensory sensation in lateral 3 and half finger consistent with Carpal tunnel syndrome and big toe and first three toes consistent with tarsal syndrome. He was subsequently investigated to exclude acromegaly, rheumatoid arthritis, psoriatic arthropathy, and thyroid acropachy. Radiography of long bone show cortical thickening, periosteal proliferation, and soft tissue. Conclusion: PDP should be made when at least two of the following; positive family history, clubbing, hypertrophic skin changes and bone pain/radiographic changes.
Patients' Perception about Rheumatoid Arthritis and their Behavior Toward Medications in Saudi Arabia: A Qualitative Study
Lobna A. Aljuffali1, Haya M. Almalag1, Mohammed A. Omair2
1Department of Clinical Pharmacy, College of Pharmacy, King Saud University, 2Department of Medicine, Rheumm Rheumatology Unit, King Saud University Medical City, Riyadh, Saudi Arabia
Background: Saudi patient experience with rheumatoid arthritis and medication is not studied. There is a need to understand the challenges and preferences in treatment. Objectives: The objective of this study was to explore rheumatoid arthritis (RA) patients' perceptions, beliefs, and experiences about the disease and treatment in Saudi Arabia. Methods: Three focus groups were conducted in Riyadh, Saudi Arabia, between January and May 2021. Purposeful sampling was used. Each focus group included participants in a similar age range and the same gender with different educational and socioeconomic backgrounds. The groups comprised “female aged 35–50 years” (n = 6), “male” (n = 4), and “female above 50 years” (n = 5). All group discussions were recorded transcribed. Thematic analysis was performed. Results: Main themes identified: Stress and losing a loved one were identified as the main causes of RA development, delay in diagnosis of RA, and beliefs about particular food trigger RA flare-up. The most experienced side effect was weight gain, nausea, and infections. Participants were open to starting a new medication. Stiffness was the main unmet need among participants. Side effects, pain management, and contraception were the main factors in treatment transition. Prices and availability of medication were a concern among the younger participants. Physical exercises and physical therapy were identified as important complementary therapies to improve quality of life. The lockdown during the pandemic had a positive effect on female symptoms. Although each age group had different challenges, young women identified the transition of treatment before and after contraception, losing their jobs, meeting their children and family needs, and pursuing their dreams. Men identified problems with fertility as a main challenge and fear of needles. Psychological and social challenges were the main theme in the elderly group. Conclusion: This study identified different patient preferences and needs according to age and gender in Saudi Arabia.
Experiences, patients' perception, qualitative research, rheumatoid arthritis
Pattern of Clinical Manifestations and Outcome of Multisystem Inflammatory Syndrome in Children
Banan Alrewaithi1,2, Mohammed Olfat1,2, Asmaa Jokhdar1,2, Moroj Aljohani1, Reem Tharwat1, Shaima Alhazmi1
1Pediatric Rheumatology Section, King Salman Medical City, Ministry of Health, 2Department of Pediatric, King Salman Medical City, Ministry of Health, Medinah, Saudi Arabia
Background: Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious complication associated with coronavirus disease 2019 (COVID-19). It has variable clinical presentation based on age and time of presentation and clinical subtypes. Our objective was to study the clinical, laboratory evaluation, treatment, and outcome in childhood multisystem inflammatory syndrome. Methods: We performed a single-center retrospective cohort study of children with evidence of MIS-C between May 2020 and June 2021. The study included 13 hospitalized patients who were younger than 14 years old. Results: Thirteen patients were diagnosed with (MIS-C). Seven of them (53.8%) were female. The median age of presentation was 7 years old. 92.3% had no comorbidities. 69.2% had a history of contact with COVID-19 patients. The median time from exposure to presentation was 4 weeks. However, only two patients (15.3%) had positive polymerase chain reactions. Most of our patients were noted to have conjunctivitis with puffy eyes and GI symptoms (92.3%). At presentation, 76.9% had skin rash and sore throat, 61.5% had respiratory symptoms, and 30.7% of them required invasive mechanical ventilation. Moreover, 84.5% had depressed cardiac function and echocardiographic abnormalities. 69.2% of them required inotropic support. All patients were treated with intravenous immunoglobulin and high-dose steroids according to the treatment strategy guided by ACR protocol on June 2020 (clinical guidance for pediatric patients with MISC). 76.9% of them received adjunctive biological medications. Most patients recovered completely and the survival rate was 92.3%. Conclusion: Multisystem inflammatory syndrome in children (MIS-C) is a serious condition that requires high index of suspicion. However, early diagnosis and early treatment with adjunctive anakinra or/and tocilizumab may improve the outcome.
Posterior Reversible Encephalopathy Syndrome an Undesired Effect of RTX in Two Cases of Severe Systemic Lupus Erythematosus Patients
Hiba Khogali, Walaa Eldin Osama Saeed
Background: Rituximab is an effective potent biological medication used to neutralize systemic lupus erythematosus (SLE) severity with good outcomes. However, rituximab can result in a serious complications such as posterior reversible encephalopathy syndrome (PRES). PRES is a rare neurological manifestation; where it is characterized by the alteration in mental status, headaches, visual disturbances, and seizures. The syndrome can be associated with an acute onset of high blood pressure. The objective of reporting these two cases is to highlight the undesired side effect of RTX in its usage to treat significant SLE manifestations. Cases Summary: We are reporting two cases that have fulfilled the SLE criteria according to ACR/SILCC 2012 and were treated with rituximab. After initiation of rituximab therapy, both patients developed PRES. Both cases, a 20-year-old Egyptian female and a 32-year-old Emirati female, satisfy the clinical and laboratory criteria for severe SLE (SLEDAI CK score of 32and 39, respectively) and were managed with plus steroids (1000 mg daily for 3 consecutive days), full dose of hydroxychloroquine, and two doses of RTX 1000 mg, respectively. Each of the beforementioned cases responded well clinically to the emergency management and demonstrated a significant improvement in the laboratory markers of SLE. However, the two cases have developed PRES after taking the second dose of rituximab. The 20-year-old Egyptian female developed PRES within 2 days of receiving the second dose of rituximab, whereas the 32-year-old Emirati patient developed PRES within 31 days. The cases illustrated manifestations of altered mental status, confusion, seizures, and acute high blood pressure. Radiological imaging such as computed tomography, Electroencephalogram (EEG), magnetic resonance angiography as well as magnetic resonance venography were all negative, whereas an magnetic resonance imaging of the brain showed enhanced hypertense lesions at the parietooccipital region and the cerebellum. These signs and symptoms were consistent with posterior reversible encephalopathy syndrome. Both patients did not exhibit any signs of sepsis and were not on any other medications as well they did not have any pre-exiting medical illness. Conclusion: Rituximab treatment in severely ill SLE patients can induce PRES both acutely and at long-term.
The Impact of Rheumatological Diseases on Voiding Function among Men in Saudi Arabia: A Cross-sectional Study
Rahaf Alodaini, Mohammed Omair
Objective: The objective of this study was to assess the impact of rheumatic diseases on voiding function compared to the general population. Methodology: Study design is a comparative cross-sectional study, designed as two groups: the rheumatological patient group and the controlled healthy group. Exclusion criteria include age <18, patients diagnosed or treated for any voiding dysfunction. International Prostate Symptom Score (IPSS) questionnaire was given to both groups to assess both voiding function and its symptoms on quality of life. Arabic version of this questionnaire will be used as most of our targeted patients speak the Arabic language. Results: A total of 265 patients filled out the (IPS) questionnaire. Among the total, 47 (17.7%) were diagnosed with rheumatological disease. Overall median (interquartile range) IPSS score was 7 (3–12). Comparing between both controlled healthy group and patients with rheumatological disease group, upon questioning about how often it is difficult to postpone urination in the past 1 month, it was significantly higher in the diseased patients with P value of 0.003. A significant difference was found in the response among the participants as they were asked to consult a specialist doctor (for urination problems), 61.7% of rheumatoid patients agreed to, while only 20.6% agreed to consult a specialist with P < 0.001. Conclusion: Our results suggest that patients with rheumatological disease experience an increased prevalence of voiding dysfunction with urgency symptoms more prominent. Relevance to Clinical Practice: This study highlighted that voiding dysfunction is a significant feature among male patients with rheumatological diseases, which suggests that both patients and clinicians should be aware of the potential impact of rheumatological disease on lower urinary tract dysfunction. Besides, more specific measurements should be combined with the IPSS questionnaire to assess voiding dysfunction in rheumatology patients.
Unilateral Renal Artery Stenosis as Presenting Manifestation of Abdominal Takayasu's Arteritis
Marwa Abo Elmaaty Besar, Adel Abdelsalam, Ahmed Eleshra, Tamer Khafagy, Ehab Saad
Objective: Takayasu's arteritis (TA) is a rare disorder characterized by granulomatous and necro-inflammatory disease of the aorta and its major branches, the involvement of renal is found in 38% of patients resulting in severe hypertension and unilateral renal atrophy. Case: We report a 17-year-old female diagnosed as hypertension at the age of 15, difficult to control despite different types of antihypertension. Acute-phase reactant was elevated and secondary hyperaldosteronism. Abdominal ultrasound showed unilateral small left kidney with impaired Doppler flow. Computed tomography angiography detected diffuse mural thickness with enhancement of the abdominal aorta and extending into mesenteric arteries and renal arteries. Finding suggestive to large vessel vasculitis. Our patient was diagnosed as TA-induced renal artery stenosis (TARAS). The patient started anti-inflammatory medication (DMARDS) and was referred for microsurgical correction of renal vessel. Conclusion: TARAS results in renal ischemia and resistant hypertension. Revascularization led to a significant decrease in blood pressure.
Keywords: Renal artery stenosis, resistant hypertension, revascularization, Takayasu's arteritis, vasculitis