Rheumatoid arthritis: a review of the cutaneous manifestations

Advances in the Medical Treatment of Rheumatoid Arthritis

Rheumatoid arthritis is a common, chronic autoimmune disease. Its clinical presentation includes both articular and extra-articular manifestations. The past few decades have seen significant developments in our understanding of RA pathogenesis, leading to the development of effective novel targeted treatment options. This article reviews the clinical presentation, pathogenesis, and treatment of RA, along with specific treatment considerations related to reproductive health, vaccination, and the perioperative period.

Regulation of reactive oxygen species and the role of mitochondrial apoptotic-related genes in rheumatoid arthritis

Previous research suggests mitochondrial apoptosis alleviates rheumatoid arthritis (RA), but the role of mitochondrial apoptosis-related genes (MARGs) is unclear. Urgent exploration of RA-related mitochondrial apoptosis biomarkers is needed. Gene Expression Ontology (GEO)-derived RA datasets were used to identify differentially expressed genes (DEGs) compared to normal controls, intersected with MARGs to obtain differentially expressed mitochondrial apoptosis-related genes (DE-MARGs). Three ML algorithms screened diagnostic biomarkers. A nomogram was built and validated by receiver operating characteristic (ROC) analysis. Gene Set Enrichment Analysis (GSEA), regulatory network, and drug prediction explored biomarker mechanisms. Finally, key cells analysis included clustering, type annotation, pseudo-temporal study, and interaction, focusing on validated biomarker expression in those cells. A total of 147 DE-MARGs linked to energy & ROS metabolism were identified. Four validated biomarkers (MRPS10, EEF2, HSPA9, TUFM) formed a new RA diagnostic model. Moreover, GSEA linked them to oxidative phosphorylation. YY1 regulates EEF2, HSPA9, MRPS10; FOXO3 regulates EEF2, TUFM. Drugs like Nonoxynol-9, Nedocromil, Gadobutrol target these biomarkers. In addition, biomarkers are expressed in plasmablasts, with CD74 as a key receptor binding multiple ligands. RA biomarkers (MRPS10, EEF2, HSPA9, TUFM) linked to energy & ROS, progression tied to AMPK/mTOR, CD74-MIF crucial. Study advances RA pathogenesis knowledge, supporting clinical diagnosis.

The comprehensive relationship between combined anti-inflammatory and healthy diets and all-cause mortality in rheumatoid arthritis: results from NHANES 2003-2018

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune inflammatory disorder. Diet is recognized as a modifiable factor that may influence inflammation and potentially accelerate RA progression. Nevertheless, the effects of diverse dietary patterns and their combined impact on RA progression and long-term mortality remain inadequately understood. This study examined the association between dietary patterns and mortality in patients with RA, focusing on the Healthy Eating Index (HEI-2015) and Dietary Inflammatory Index (DII) and evaluating their combined effects.

METHODS

The analysis included 2,069 patients with RA from the National Health and Nutrition Examination Survey (NHANES) spanning 2003-2018. Weighted multi-variable Cox regression models estimated the relationship between the DII, HEI-2015, combined dietary patterns, and all-cause mortality in patients with RA. Linear associations between the DII, HEI-2015, and all-cause mortality were analyzed using restricted cubic splines (RCS). Dietary factors associated with mortality were identified through the Least Absolute Shrinkage and Selection Operator (LASSO) method, and subgroup and sensitivity analyses were conducted to strengthen the findings.

RESULTS

Participants had a median age of 59 years (IQR: 48-69), with 42.1% male. Adjusting for potential confounders, the hazard ratio (HR) for individuals adhering to healthy and anti-inflammatory dietary patterns, as opposed to unhealthy and pro-inflammatory patterns, was 0.70 (95% CI: 0.53-0.92; adjusted P = 0.01; trend P = 0.02). In weighted Cox analyses of the DII and HEI-2015, higher quartiles showed no significant mortality risk difference from the lowest quartiles. The LASSO-Cox model identified 12 dietary components predictive of all-cause mortality in patients with RA, with an AUC of 0.749 (0.682-0.815) at 1 year, 0.763 (0.724-0.802) at 3 years, 0.783 (0.749-0.802) at 5 years, and 0.868 (0.712-0.938) for all death events. Kaplan-Meier analysis revealed that the low-risk dietary group exhibited significantly lower mortality compared to the high-risk group (P < 0.001).

CONCLUSIONS

These findings suggest that combining a higher HEI-2015 with a lower DII score correlates with reduced all-cause mortality risk among patients with RA, supporting dietary modification as a potential strategy to prevent premature death in this population.

The shared biomarkers and immune landscape in psoriatic arthritis and rheumatoid arthritis: Findings based on bioinformatics, machine learning and single-cell analysis

OBJECTIVE

Psoriatic arthritis (PsA) and rheumatoid arthritis (RA) are the most common types of inflammatory musculoskeletal disorders that share overlapping clinical features and complications. The aim of this study was to identify shared marker genes and mechanistic similarities between PsA and RA.

METHODS

We utilized datasets from the Gene Expression Omnibus (GEO) database to identify differentially expressed genes (DEGs) and perform functional enrichment analyses. To identify the marker genes, we applied two machine learning algorithms: the least absolute shrinkage and selection operator (LASSO) and the support vector machine recursive feature elimination (SVM-RFE). Subsequently, we assessed the diagnostic capacity of the identified marker genes using the receiver operating characteristic (ROC) curve and decision curve analysis (DCA). A transcription factor (TF) network was constructed using data from JASPAR, HumanTFDB, and GTRD. We then employed CIBERSORT to analyze the abundance of immune infiltrates in PsA and RA, assessing the relationship between marker genes and immune cells. Additionally, cellular subpopulations were identified by analyzing single-cell sequencing data from RA, with T cells examined for trajectory and cellular communication using Monocle and CellChat, thereby exploring their linkage to marker genes.

RESULTS

A total of seven overlapping DEGs were identified between PsA and RA. Gene enrichment analysis revealed that these genes were associated with mitochondrial respiratory chain complex IV, Toll-like receptors, and NF-κB signaling pathways. Both machine learning algorithms identified Ribosomal Protein L22-like 1 (RPL22L1) and Lymphocyte Antigen 96 (LY96) as potential diagnostic markers for PsA and RA. These markers were validated using test sets and experimental approaches. Furthermore, GSEA analysis indicated that gap junctions may play a crucial role in the pathogenesis of both conditions. The TF network suggested a potential association between marker genes and core enrichment genes related to gap junctions. The application of CIBERSORT and single-cell RNA sequencing provided a comprehensive understanding of the role of marker genes in immune cell function. Our results indicated that RPL22L1 and LY96 are involved in T cell development and are associated with T cell communication with NK cells and monocytes. Notably, high expression of both RPL22L1 and LY96 was linked to enhanced VEGF signaling in T cells.

CONCLUSION

Our study identified RPL22L1 and LY96 as key biomarkers for PsA and RA. Further investigations demonstrated that these two marker genes are closely associated with gap junction function, T cell infiltration, differentiation, and VEGF signaling. Collectively, these findings provide new insights into the diagnosis and treatment of PsA and RA.

Beyond rheumatoid nodules in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease predominantly affecting synovial joints. Extra-articular manifestations, including skin involvement, can also occur. The most frequent cutaneous manifestation in RA patients is rheumatoid nodules, occurring in 20-30% of seropositive individuals. These nodules are typically firm, painless, and located on pressure points such as the hands and elbows. However, in a minority of cases, other skin conditions can complicate RA, notably palisaded neutrophilic granulomatous dermatitis (PNGD). PNGD presents as erythematous papules or plaques, often pruritic and distributed symmetrically over extensor surfaces, making it challenging to differentiate from rheumatoid nodules. Histopathological examination is crucial to establish the diagnosis. High clinical suspicion and appropriate referral to Dermatology are essential for accurate diagnosis and management. Treatment of PNGD is focused on underlying disease control. Other options include topical, intralesional or systemic corticosteroids, dapsone or hydroxychloroquine. Herein, we present the case of a 71-year-old woman with RA who developed PNGD, highlighting the importance of a multidisciplinary approach for achieving a favorable clinical outcome.

Quality of evidence supporting the role of probiotics for rheumatoid arthritis: an overview of systematic reviews

Background

To evaluate the methodological quality, report quality, and evidence quality of meta-analysis (MA) and systematic review (SR) on the efficacy of probiotics in the treatment of rheumatoid arthritis (RA).

Methods

Databases were used to identify eligible SRs/MAs until February 12, 2024. The methodological quality of the studies was assessed using AMSTAR-2 tool, the quality of the literature reports was scored using PRISMA checklists, and the quality of the evidence was graded using GRADE system.

Results

Seven reviews including 21 outcomes were included. Methodological quality of the included reviews was of general low, and the entries with poor scores were 2, 4, and 7. By PRISMA checklists, there were some reporting deficiencies, and quality problems were mainly reflected in the reporting registration and protocol, comprehensive search strategy and additional analysis. GRADE results elevated the quality of evidence to be low or very low overall.

Conclusions

Probiotics may have a therapeutic effect on RA, based on the evidence provided by the SRs/MAs in this overview. Nevertheless, there is still a lack of conclusive evidence due to methodological limitations in the included research. To make trustworthy judgments regarding the efficacy of probiotics in the treatment of RA, more large-scale, high-quality randomized controlled trials are still required.

Role of macrophages and their exosomes in orthopedic diseases

Exosomes are vesicles with a lipid bilayer structure that carry various active substances, such as proteins, DNA, non-coding RNA, and nucleic acids; these participate in the immune response, tissue formation, and cell communication. Owing to their low immunogenicity, exosomes play a key role in regulating the skeletal immune environment. Macrophages are important immune cells that swallow various cellular and tissue fragments. M1-like and M2-like macrophages differentiate to play pro-inflammatory, anti-inflammatory, and repair roles following stimulation. In recent years, the increase in the population base and the aging of the population have led to a gradual rise in orthopedic diseases, placing a heavy burden on the social medical system and making it urgent to find effective solutions. Macrophages and their exosomes have been demonstrated to be closely associated with the pathogenesis and prognosis of orthopedic diseases. An in-depth understanding of their mechanisms of action and the interaction between them will be helpful for the future clinical treatment of orthopedic diseases. This review focuses on the mechanisms of action, diagnosis, and treatment of orthopedic diseases involving macrophages and their exosomes, including fracture healing, diabetic bone damage, osteosarcoma, and rheumatoid arthritis. In addition, we discuss the prospects and major challenges faced by macrophages and their exosomes in clinical practice.

The first presentation of a case of nail-patella syndrome newly diagnosed at the onset of rheumatoid arthritis: a case report

BACKGROUND

Nail-patella syndrome (NPS) is a rare autosomal dominant disorder that is characterized by dysplasia of the nails, hypoplasia and/or dislocation of the patella and the presence of iliac horns. Using the CARE guidelines, we present the first reported case of NPS that was newly diagnosed at the onset of rheumatoid arthritis (RA).

CASE PRESENTATION

A 74-year-old man was admitted to our hospital due to an 8-month history of arthralgia in bilateral wrists, elbows and fingers. He had a past history of glaucoma and left patella dislocation that had been operatively recentered at the age of 15 years. Laboratory data showed elevated levels of serum C-reactive protein and rheumatoid factor and an elevated titer of anti-SS-A antibodies, while estimated glomerular filtration rate (eGFR), titers of other antibodies and the results of a urinary test were normal. An X-ray showed deformity of bilateral radial heads and the right elbow, and magnetic resonance imaging (MRI) of his hands showed synovitis and erosion in the multiple swollen joints of the wrists and fingers. In addition to these typical features of RA, he had bilateral thumb nail dysplasia with mild hypoplasia of bilateral patellae and iliac horns as shown by the X-ray. He was diagnosed as having autosomal dominant disorder NPS co-existing with RA and he was treated with methotrexate in combination with an oral Janus kinase (JAK) inhibitor, leading to induction of remission.

CONCLUSIONS

We have presented a rare case of NPS that was newly diagnosed at the onset of RA. Clinical and radiographic findings of NPS are highlighted in this case report for diagnosing NPS on the basis of typical manifestations.

Icariin decreases cell proliferation and inflammation of rheumatoid arthritis-fibroblast like synoviocytes via GAREM1/MAPK signaling pathway

OBJECTIVE

Rheumatoid arthritis (RA) is an autoimmune disorder characterized by chronic inflammation and joint damage, leading to pain and reduced joint function. Icariin, a flavonoid compound, has been studied for its potential therapeutic role in RA due to its anti-inflammatory and anti-proliferative effects. Here, we aimed to investigate the action mechanism of icariin in regulating RA.

MATERIALS AND METHODS

Fibroblast-like synoviocytes (FLS) were obtained from RA and trauma patients, generating RA-FLS and normal FLS. The cells were treated with varying concentrations of icariin (0, 10, 20, 40, 80 μM). We assessed the effects of icariin on cell proliferation, apoptosis, and levels of inflammatory factors using the CCK-8 assay, flow cytometry, and enzyme-linked immunosorbent assay, qRT-PCR, and western blotting.

RESULTS

Icariin treatment had no significant impact on the cell proliferation of normal FLS. However, it dose-dependently repressed cell proliferation, reduced TNF-α, IL-6, and IL-1β levels, and increased apoptosis in RA-FLS. The expression of GAREM1, p-p38, and p-ERK1/2 was upregulated in RA-FLS, which was reversed by icariin treatment. Overexpression of GAREM1 reversed the inhibitory effects of icariin on cell proliferation and inflammatory factor levels in RA-FLS.

CONCLUSION

Our findings suggest that icariin treatment can alleviate the development of RA by reducing cell proliferation and inflammation in RA-FLS through the regulation of the GAREM1/MAPK signaling pathway. These results support the potential of icariin as a therapeutic agent for RA treatment. As icariin is safe and well-tolerated in previous studies, further research is warranted to explore its efficacy in clinical settings.

Rheumatoid arthritis with pulmonary accelerated rheumatoid nodules treated by baricitinib: a case-based review

Pulmonary accelerated rheumatoid nodules (ARN) represent a rare occurrence within the context of rheumatoid arthritis (RA), with conventional treatment typically involving corticosteroids. In this report, we present a unique case of pulmonary ARN managed with baricitinib, a Janus kinase inhibitor. The patient, a 46-year-old woman diagnosed with RA, initially displayed no evident pulmonary nodules upon pulmonary imaging. Her treatment regimen encompassed corticosteroids, methotrexate, and leflunomide. Nevertheless, a chest computed tomography (CT) scan conducted after a year unveiled the presence of multiple bilateral pulmonary nodules. A thoracoscopic biopsy of these nodules confirmed the presence of rheumatoid nodules. Treatment with baricitinib, a Janus kinase inhibitor or synthetic disease-modifying antirheumatic drug (DMARD), effectively reduced the size of the nodules. Our review of 45 articles on ARN published since 1986 found that nine of them reported 13 cases of pulmonary ARN. These nodules may be caused by certain synthetic and biological DMARDs and often present with respiratory symptoms. CT scans typically reveal multiple solid nodules or ground-glass opacities, some of which may have cavities. Treatment customarily involves discontinuing the suspected drugs and administering corticosteroids. This case suggests that Janus kinase inhibitors may be an effective treatment option for ARN.

Vasculitis, an Early Unusual Presentation of Rheumatoid Arthritis: A Case Report

Rheumatoid arthritis (RA) is a chronic inflammatory disease, with rheumatoid vasculitis (RV) being its most threatening complication. We report a case of a 70-year-old female presenting with gangrene of the tips of fingers and toes early in the course of RA, which is a rare manifestation. The skin is the most commonly affected organ in RV, followed by the peripheral nerves. However, almost every organ system can get implicated. The management of RV is mostly empirical, with high-dose glucocorticoids and cyclophosphamide. Early diagnosis and optimum management are essential in preventing severe complications of the disease.

Nano-platform Strategies of Herbal Components for the Management of Rheumatoid Arthritis: A Review on the Battle for Next-Generation Formulations

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that initially affects small joints and then spreads to the bigger joints. It also affects other organs of the body such as lungs, eyes, kidneys, heart, and skin. In RA, there is destruction of cartilage and joints, and ligaments and tendons become brittle. Damage to the joints leads to abnormalities and bone degradation, which may be quite painful for the patient.

METHOD

The nano-carriers such as liposomes, phytosomes, nanoparticles, microcapsules, and niosomes are developed to deliver the encapsulated phytoconstituents to targeted sites for the better management of RA.

RESULTS

The phytoconstituents loaded nano-carriers have been used in order to increase bioavailability, stability and reduce the dose of an active compound. In one study, the curcumin-loaded phytosomes increase the bioavailability of curcumin and also provides relief from RA symptoms. The drug-loaded nano-carriers are the better option for the management of RA.

CONCLUSION

In conclusion, there are many anti-arthritic herbal and synthetic medicine available in the market that are currently used in the treatment of RA. However, chronic use of these medications may result in a variety of side effects. Because therapy for RA is frequently necessary for the rest of ones life. The use of natural products may be a better option for RA management. These phytoconstituents, however, have several disadvantages, including limited bioavailability, low stability, and the need for a greater dosage. These problems can be rectified by using nano-technology.

Successful peficitinib monotherapy for the new-onset skin manifestations of rheumatoid vasculitis after long-term treatment with tocilizumab for rheumatoid arthritis

Rheumatoid vasculitis (RV) is a severe extra-articular systemic manifestation of rheumatoid arthritis (RA). Its prevalence has been decreasing for decades because of improved early diagnosis of RA and advances in RA treatment, but it remains a life-threatening disease. The standard treatment for RV has been a glucocorticoid and disease-modifying antirheumatic drugs. Biological agents, including antitumour necrosis factor inhibitors, are also recommended for refractory cases. However, there are no reports of Janus kinase (JAK) inhibitor use in RV. We experienced a case of an 85-year-old woman with a 57-year history of RA who had been treated with tocilizumab for 9 years after receiving three different biological agents over 2 years. Her RA seemed to be in remission in her joints, and her serum C-reactive protein had decreased to 0.0 mg/dL, but she developed multiple cutaneous leg ulcers associated with RV. Because of her advanced age, we changed her RA treatment from tocilizumab to the JAK inhibitor peficitinib in monotherapy, after which the ulcers improved within 6 months. This is the first report to indicate that peficitinib is a potential treatment option for RV that can be used in monotherapy without glucocorticoids or other immunosuppressants.

Rheumatoid nodules: a narrative review of histopathological progression and diagnostic consideration

Rheumatoid nodules (RNs) are the most common extra-articular manifestation of rheumatoid arthritis and are also seen in patients with other autoimmune and inflammatory diseases. The development of RNs includes histopathological stages of acute unspecified inflammation, granulomatous inflammation with no or minimal necrosis, necrobiotic granulomas typically with central fibrinoid necrosis surrounded by palisading epithelioid macrophages and other cells, and likely an advanced stage of "ghost" lesions containing cystic or calcifying/calcified areas. In this article, we review RN pathogenesis, histopathological features in different stages, diagnostically related clinical manifestations, as well as diagnosis and differential diagnosis of RNs with an in-depth discussion about challenges in distinguishing RNs from their mimics. While the pathogenesis of RN formation remains elusive, it is hypothesized that some RNs with dystrophic calcification may be in transition and may be in coexistence or collision with another lesion in patients with RA or other soft tissue diseases and comorbidities. The diagnosis of typical or mature RNs in usual locations can be readily made by clinical findings often with classic RN histopathology, but in many cases, particularly with atypical or immature RNs and/or unusual locations, the clinical and histopathological diagnosis can be challenging requiring extensive examination of the lesional tissue with histological and immunohistochemical markers to identify unusual RNs in the clinical context or other lesions that may be coexisting with classic RNs. Proper diagnosis of RNs is critical for appropriate treatment of patients with RA or other autoimmune and inflammatory diseases.

Metformin Treatment Reduces the Incidence of Rheumatoid Arthritis: A Two-Sample Mendelian Randomized Study

Several studies have shown that rheumatologic patients can benefit from metformin, but it remains unclear whether metformin treatment is causally associated with the risk of rheumatoid arthritis (RA). A two-sample Mendelian randomization (MR) study was conducted to investigate the causal relationship between metformin treatment and the incidence of rheumatoid arthritis. The genome-wide significant (p < 5 × 10^-8) single-nucleotide polymorphisms (SNPs) associated with metformin use were selected as instrumental variables (IVs). Summary statistics on RA were extracted from a large genome-wide association study (GWAS) meta-analysis. The inverse variance-weighted (IVW) method was used as the determinant of the causal effects of metformin treatment on RA. Cochran's Q was used to detect heterogeneity. Mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO) test and MR-Egger regression were used to detect horizontal pleiotropy. A total of 34 SNPs significantly associated with metformin treatment were obtained. Thirty-two SNPs were selected as IVs after removing two SNPs for being palindromic with intermediate allele frequencies (rs11658063 and rs4930011). The IVW results showed a negative causal association between metformin treatment and RA (OR = 0.0232, 95% CI 1.6046 × 10^-3 - 0.3368; p = 0.006). Meanwhile, no heterogeneity or pleiotropy was detected, indicating that the results were reliable. This study indicated a negative causality between metformin treatment and RA, indicating that the treatment of metformin can prevent the pathogenesis of RA.

What the rheumatologist needs to know about skin biopsy

The skin biopsy plays an important and powerful role in helping diagnose rheumatic diseases that present with cutaneous findings. As the skin is a very accessible organ, and the skin biopsy can be performed quickly as an in-office procedure, the skin biopsy is utilized frequently in patients with rheumatic diseases. However, the more challenging aspects of performing the biopsy, such as identifying the type of biopsy to perform, the site (s) to biopsy, the type of media to use, and the interpretation of histopathologic data are nuanced and require considerable thought. In this review, we discuss the common skin findings in rheumatic diseases and the general indications for skin biopsies in these diseases. We then summarize how to perform various skin biopsy techniques and how to select the biopsy technique. Finally, we discuss important rheumatic disease-specific considerations for skin biopsy, including where to biopsy and how to interpret the pathologic reports.

Does Having Rheumatoid Arthritis Increase the Dose of Depression Medications? A Mendelian Randomization Study

BACKGROUND

Rheumatoid arthritis (RA) increases the risk of depression. However, studies on the effects of RA on the dose of depression medications are limited. Therefore, in this study, we used two-sample Mendelian randomization (MR) to explore whether RA increases the dose of depression medications and gain a more comprehensive understanding of the relationship between RA and depression.

METHODS

Two-sample MR was used to evaluate the causal effect of RA on the dose of depression medications. The aggregated data on RA originated from extensive genome-wide association studies (GWASs) of European descent (14,361 cases and 42,923 controls). The summary GWAS data for the dose of depression medications were derived from the FinnGen consortium (58,842 cases and 59,827 controls). Random effects inverse-variance weighted (IVW), MR-Egger regression, weighted median, and fixed effects IVW methods were used for the MR analysis. Random effects IVW was the primary method. The heterogeneity of the MR results was detected using the IVW Cochran's Q test. The pleiotropy of the MR results was detected using MR-Egger regression and the MR pleiotropy residual sum and outlier (MR-PRESSO) test. Finally, a leave-one-out analysis was performed to determine whether the MR results were affected by a specific single-nucleotide polymorphism (SNP).

RESULTS

The primary method, random effects IVW, revealed that genetically predicted RA had a positive causal association with the dose of depression medications (Beta, 0.035; 95% confidence interval (CI), 0.007-0.064; p = 0.015). The IVW Cochran's Q test results revealed no heterogeneity in the MR analysis (p > 0.05). The MR-Egger regression and MR-PRESSO tests revealed that there was no pleiotropy in our MR analysis. The leave-one-out analysis confirmed that a single SNP did not affect the MR results, indicating the study's robustness.

CONCLUSION

Using MR techniques, we discovered that having RA increases the dose of depression medications; however, the exact mechanisms and pathways still need to be further explored.

Osteoimmunology: The effect of autoimmunity on fracture healing and skeletal analysis

Understanding factors that affect bone response to trauma is integral to forensic skeletal analysis. It is essential in forensic anthropology to identify if impaired fracture healing impacts assessment of post-traumatic time intervals and whether a correction factor is required. This paper presents a synthetic review of the intersection of the literature on the immune system, bone biology, and osteoimmunological research to present a novel model of interactions that may affect fracture healing under autoimmune conditions. Results suggest that autoimmunity likely impacts fracture healing, the pathogenesis however, is under researched, but likely multifactorial. With autoimmune diseases being relatively common, significant clinical history should be incorporated when assessing skeletal remains. Future research includes the true natural healing rate of bone; effect of autoimmunity on this rate; variation of healing with different autoimmune diseases; and if necessary, development of a correction factor on the natural healing rate to account for impairment in autoimmunity.

Computer-Aided Diagnosis of Pulmonary Nodules in Rheumatoid Arthritis

(1) Background: Rheumatoid arthritis (RA) is considered a systemic inflammatory pathology characterized by symmetric polyarthritis associated with extra-articular manifestations, such as lung disease. The purpose of the present study is to use CAD in the detection of rheumatoid pulmonary nodules. In addition, we aim to identify the characteristics and associations between clinical, laboratory and imaging data in patients with rheumatoid arthritis and lung nodules. (2) Methods: The study included a number of 42 patients diagnosed with rheumatoid arthritis according to the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria, examined from January 2017 to November 2022 in the Departments of Rheumatology and Radiology and Medical Imaging of the University of Medicine and Pharmacy of Craiova. Medical records were reviewed. A retrospective blinded review of CT for biopsy-proven pulmonary nodules in RA using Veolity LungCAD software was performed (MeVis Medical Solutions AG, Bremen, Germany). Imaging was also reviewed by a senior radiologist. (3) Results: The interobserver agreement proved to be moderate (κ = 0.478) for the overall examined cases. CAD interpretation resulted in false positive results in the case of 12 lung nodules, whereas false negative results were reported in the case of 8 lung nodules. The mean time it took for the detection of lung nodules using CAD was 4.2 min per patient, whereas the detection of lung nodules by the radiologist was 8.1 min per patient. This resulted in a faster interpretation of lung CT scans, almost reducing the detection time by half (p < 0.001). (4) Conclusions: The CAD software is useful in identifying lung nodules, in shortening the interpretation time of the CT examination and also in aiding the radiologist in better assessing all the pulmonary lung nodules. However, the CAD software cannot replace the human eye yet due to the relative high rate of false positive and false negative results.

A challenging case of rheumatoid arthritis-associated aortitis presenting with erythema nodosum after ST-segment elevation myocardial infarction: A case report

Rheumatoid arthritis is a systemic inflammatory disease that has many extra-articular manifestations. Cardiovascular involvement, including coronary vasculitis and aortitis and skin lesion of erythema nodosum are uncommon findings of patients with rheumatoid arthritis, and thus, it is challenging for diagnosis of this case from those unusual extra-articular presentation.

Calcium-Permeable Channels Cooperation for Rheumatoid Arthritis: Therapeutic Opportunities

Rheumatoid arthritis is a common autoimmune disease that results from the deposition of antibodies–autoantigens in the joints, leading to long-lasting inflammation. The main features of RA include cartilage damage, synovial invasion and flare-ups of intra-articular inflammation, and these pathological processes significantly reduce patients’ quality of life. To date, there is still no drug target that can act in rheumatoid arthritis. Therefore, the search for novel drug targets has become urgent. Due to their unique physicochemical properties, calcium ions play an important role in all cellular activities and the body has evolved a rigorous calcium signaling system. Calcium-permeable channels, as the main operators of calcium signaling, are widely distributed in cell membranes, endoplasmic reticulum membranes and mitochondrial membranes, and mediate the efflux and entry of Ca2+. Over the last century, more and more calcium-permeable channels have been identified in human cells, and the role of this large family of calcium-permeable channels in rheumatoid arthritis has gradually become clear. In this review, we briefly introduce the major calcium-permeable channels involved in the pathogenesis of RA (e.g., acid-sensitive ion channel (ASIC), transient receptor potential (TRP) channel and P2X receptor) and explain the specific roles and mechanisms of these calcium-permeable channels in the pathogenesis of RA, providing more comprehensive ideas and targets for the treatment of RA.

Differentialdiagnose Vaskulitis und Vaskulopathie aus dermatologischer Sicht

Vaskulopathien und Vaskulitiden stellen diagnostisch und therapeutisch eine interdisziplinäre Herausforderung dar. Zugrunde liegen unterschiedliche pathophysiologische Mechanismen, die zu vielfältigen klinischen Krankheitsbildern führen können und therapeutisch unterschiedliche Ansätze erlauben. Sowohl Vaskulitiden als auch Vaskulopathien müssen nicht zwangsläufig mit einer Systembeteiligung einhergehen, sondern können auch als rein kutane Varianten auftreten. Aufgrund mangelnder pathognomonischer Laborparameter ist die Diagnose häufig klinisch zu stellen. Dieser Artikel soll den differentialdiagnostischen Blick, insbesondere auf die kutanen Manifestationsformen bei Vaskulopathien und Vaskulitiden, schärfen.

Identification of Critical Biomarkers and Immune Infiltration in Rheumatoid Arthritis Based on WGCNA and LASSO Algorithm

Rheumatoid arthritis(RA) is the most common inflammatory arthritis, and a significant cause of morbidity and mortality. RA patients' synovial inflammation contains a variety of genes and signalling pathways that are poorly understood. It was the goal of this research to discover the major biomarkers related to the course of RA and how they connect to immune cell infiltration. The Gene Expression Omnibus was used to download gene microarray data. Differential expression analysis, weighted gene co-expression network analysis (WGCNA), and least absolute shrinkage and selection operator (LASSO) regression were used to identify hub markers for RA. Single-sample GSEA was used to examine the infiltration levels of 28 immune cells and their connection to hub gene markers. The hub genes' expression in RA-HFLS and HFLS cells was verified by RT-PCR. The CCK-8 assay was applied to determine the roles of hub genes in RA. In this study, we identified 21 differentially expressed genes (DEGs) in RA. WGCNA yielded two co-expression modules, one of which exhibited the strongest connection with RA. Using a combination of differential genes, a total of 6 intersecting genes was discovered. Six hub genes were identified as possible biomarkers for RA after a lasso analysis was performed on the data. Three hub genes, CKS2, CSTA, and LY96, were found to have high diagnostic value using ROC curve analysis. They were shown to be closely related to the concentrations of several immune cells. RT-PCR confirmed that the expressions of CKS2, CSTA and LY96 were distinctly upregulated in RA-HFLS cells compared with HFLS cells. More importantly, knockdown of CKS2 suppressed the proliferation of RA-HFLS cells. Overall, to help diagnose and treat RA, it's expected that CKS2, CSTA, and LY96 will be available, and the aforementioned infiltration of immune cells may have a significant impact on the onset and progression of the disease.

[Granulomatous dermatoses]

The group of granulomatous dermatoses refers to a multitude of clinically different diseases, which are characterized by a histopathologically similar pattern of inflammation. The cause of granulomatous inflammatory reactions can be infections and also noninfectious stimuli, such as cell disintegration or foreign bodies. The aim of this immunological defence reaction is encapsulation in order to prevent further spread and delimitation from healthy tissue. This is histologically expressed as a granuloma in the sense of a circumscribed aggregation of histiocytes and multinucleated giant cells mostly in dermal connective tissue. The following can be histologically differentiated: sarcoid granuloma characterized by a sparse lymphocytic inflammatory infiltrate and tuberculous granuloma with central necrosis and denser lymphocytic inflammatory infiltrate. Neutrophilic granulocytes together with macrophages occur in suppurative granulomas and palisaded granulomas are characterized by peripherally arrayed macrophages.

Diagnosis and Management of a Chronic Lower-Limb Wound in a Patient with Felty Syndrome

ABSTRACT

The authors report the case of a 55-year-old patient with a chronic lower-limb wound thought to be secondary to vasculitis. This case illustrates the importance of maintaining a high index of suspicion for vasculitic ulcers in patients with autoimmune disease. Management considerations in this context are also discussed.

CKS2 and S100A12: Two Novel Diagnostic Biomarkers for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic systematicness autoimmunity disease with joint inflammation. RA etiology is still unknown. Early and exact diagnosing is still hard to reach. In the paper, we purposed to discover novel diagnosis biological marker for RA. Two open, usable gene expression profiles of human RA as well as controlled specimens (dataset GSE17755 as well as GSE93272) were downloaded from the GEO database. Differentially expressed genes (DEGs) were screened between 331 RA and 88 control samples. Functional enrichment analysis was applied to explore the possible function of DEGs. Expression levels as well as diagnosis values of biological marker in RA were further verified in our cohort by the use of RT-PCR and ROC assays. We identified 13 DEGs between RA samples and control samples. 13 DEGs were remarkably abundant in NF-kappa B signal pathway. Among the 13 DEGs, CKS2, S100A12, LY96, and ANXA3 exhibited a strong diagnostic ability in screening RA specimens from normal specimens using all AUC > 0.8. Moreover, we confirmed that the expression of CKS2 and S100A12 was distinctly upregulated in RA specimens contrasted to normal specimens. Overall, serum CKS2 and S100A12 could be used as novel diagnosis biological markers for RA patients.

Extraarticular Manifestations and Comorbidities in Patients With Rheumatoid Arthritis

We read with great interest the article by Gunderson et al, which reported the multimorbidity burden in rheumatoid arthritis (RA).1 We appreciate that the authors estimated comorbidities in RA with a novel perspective, thus giving us a chance to further clarify the RA patient complexity. We would like, however, to discuss some key points.

Clinical characteristics of multicentric reticulohistiocytosis and distinguished features from rheumatoid arthritis: a single-center experience in China

OBJECTIVE

To investigate the clinical features of multicentric reticulohistiocytosis (MRH).

METHODS

The clinical manifestations, laboratory examination results and histologic characteristics of eleven patients with MRH were collected and compared with those of 33 patients with rheumatoid arthritis.

RESULTS

In total, 72.7% of the MRH patients were women. The median age was 46 years (range 33-84 years). Diagnosed by specific pathologic features, all MRH patients exhibited cutaneous involvement. The dorsa of the hands, arms, face and auricle were the most commonly affected areas. Nodules were also located on the legs, scalp, trunk, neck, and even the hypoglossis and buccal mucosa. Ten MRH patients (90.9%) had symmetric polyarthritis. Compared with rheumatoid arthritis (RA) patients, MRH patients were more likely to have distal interphalangeal joint (DIP) involvement (63.6% vs 24.2%, P = 0.017) and less likely to have elbow (36.4% vs 72.7%, P = 0.003), ankle (45.5% vs 93.9%, P < 0.001) and metacarpophalangeal joint (MCP) (36.4% vs 78.8%, P = 0.009) involvement. Positivity for rheumatoid factor (RF) (36.4% vs 84.6%, P = 0.001) and anti-CCP antibody (9.1% vs 81.8%, P = 0.000), as well as the median RF titer [43.8 (31.7-61.0) vs 175.4 (21.3-940.3), P = 0.021], in MRH patients was lower than in RA patients. Elevation of the erythrocyte sedimentation rate (ESR) was also less common in MRH patients than in RA patients (36.4% vs 72.7%, P = 0.030). After treatment with median- to large-dose corticosteroids and disease-modifying antirheumatic drugs, 8 patients achieved complete remission and 2 patients partial remission (skin lesions ameliorated, joint lesions not ameliorated).

CONCLUSION

Always pathologically diagnosed, MRH is a systemic disease involving RA-like erosive polyarthritis and a specific distribution of skin nodules characterized by "coral beads". More DIP involvement and less elbow, ankle and MCP involvement are seen in MRH than in RA. In addition, less positivity and lower-titer RF, uncommon presence of anti-CCP antibodies and ESR elevation may be helpful to distinguish MRH from RA.

A deep learning classification of metacarpophalangeal joints synovial proliferation in rheumatoid arthritis by ultrasound images

OBJECTIVE

To evaluate if an automatic classification of rheumatoid arthritis (RA) metacarpophalangeal joint conditions in ultrasound images is feasible by deep learning (DL) method, to provide a more objective, automated, and fast way of RA diagnosis in clinical setting.

MATERIALS AND METHODS

DenseNet-based DL model was used and both training and testing are implemented in TensorFlow 1.13.1 with Keras DL libraries. The area under curve (AUC), accuracy, sensitivity, and specificity values with 95% CIs were reported. The statistical analysis was performed by using scikit-learn libraries in Python 3.7.

RESULTS

A total of 1337 RA ultrasound images were acquired from 208 patients, the number of images is 313, 657, 178, and 189 in OESS Grade L0, L1, L2, and L3, respectively. In Classification Scenario 1 SP-no versus SP-yes, three experiments with region of interest of size 192 × 448 (Group 1), 96 × 224 (Group 2), and 96 × 224 stacked with pre-segmented annotated mask of SP area (Group 3) as input achieve an AUC of 0.863 (95% CI: 0.809, 0.917), 0.861 (95% CI: 0.805, 0.916), and 0.886 (95% CI: 0.836, 0.936), respectively. In Classification Scenario 2 Healthy versus Diseased, experiments in Group 1, Group 2 and Group 3 achieve an AUC of 0.848 (95% CI: 0.799, 0.896), 0.864 (95% CI: 0.819, 0.909), and 0.916 (95% CI: 0.883, 0.952), respectively.

CONCLUSION

We combined DenseNet model with ultrasound images for RA condition assessment. The feasibility of using DL to create an automatic RA condition classification system was also demonstrated. The proposed method can be an alternative to the initial screening of RA patients.

A Review of the Effects of Collagen Treatment in Clinical Studies

Collagen, an abundant extracellular matrix protein, has been found to have a lot of pharmaceuticals, medicine, food, and cosmetics applications. Increased knowledge of collagen sources, extraction techniques, structure, and properties in the last decades has helped develop more collagen-based products and tissue engineering biomaterials. Collagen products have been playing an important role in benefiting the health of the human body, especially for aging people. In this paper, the effects of collagen treatment in different clinical studies including skin regeneration, bone defects, sarcopenia, wound healing, dental therapy, gastroesophageal reflux, osteoarthritis, and rheumatoid arthritis have been reviewed. The collagen treatments were significant in these clinical studies. In addition, the associations between these diseases were discussed. The comorbidity of these diseases might be closely related to collagen deficiency, and collagen treatment might be a good choice when a patient has more than one of these diseases, including the coronavirus disease 2019 (COVID-19). It concludes that collagen-based medication is useful in treating comorbid diseases and preventing complications.

[Rheumatoid arthritis : These dermatoses lead you to the diagnosis]

BACKGROUND

Rheumatoid arthritis is one of the most common autoimmune disorders. In addition to chronic arthritis, rheumatoid arthritis may present a variety of extra-articular manifestations, most commonly of the skin.

OBJECTIVES

Cutaneous manifestations associated with rheumatoid arthritis can be diverse, both specific and nonspecific. Which dermatoses should lead you to the diagnosis of an underlying rheumatoid arthritis?

METHODS

Evaluation of exemplary overviews, case presentations and relevant textbook articles.

RESULTS

Rheumatoid arthritis presents various specific and nonspecific skin manifestations. Besides visual diagnosis like classic rheumatoid nodules a histopathologic correlation or an interdisciplinary approach is often needed, such as for diagnosis of pyoderma gangrenosum.

CONCLUSIONS

The early detection and correct classification of cutaneous manifestations associated with rheumatoid arthritis can be groundbreaking for a successful therapy and a consequently better prognosis for patients with rheumatoid arthritis. Therefore dermatologists bear responsibility in the patient-centered care.

The Co-existence of Rheumatoid Arthritis and Granulomatosis With Polyangiitis: Two Cases and Review of the Literature

Granulomatosis with polyangiitis (GPA) and rheumatoid arthritis (RA) have shared features including vasculitis, ocular inflammation, interstitial lung disease, and arthritis but existing evidence indicates they are distinct conditions. Interestingly, the co-existence of GPA and RA has been described in the literature. Herein, we report two cases of GPA developing in patients with underlying RA and examine the relationship between the two conditions.

Two cases of GPA that developed in patients with preexisting RA are described in detail. Additionally, PubMed was searched for articles in English showing an association of RA and GPA using keywords “rheumatoid arthritis, and vasculitis, and Wegener’s, and ANCA, and granulomatosis polyangiitis.”

In addition to our two cases of RA and GPA overlap, 14 reports were identified in PubMed library from 1970 to 2020. Most of the cases were females (14/16, 88%), and had RA as the initial diagnosis (15/16, 94%). The mean age of RA diagnosis was 45.5 years, the mean age of GPA diagnosis was 52 years and the mean interval between both diagnoses was 101 months. Cyclophosphamide and steroid therapy were used in most of the cases.

There are numerous reports of GPA and RA overlap in the literature. GPA should be considered in the differential diagnosis when vasculitis develops in patients with RA.

Hidradenitis suppurativa and rheumatoid arthritis: evaluating the bidirectional association

Despite some common pathogenic themes, the association of hidradenitis suppurativa (HS) and rheumatoid arthritis (RA) has been poorly investigated. We aimed to evaluate the bidirectional association between HS and RA. A population-based study was conducted to compare HS patients (n = 6779) with age-, sex- and ethnicity-matched control subjects (n = 33,260) with regard to the incidence of new-onset and the prevalence of preexisting RA. Adjusted hazard ratios (HRs) and adjusted odds ratios (ORs) were estimated. The prevalence of preexisting RA was greater among patients with HS relative to controls (0.5% vs 0.3%. respectively; p = 0.019). The odds of being diagnosed with HS were 1.6-fold higher in patients with a history of RA (fully-adjusted OR, 1.66; 95% CI, 1.11–2.49; p = 0.014). The incidence rate of new-onset RA was estimated at 4.3 (95% CI, 2.5–6.8) and 2.4 (95% CI, 1.8–3.2) cases per 10,000 person-years among patients with HS and controls, respectively. The risk of RA was comparable between patients with HS and controls (fully-adjusted HR, 1.45; 95% CI, 0.77–2.72; p = 0.249). Compared to other patients with HS, those with HS and comorbid RA were older, had a higher prevalence of diabetes mellitus, hypertension, and hyperlipidemia, and had a comparable risk of all-cause mortality. In conclusions, a preexisting diagnosis of RA predisposes individuals to develop HS. Clinicians managing patients with HS and RA should be aware of this association. Further research is required to delineate the underlying pathomechanism of this observation.

Inflammatory arthritis-associated pyoderma gangrenosum: a systematic review

INTRODUCTION/OBJECTIVES

Pyoderma gangrenosum (PG) is a rare, rapidly progressive neutrophilic dermatosis commonly associated with systemic inflammatory diseases. We aimed to characterize the association of PG and inflammatory arthritis, as little is known outside of case reports and small cohort studies.

METHOD

We performed a systematic review in PubMed, EMBASE, and Scopus from inception to present using the terms arthritis and pyoderma gangrenosum. Patient demographics, clinical presentation, and treatment outcomes were recorded. Descriptive statistics and stratified analysis were used to compare factors of interest by type of arthritis.

RESULTS

A total of 1399 articles were screened, and 129 patients with inflammatory arthritis and PG were included in the review. The most common types of arthritis were rheumatoid arthritis (RA) (50.4%), inflammatory bowel disease (IBD)-associated arthritis (10.9%), and psoriatic arthritis (8.5%). In the vast majority of cases, joint symptoms preceded PG, by a median of 10 years (inter-quartile range [IQR] 5-16). Corticosteroid monotherapy and biologic therapies, used alone or in combination, resulted in improvement or complete resolution of ulcers 71.4% and 67.3% of the time, respectively. Within the latter, infliximab, adalimumab, and anakinra were most successful in inducing remission overall. RA and non-RA did not differ significantly in treatment success or healing time.

CONCLUSIONS

This study shows that PG is frequently preceded by inflammatory arthritis, most commonly RA. Clinicians used a wide variety of treatment regimens with variable outcomes. While larger studies are needed to standardize the treatment of inflammatory arthritis-associated PG, this study suggests that in addition to systemic corticosteroids, biologic medications can be effective treatment options for these patients.

KEY POINTS

• Inflammatory arthritis, most commonly rheumatoid arthritis, often precedes rather than follows pyoderma gangrenosum. • Other forms of arthritis associated with PG included IBD-associated arthritis and psoriatic arthritis. • Biologic therapies, such as infliximab, adalimumab, and anakinra, were largely successful in treating arthritis-associated pyoderma gangrenosum and may play an important role in corticosteroid-sparing therapy or in a maintenance regimen for this subset of patients. • The type of inflammatory arthritis associated with pyoderma gangrenosum may not be a helpful treatment guide as it was not significantly associated with treatment outcomes or healing time.

Granulomas in Dermatopathology: Principal Diagnoses - Part 1

This series of 2 articles on dermatopathologic diagnoses reviews conditions in which granulomas form. Part 1 clarifies concepts, discusses the presentation of different types of granulomas and giant cells, and considers a large variety of noninfectious diseases. Some granulomatous diseases have a metabolic origin, as in necrobiosis lipoidica. Others, such as granulomatous mycosis fungoides, are related to lymphomas. Still others, such as rosacea, are so common that dermatologists see them nearly daily in clinical practice.

Cutaneous manifestations are frequent and diverse among patients with rheumatoid arthritis and impact their quality of life: a cross-sectional study in a cohort of patients with recent-onset disease

INTRODUCTION/OBJECTIVES

Cutaneous involvement is often overlooked in rheumatoid arthritis (RA). We described cutaneous findings in outpatients attending a recent-onset cohort and identified factors associated with skin involvement and reduced (R) dermatological quality of life (DQoL).

METHODS

Skin and rheumatological examinations were performed in 122 patients. DQoL was assessed through the Dermatology Life Quality Index (DLQI). Skin findings were classified as RA-specific and RA-nonspecific. Multiple regression analysis identified factors associated to skin involvement and RDQoL (DLQI score > 1).

RESULTS

Patients were middle-aged females (91%), with a 1-year mean disease activity score in 28 joints as 2.0 (interquartile range: 1.5-2.6). There were 94 (77%) patients in whom at least one cutaneous finding was observed: 17 (13.1%) had RA-specific findings (all were rheumatoid nodules) and 91 (96.8%) had at least one RA-nonspecific finding, further classified into skin diseases (35.2%), hair diseases (20.9%), and skin-related signs (76.9%, among whom 94.3% had xerosis). Age (odds ratio [OR]: 1.054, 95% confidence interval [CI]: 1.015-1.094) and skin-health concerns (OR: 5.657, 95% CI: 1.771-18.070) were associated with cutaneous involvement, whereas increased age and DLQI score were associated with a higher number of skin findings/patient. There were 29 patients (24.2%) with RDQoL, which were associated with the Short Form-36 emotional component (OR: 0.955, 95% CI: 0.923-0.988) and the number of skin findings/patient (OR 2.873, 95% CI 1.723-4.791). Pruritus and hair diseases were the individual categories associated with RDQoL.

CONCLUSIONS

Cutaneous manifestations are frequent in RA patients and have the potential to impact the emotional component of health-related quality of life. Key Points • Up to 77% of the RA patients with substantial follow-up, from a recent-onset disease cohort, had cutaneous manifestations; these were primarily RA-nonspecific findings, whereas 13.1% had RA-specific findings. • Skin-health concerns and age were associated with cutaneous involvement; meanwhile, increased age and Dermatology Life Quality Index (DLQI) score were associated with a higher number of cutaneous findings/patient. • Reduced dermatological quality of life (RDQoL) was documented in one in four patients and was associated with the SF-36 emotional component and the number of cutaneous findings/patient.

Mitral valvulitis as a severe extra-articular manifestation of rheumatoid arthritis: a case report

Background

Extra-articular manifestations (EAMs) are common in patients with rheumatoid arthritis (RA). Cardiac EAMs are rare but may cause complete heart block and damage to the heart valves.

Case summary

We present the case of a middle-aged woman with long-standing RA and EAMs as the most prominent symptoms. The patient experienced complete atrioventricular heart block and developed nodular vegetations affecting the mitral valve, ultimately leading to severe mitral regurgitation and valve replacement.

Discussion

The diagnosis of cardiac EAMs in RA may be challenging for the clinicians. Symptoms and findings may mimic more common conditions such as malignancy and infectious endocarditis. A multidisciplinary approach is of paramount importance in order to make an early diagnosis and to provide optimal treatment to patients with RA and cardiac complications.

Granulomatous Cutaneous Drug Eruptions: A Systematic Review

BACKGROUND

Granulomatous drug eruptions are rare entities, where granuloma formation occurs as an attempt to contain an exogenous or endogenous inciting agent. Granulomatous drug eruptions may be localized to the skin or may include major systemic involvement, and their characteristics depend both on the properties of the causative irritant and host factors. Because of the overlapping features amongst noninfectious granulomatous diseases, granulomatous drug eruptions are challenging to diagnose and distinguish both histologically and clinically.

OBJECTIVE

The objective of this article is to provide a review and summary of the current literature on the five major types of cutaneous granulomatous drug eruptions: interstitial granulomatous drug reaction, drug-induced accelerated rheumatoid nodulosis, drug-induced granuloma annulare, drug-induced sarcoidosis, and miscellaneous presentations.

METHODS

A systematic review was conducted through PubMed using the search terms "granulomatous drug eruption" and "cutaneous" or "skin". English full-text studies that included human subjects experiencing a cutaneous reaction comprising granulomatous inflammation as the direct result of a drug were included. Of 205 studies identified, 48 articles were selected after a full-text review. Evidence was evaluated using the Tool for evaluating the methodological quality of case reports and case series.

RESULTS

Polypharmacy and a prolonged lag period from drug ingestion to rash onset may create diagnostic challenges. Ruling out tuberculosis is imperative in the endemic setting, particularly where anti-tumor necrosis factor therapy is the presumed cause. Interstitial granulomatous drug reactions and granuloma annulare are often localized to the skin whereas accelerated rheumatoid nodulosis and sarcoidosis may sometimes be associated with systemic features as well. Granulomatous drug eruptions typically resolve on discontinuing the offending medication; however, the decision for drug cessation is dependent on a risk-benefit assessment. In some situations, supplementation of an additional agent to suppress the reaction may resolve symptoms. In some cases, granulomatous drug eruptions may be pivotal in the successful outcome of the drug, as in cases of melanoma treatment. In all situations, the decision to continue or withdraw the drug should be carefully based on the severity of the eruption, necessity of continuing the drug, and availability of a suitable alternative.

CONCLUSIONS

Granulomatous drug eruptions should always be considered in the differential diagnosis of noninfectious granulomatous diseases of the skin. Further research examining dose-response relationships and the recurrence of granulomatous drug eruptions on the rechallenge of offending agents is required. Increased awareness of granulomatous drug eruption types is important, especially with continuous development of new anti-cancer agents that may induce these reactions.

CLINICAL TRIAL REGISTRATION

PROSPERO registration number CRD42020157009.

Giant Infrascapular Rheumatoid Nodules Mimicking Elastofibroma Dorsi: A Case Report

Rheumatoid nodules are the most common extra-articular presentations of rheumatoid arthritis. Although rheumatoid nodules can develop anywhere in the body, they develop most commonly in the subcutaneous region, where they are easily exposed to repetitive trauma or pressure. However, an infrascapular presentation has not yet been reported. We report a case of giant bilateral rheumatoid nodules that developed in the infrascapular area, complicating its distinction from elastofibroma dorsi on radiological examination.

Clinical Relevance and Immunohistochemical Patterns of Silent Pituitary Adenomas: 10 Years of Single-centre Experience

BACKGROUND

Silent pituitary adenomas are clinically non-functional (i.e., without clinically evident pituitary hormone production).

INTRODUCTION

The aim of this study was to investigate subjects with silent pituitary adenomas for possible variations in their clinical status.

METHODS

A total of 102 patients who had undergone surgery for pituitary adenoma and had been diagnosed with silent pituitary adenoma was included in the study. The patients' preoperative and postoperative hormonal parameters and magnetic resonance imaging (MRI) features were collected, and pathological specimens were re-evaluated.

RESULTS

Immunohistochemistry results of the 102 patients were as follows: hormone-negative adenomas (n=35) 35.5%; FSH+LH-positivity (n=32) 31.3%; ACTH-positivity (n=11) 10.7%; α-subunit- positivity (n= 9) 8.8%; prolactin-positivity (n=8) 7.8%; GH-positivity (n=6) 5.4%; and plurihormonal adenoma (n=1). The mean sizes of SGA, SGHA, and SCA were 28.0±12.7, 30.0±16.0, and 27.7±8.9mm (p>0.05), respectively. With the exception of silent gonadotroph adenomas (SGAs), female gender dominance was shown in patients with silent growth hormone adenoma (SGHA) and silent corticotroph adenoma (SCA). Although no clinical relevance was observed in relation to hormonal excess, preoperative GH (4.21±4.6, vs. 0.27±0.36 p=0.00) was slightly more elevated in SGHA than in GH-negative adenomas. Additionally, preoperative basal ACTH values (47.3±28.7 vs. 23.9±14.4, p=0.003) were also higher in SCA compared to the other types. Our findings revealed SCAs to be of more aggressive behaviour than SGHAs and SGAs due to invasiveness in radiological imaging, their elevated re-operation, and postoperative ACTH values.

CONCLUSION

Silent pituitary adenomas represent a challenging diagnostic tumour group. Careful initial evaluation of patients with pituitary adenomas should consider any mild signs and symptoms of functionality, particularly in cases of GH- and ACTH-secreting adenomas.

Beyond the joints, the extra-articular manifestations in rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory disease typically affecting the joints, but the systemic inflammatory process may involve other tissues and organs. Many extra-articular manifestations are recognized, which are related to worse long outcomes. Rheumatoid nodules are the most common extra-articular feature, found in about 30% of patients. Secondary Sjögren's syndrome and pulmonary manifestations are observed in almost 10% of patients, also in the early disease. Active RA with high disease activity has been associated with an increased risk of such features. Male gender, smoking habit, severe joint disease, worse function, high pro-inflammatory markers levels, high titer of rheumatoid factor, and HLA-related shared epitope have been reported as clinical predictors of occurrence of these rheumatoid complications. In addition, there is a little evidence deriving from randomized controlled trials in this field, thus the therapeutic strategy is mainly empiric and based on small case series and retrospective studies. However, considering that these extra-articular manifestations are usually related to the more active and severe RA, an aggressive therapeutic strategy is usually employed in view of the poor outcomes of these patients. The extra-articular features of RA remain, despite the improvement of joint damage, a major diagnostic and therapeutic challenge, since these are associated with a poor prognosis and need to be early recognized and promptly managed.

Liver rheumatoid nodules imitating liver malignancy: a rare occurrence

We describe a case of a 61-year-old man with a background of rheumatoid arthritis who presented to the emergency department with a single-reported episode of haemoptysis on the background of an upper respiratory tract infection. A CT scan revealed an incidental 40 mm mass in upper right lobe of the liver abutting the diaphragmatic surface. A subsequent positron emission tomography scan confirmed the mass and raised the possibility of another lesion in the liver raising the suspicion of malignancy. The case was complicated by the inability to perform a fine needle aspiration biopsy due to the mass' proximity to the diaphragm. After discussion with the patient, it was decided to resect the affected liver segment. Histological analysis of the mass revealed localised necrotising granulomatous inflammation suggestive of a rheumatoid nodule, which is seldom reported in the literature.