BACKGROUNDThe COVID-19 pandemic has caused both direct and indirect challenges to healthcare services worldwide. Decline in outpatient visits has been reported in the United States and across Europe. However, objective data in South America is still scarce on how the follow-up of chronic autoimmune diseases has been impaired. METHODSHere we evaluated the profile of rheumatoid arthritis (RA) outpatient care at the Rheumatology Department of a Brazilian university hospital during the COVID-19 pandemic. Through chart reviews of in-person and telemedicine visits between January 2020 and May 2022, we aimed to evaluate the follow-up of a long-term RA patient cohort, previously approved by national and local research ethics committees. Deaths were evaluated through the Brazilian National Death Registry website. RESULTSSince 2004, a cohort of 182 patients with RA was followed-up in our database. In 2022, they would have a mean age of 71.2 (± 0.7) years, with 29.5 (± 9.8) years of symptoms and 25.0 (± 6.7) years of treatment. In total, only 37 of those patients (20.32%) attended to at least one outpatient visit between January 2020 and May 2022, of which 1 was excluded due to change in diagnosis. There were 73 deaths (40.1%), of which 3 occurred during the pandemic. The remaining 72 patients (39.56%) were lost to follow-up by other causes. We further evaluated the 36 patients with regular follow-up. They had a mean age of 65.2 (± 8.8) years, with 27.4 (± 7.7) years of symptoms and 24.1 (± 6.3) years of treatment. Between 2004-2008, they had a mean disease activity by DAS28 of 3.94 (± 1.99) and only 4 patients (23.62%) achieved remission. In comparison, between 2020-2022, they had a mean DAS28 of 3.18 (± 1.49) and 14 patients (38.88%) achieved remission. CONCLUSIONWe evaluated a cohort consisting of several patients with long-term RA, not usually covered in studies. We observed many losses since the start of follow-up in 2006. Despite the long-term disease, the patients who maintained the follow up achieved better disease control, higher remission rates and optimized treatment (with an increase in the number of patients using immunobiological therapy). However, a limitation of the study was that we could not evaluate the causes of death. We intend to maintain the follow-up of the patients in the sample, focusing on the evaluation of disease progression and control in long-term RA.
This was a case of a patient with rheumatoid arthritis and irregular treatment, developing oligoarthritis septic by P. mirabilis. This pathogen is an anaerobic gram-negative bacterium, with few reports in the literature as the cause of infectious arthritis. We conclude that pulse therapy contributed to this type of articular involvement and to the atypical germ isolated.
BACKGROUNDThere are many reports about systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) overlap syndromes, but few associations with the sine scleroderma form. We aim to relate a case and discuss whether all manifestations could be attributed to SLE. CASE REPORTWe report the case of a 60-year-old white female patient that presented to the Rheumatology Service with a one-year evolution of malnutrition and significant weight loss, as well as facial telangiectasias, dysphagia, polyarthritis and Jaccoud syndrome, oral ulcers, xerostomia, xerophthalmia, Raynaud syndrome without pitting scars, leukopenia with lymphocytopenia and confusional states with complex hallucinations. There was no skin induration upon physical examination. The patient was admitted for investigation. Laboratory workup showed a positive antinuclear factor of 1:5,120 with a cytoplasmic dense fine speckled pattern, anti-DNA of 1:10, isolated consumption of C4 and polyclonal gammopathy with an IgG of 3,261. She also showed indeterminate reactivity to anti-SSA and anti-U1-RNP autoantibodies. Anti-Sm, anti-SCl-70 and anti-centromere were negative. Chest tomography showed initial nonspecific interstitial pneumonia. Capillaroscopy was compatible with SD pattern and transthoracic echocardiogram revealed an elevated pulmonary artery systolic pressure. Precapillary pulmonary hypertension was confirmed by right ventricle catheterization, with a borderline pulmonary artery mean pressure of 21 mmHg. The patient was initially treated with pulse therapy with methylprednisolone 3 g/day for 3 days, with general status improvement. The patient fulfilled the 2019 EULAR/ACR classification criteria for SLE, as well as ACR/EULAR 2013 systemic sclerosis classification criteria. Azathioprine was initiated and the patient was discharged after two months on prednisone reduction. CONCLUSIONThis case showed a patient with mixed features of SLE and SSc, but neither scleroderma nor specific autoantibodies for systemic sclerosis were found. We do know that many of those manifestations could possibly be attributed to SLE, even the SD pattern being described in 5% of SLE patients. Only one case of SLE and systemic sclerosis sine scleroderma overlap was found on the literature. Overlap syndromes and even SLE are more prevalent in younger ages, the opposite of this patient. Overall, classification criterion for both diseases were fulfilled and the patient received adequate treatment directed to systemic manifestations.
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