Objective: To assess the frequency of methotrexate intolerance in patients with rheumatoid arthritis by using methotrexate intolerance severity scale. Study Design: Cross Sectional study. Setting: DHQ Teaching Hospital Sahiwal. Period: November 2021 – April 2022. Material & Methods: Sample of 178 cases were selected through non-probability consecutive sampling. Patients of age 20-80 years, either gender, diagnosed with rheumatoid arthritis were enrolled. The MISS questionnaire was used to note the information and in tolerance was noted. Data analysis was done in SPSS version 25.0. Results: In this study, the mean age of patients was 35.12 ± 11.16 years. Out of 178 patients, 24 (13.5%) were males and 154 (86.5%) were females. The mean duration of disease was 31.22 ± 23.94 months. Mean duration of using methotrexate was 12.03 ± 12.61 months. About 33.7% patients had mild to moderate complaint of abdominal pain after taking methotrexate, abdominal pain anticipatory was absent in 98.9% patients and abdominal pain associative was also absent in 96.6% cases. Restlessness was mild in 20 (11.2%) cases, moderate in 22 (12.4%) and severe in 4 (2.2%) cases. Irritability was mild in 22 (12.4%) cases, moderate in 20 (11.2%) and severe in 4 (2.2%) cases. Overall refusal of methotrexate was noted in 38 (21.3%) cases. The mean MISS score attained by patients was 2.93 ± 3.82. Out of 178 patients, 44 (24.7%) had intolerance against methotrexate use for rheumatoid arthritis. Conclusion: The frequency of intolerance against methotrexate in patients of rheumatoid arthritis is high and cannot be ignored. Further trials should be done at adjust dose and alterations must be done to improve the tolerance and outcome of treatment.
Aquaporin-4 antibodies are hallmark of neuromyelitis optica (NMO) and neuromyelitis optica spectrum disorders (NMOSD) that are distinct disease entities. We report a 24-year male with NMO, who presented with Brown-Sequard syndrome. Clinical and laboratory parameters confirmed the diagnosis of systemic lupus erythematosus (SLE). Involvement of sympathetic trunk causing Horner's syndrome and a wide time lapse of 13 years from the occurrence of optic neuritis to myelitis with no relapses in between is a rarity to be seen in NMO associated with SLE.
Systemic lupus erythematosus (SLE) is an autoimmune disease that is frequently treated with high doses of corticosteroids and other immunosuppressive drugs. Thus patients with SLE are at increased risk for infections with several pathogens including Mycobacterium tuberculosis. There are no established guidelines available for treatment of tuberculosis in SLE patients with high disease activity due to lack of relevant studies and management based more on physician expertise. We report a case of a young SLE patient with high disease activity index (SLEDAI19) as evidenced by the presence of a vasculitic rash, non-healing ulcer on forearm and proteinuria of >1 g/d along with miliary tuberculosis. She was treated with intravenous methylprednisolone pulse up to 3 g and antituberculous therapy, but the result was a fatal outcome. This case report emphasizes the need for formal guidelines for co-management of active tuberculosis and SLE with high disease activity.
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