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Basheer M, Waked H, Jeries H, Azrilin O, Paz D, Assy N, Naffaa ME, Badarny S. Neurosarcoidosis: The Presentation, Diagnosis and Treatment Review of Two Cases. Life (Basel) 2023; 14:69. [PMID: 38255684 PMCID: PMC10820900 DOI: 10.3390/life14010069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/13/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Sarcoidosis is a chronic granulomatous disease of unknown cause characterized by the presence of non-caseating granulomas. The disease can affect any organ including the nervous system. Neurosarcoidosis occurs in about 5% patients with sarcoidosis. The clinical presentation of neurosarcoidosis is varied, and it can involve the brain, spinal cord and peripheral nervous system, separately or in different combinations. The diagnosis of neurosarcoidosis is challenging, as biopsies from the nervous system are not readily available. Anti-TNFα agents are becoming one of the cornerstone treatments for neurosarcoidosis. In this case-based review, we discuss two cases of neurosarcoidosis with different clinical presentations. The first patient presented with confusion, while the second presented with walking difficulty and neurogenic bladder. Both patients were treated with methylprednisolone pulse therapy with rapid, but non-complete, improvement. Therefore, infliximab was initiated in both cases with subsequent improvement in the clinical manifestations and imaging findings, emphasizing the effectiveness and safety of infliximab in cases of severe neurosarcoidosis. In conclusion, the goal of neurosarcoidosis management is to prevent organ system damage and minimize the toxic cumulative adverse effects of glucocorticoid use. In this case-based review we discuss the various presentations, the diagnosis and the treatment of neurosarcoidosis.
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Affiliation(s)
- Maamoun Basheer
- Internal Medicine Department, Galilee Medical Center, Nahariya 221001, Israel;
| | - Hamd Waked
- Neurology Department, Galilee Medical Center, Nahariya 221001, Israel; (O.A.); (S.B.)
| | - Helana Jeries
- Rheumatology Unit, Galilee Medical Center, Nahariya 221001, Israel;
| | - Olga Azrilin
- Neurology Department, Galilee Medical Center, Nahariya 221001, Israel; (O.A.); (S.B.)
| | - Dan Paz
- Radiology Department, Galilee Medical Center, Nahariya 221001, Israel; (D.P.); (M.E.N.)
| | - Nimer Assy
- Internal Medicine Department, Galilee Medical Center, Nahariya 221001, Israel;
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Mohammad E. Naffaa
- Radiology Department, Galilee Medical Center, Nahariya 221001, Israel; (D.P.); (M.E.N.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Samih Badarny
- Neurology Department, Galilee Medical Center, Nahariya 221001, Israel; (O.A.); (S.B.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
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Hassan F, Khoury A, Awad J, Jeries H, Naffaa ME. A very rare cause of blue finger: A case-based review. J Scleroderma Relat Disord 2023; 8:NP1-NP5. [PMID: 37744045 PMCID: PMC10515991 DOI: 10.1177/23971983231162679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/21/2023] [Indexed: 09/26/2023]
Abstract
Introduction Cryofibrinogen is an abnormal, cold-insoluble protein composed of a combination of fibrinogen, fibrin, and fibronectin. Cryofibrinogenemia can be essential (e.g. primary) or secondary to various conditions. While low levels of cryofibrinogen can be seen in asymptomatic healthy individuals without evidence of clinical features typical of cryofibrinogenemia, cryofibrinogenemia associated with clinical features is considered very rare. The clinical features of cryofibrinogenemia ranges from skin manifestations, including Raynaud's phenomenon and livedo reticularis, to more severe organ-threatening manifestations such as tissue ischemia and gangrene. Case description We report a case of a 48-year-old male who presented with blue finger and palpable purpura on his distal extremities. Laboratory workup was positive for anti-nuclear antibodies, anti-double-stranded DNA, anti-ribonucleoprotein, and rheumatoid factor, while antineutrophil cytoplasmic antibodies and cryoglobulins were negative. Testing for hypercoagulable states and infectious etiologies was unrevealing. Later, angiographic computed tomography showed multiple pulmonary embolisms and disruption of blood flow to the left fifth digit. As the aforementioned workup could not explain the presence of the thrombus by a thromboembolic cause, a search for an in situ cause other than antiphospholipid syndrome was initiated and concentrated mainly on cryofibrinogenemia. Blood samples collected using prewarmed anticoagulant containing tubes were sent to central lab familiar with performing the test. Two weeks later, a positive result for the presence of cryofibrinogen confirmed the diagnosis of cryofibrinogenemia. Due to the presence of multiple signs compatible with mixed connective tissue disease, he was diagnosed with cryofibrinogenemia secondary to mixed connective tissue disease, and treatment with prednisone, low-molecular-weight heparin, prostacyclin and hydroxychloroquine was initiaed with favorable outcome. Conclusion Cryofibrinogenemia is a rare and underdiagnosed condition. Clinicians should be aware of this cryopathy especially in the cases of Raynaud's phenomenon and ischemic ulcers not explained by other causes. Precautions must be taken during the diagnostic process, and therapy should be given as soon as possible.
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Affiliation(s)
- Fadi Hassan
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
| | - Amir Khoury
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Department of Internal Medicine “F”, Galilee Medical Center, Nahariya, Israel
| | - Jamal Awad
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Department of Internal Medicine “F”, Galilee Medical Center, Nahariya, Israel
| | - Helana Jeries
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
| | - Mohammad E Naffaa
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
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3
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Keret S, Henig I, Zuckerman T, Kaly L, Shouval A, Awisat A, Rosner I, Rozenbaum M, Boulman N, Dortort Lazar A, Molad Y, Sabbah F, Naffaa ME, Hardak E, Slobodin G, Rimar D. Outcomes in progressive systemic sclerosis treated with autologous hematopoietic stem cell transplantation compared with combination therapy. Rheumatology (Oxford) 2023:kead457. [PMID: 37672021 DOI: 10.1093/rheumatology/kead457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/31/2023] [Accepted: 08/14/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES Autologous hematopoietic stem cell transplantation (AHSCT) has been shown to improve long-term survival for early diffuse progressive systemic sclerosis (SSc) compared with cyclophosphamide. Cyclophosphamide, however, does not provide a long-term benefit in SSc. The combination of mycophenolate mofetil (MMF) and rituximab is a potent alternative regimen. We aimed to retrospectively compare the outcomes of SSc patients who underwent AHSCT to patients who met the eligibility criteria for AHSCT but received upfront combination therapy with MMF and rituximab. METHODS Repeated assessments of modified Rodnan Skin Score (mRSS), forced vital capacity (FVC), and diffusing capacity (DLCO) values were conducted. Clinical improvement was defined as an mRSS decrease > 25% or an FVC increase > 10%. Event-free survival (EFS) was defined in the absence of persistent major organ failure or death. RESULTS Twenty-one SSc patients in the combination therapy group were compared with sixteen in the AHSCT group. Age, sex and disease duration were similar between the two groups. Clinical improvement at 12 months was seen in 18 (86%) patients in the combination group compared with 13 (81%) in the AHSCT group (p= 0.7). The hazard ratio for EFS at 24 months favored the combination group (HR = 0.09, P= 0.04). During follow-up, both groups exhibited a significant and comparable reduction in mRSS and an increase in FVC values at each time interval up to 24 months. CONCLUSION MMF and rituximab compared with AHSCT in SSc patients eligible for AHSCT resulted in similar skin and lung clinical improvement with a better safety profile at 24 months.
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Affiliation(s)
- Shiri Keret
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Israel Henig
- Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center, Haifa, Israel
| | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center, Haifa, Israel
| | - Lisa Kaly
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Aniela Shouval
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Abid Awisat
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Itzhak Rosner
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Michael Rozenbaum
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Nina Boulman
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | | | - Yair Molad
- Institute of Rheumatology, Rabin Medical Center, Petah Tikva, Israel
| | - Firas Sabbah
- Rheumatology Unit, Baruch Padeh Medical Center, Poriya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Mohammad E Naffaa
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
| | - Emilia Hardak
- Pulmonary Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Gleb Slobodin
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Doron Rimar
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
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4
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Katony Eizenstat E, Hassan F, Golan Cohen A, Merzon E, Green I, Paz Z, Naffaa ME. Biologic therapy is associated with malignancies among Israeli patients with rheumatoid arthritis: A population-based study. Int J Rheum Dis 2023. [PMID: 37269484 DOI: 10.1111/1756-185x.14744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/30/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2023]
Abstract
AIMS To examine whether biologic disease-modifying anti-rheumatic drugs (bDMARDs) are associated with increased risk of malignancy among Israeli patients with rheumatoid arthritis (RA). METHODS We identified RA patients meeting specified inclusion and exclusion criteria from the Leumit healthcare services database between the years 2000 and 2017. Data were collected regarding bDMARD and conventional DMARD consumption, types of malignancies, and their temporal relation to RA diagnosis. The association between baseline variables and occurrence of malignancies was examined by Cox regression. RESULTS Among 4268 eligible RA patients, 688 (16.12%) were diagnosed with any malignancy. Melanoma skin cancer (MSC) was the most prevalent malignancy (148/688, 21.5%). The proportions out of all malignancies of MSC and non-melanoma skin cancer (NMSC) were higher after than before RA diagnosis (24.7% vs 19.1%, p = .025 and 24.7% vs 13.0%, p = .021, respectively). A higher proportion of RA patients diagnosed with malignancy used bDMARDs in comparison with RA patients who were malignancy-free (40.2% vs 17.5%, p < .001). After adjusting for demographic and clinical variables, bDMARDs were associated with an increased risk of malignancy (hazard ratio 1.42, 95% confidence interval 1.10-1.78). CONCLUSIONS Biologic DMARDs are associated with increased risk of malignancy among Israeli RA patients, presumably contributed by MSC and NMSC. MSC was the most prevalent type of malignancy in this cohort and may indicate a predisposition state among Israeli RA patients.
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Affiliation(s)
| | - Fadi Hassan
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
| | - Avivit Golan Cohen
- Leumit Health Services, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eugene Merzon
- Leumit Health Services, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Green
- Leumit Health Services, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ziv Paz
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
| | - Mohammad E Naffaa
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
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Hassan F, Jeries H, Naffaa ME. Challenges in the Timely Diagnosis of Behcet's Disease. Life (Basel) 2023; 13:life13051157. [PMID: 37240802 DOI: 10.3390/life13051157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/29/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Behcet's disease (BD) is a chronic, multi-systemic inflammatory disorder mainly characterized by recurrent oral and genital ulcers, skin lesions, and uveitis. As no pathognomonic laboratory test exists for BD, the diagnosis relies solely on clinical features. Over the years, great efforts have been invested in creating clinical diagnostic and classification criteria. The international study group criteria introduced in 1990 were the first true multinational set of criteria. Despite improving the ability to diagnose BD, these criteria still have limitations, including the inability to diagnose patients presenting without oral ulcers or presenting with rare manifestations of the disease. This led to the introduction of the international criteria for BD in 2013, which improved the sensitivity with minimal compromise on specificity. Despite the efforts made and as our understanding of the clinical manifestations of BD and genetic pathogenesis continue to evolve, efforts should be made to further enhance the currently accepted international classification criteria, perhaps by incorporating genetic testing (e.g., family history or HLA typing) as well as ethnic group-specific features.
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Affiliation(s)
- Fadi Hassan
- Rheumatology Unit, Galilee Medical Center, Naharyia 2210001, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Helana Jeries
- Rheumatology Unit, Galilee Medical Center, Naharyia 2210001, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Mohammad E Naffaa
- Rheumatology Unit, Galilee Medical Center, Naharyia 2210001, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
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6
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Hassan F, Sabbah F, Naffaa ME. Normotensive scleroderma renal crisis as the presenting symptom of systemic sclerosis sine scleroderma: A case report. J Scleroderma Relat Disord 2023; 8:NP1-NP5. [PMID: 36743817 PMCID: PMC9896193 DOI: 10.1177/23971983221101296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022]
Abstract
Scleroderma renal crisis is a rare but serious complication of systemic sclerosis. It is usually associated with marked hypertension and carries significant risk for morbidity and mortality. Its occurrence prior to the development of skin sclerosis is exceedingly rare. We report a case of a patient who presented with recurrent pericardial effusion and later tested positive for anti-nuclear and anti-topoisomerase antibodies. He later developed normotensive renal crisis as confirmed by kidney biopsy despite complete absence of skin involvement. To our knowledge, this is the first published case of a patient presenting with normotensive renal crisis without any skin involvement.
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Affiliation(s)
- Fadi Hassan
- Rheumatology Unit, Galilee Medical Center,
Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan
University, Safed, Israel
| | - Firas Sabbah
- Azrieli Faculty of Medicine, Bar-Ilan
University, Safed, Israel
- Baruch Padeh Medical Center, Poriya,
Israel
| | - Mohammad E Naffaa
- Rheumatology Unit, Galilee Medical Center,
Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan
University, Safed, Israel
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7
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Naffaa ME, Hassan F, Golan-Cohen A, Merzon E, Green I, Saab A, Paz Z. Factors associated with drug survival on first biologic therapy in patients with rheumatoid arthritis: a population-based cohort study. Rheumatol Int 2021; 41:1905-1913. [PMID: 34529109 DOI: 10.1007/s00296-021-04989-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 09/02/2021] [Indexed: 11/24/2022]
Abstract
Lack of sufficient head-to-head trials comparing biologic disease-modifying antirheumatic drugs (bDMARDs) in rheumatoid arthritis (RA), makes the choice of the first bDMARD a matter of rheumatologist's preference. Longer drug survival on the first bDMARD usually correlates with early remission. We aimed to identify factors associated with longer drug survival. We conducted a population-based retrospective longitudinal cohort study. We identified RA patients using the relevant International Classification of Disease 9th codes. "True" RA patients were defined as patients fulfilling, additionally, at least one of the following: receiving conventional DMARDs (cDMARDs), being positive for rheumatoid factor or anti-cyclic citrullinated peptide, or being diagnosed by a rheumatologist. We compared drug survival times and identified factors associated with longer drug survival. We identified 4268 true RA patients between the years of 2000-2017. 820 patients (19.2%) received at least one bDMARD. The most commonly prescribed bDMARDs were etanercept (352, 42.9%), adalimumab (143, 17.4%), infliximab (142, 17.3%) and tocilizumab (58, 7.1%). Infliximab was associated with the longest drug survival (47.1 months ± 46.3) while golimumab was associated with the shortest drug survival (14.9 months ± 15.1). Male gender [hazard ratio (HR) = 0.76, 95% confidence interval (CI), 0.63-0.86, p = 0.001], concurrent conventional DMARDs use (HR = 0.79, 95% CI 0.68 - 0.98, p = .031) and initiating bDMARD therapy in earlier calendric years (HR = 1.12, 95% CI 1.10 -1.18, p = 0.0001) were associated with longer drug survival. Male gender, concomitant cDMARDs and initiating biologic therapy at earlier calendric years are associated with longer drug survival.
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Affiliation(s)
- Mohammad E Naffaa
- Rheumatology Unit, Galilee Medical Center, Road 89, Naharyia, Israel. .,Azrieli Faculty of Medicine, Bar-Ilan University, Zefat, Israel.
| | - Fadi Hassan
- Azrieli Faculty of Medicine, Bar-Ilan University, Zefat, Israel.,Internal Medicine "E", Galilee Medical Center, Naharyia, Israel
| | - Avivit Golan-Cohen
- Leumit Health Services, Tel Aviv-Yafo, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | | | - Ilan Green
- Leumit Health Services, Tel Aviv-Yafo, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Amir Saab
- Azrieli Faculty of Medicine, Bar-Ilan University, Zefat, Israel.,Internal Medicine "E", Galilee Medical Center, Naharyia, Israel
| | - Ziv Paz
- Rheumatology Unit, Galilee Medical Center, Road 89, Naharyia, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Zefat, Israel
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8
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Watad A, De Marco G, Mahajna H, Druyan A, Eltity M, Hijazi N, Haddad A, Elias M, Zisman D, Naffaa ME, Brodavka M, Cohen Y, Abu-Much A, Abu Elhija M, Bridgewood C, Langevitz P, McLorinan J, Bragazzi NL, Marzo-Ortega H, Lidar M, Calabrese C, Calabrese L, Vital E, Shoenfeld Y, Amital H, McGonagle D. Immune-Mediated Disease Flares or New-Onset Disease in 27 Subjects Following mRNA/DNA SARS-CoV-2 Vaccination. Vaccines (Basel) 2021; 9:vaccines9050435. [PMID: 33946748 PMCID: PMC8146571 DOI: 10.3390/vaccines9050435] [Citation(s) in RCA: 244] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Infectious diseases and vaccines can occasionally cause new-onset or flare of immune-mediated diseases (IMDs). The adjuvanticity of the available SARS-CoV-2 vaccines is based on either TLR-7/8 or TLR-9 agonism, which is distinct from previous vaccines and is a common pathogenic mechanism in IMDs. METHODS We evaluated IMD flares or new disease onset within 28-days of SARS-CoV-2 vaccination at five large tertiary centres in countries with early vaccination adoption, three in Israel, one in UK, and one in USA. We assessed the pattern of disease expression in terms of autoimmune, autoinflammatory, or mixed disease phenotype and organ system affected. We also evaluated outcomes. FINDINGS 27 cases included 17 flares and 10 new onset IMDs. 23/27 received the BNT - 162b2 vaccine, 2/27 the mRNA-1273 and 2/27 the ChAdOx1 vaccines. The mean age was 54.4 ± 19.2 years and 55% of cases were female. Among the 27 cases, 21 (78%) had at least one underlying autoimmune/rheumatic disease prior the vaccination. Among those patients with a flare or activation, four episodes occurred after receiving the second-dose and in one patient they occurred both after the first and the second-dose. In those patients with a new onset disease, two occurred after the second-dose and in one patient occurred both after the first (new onset) and second-dose (flare). For either dose, IMDs occurred on average 4 days later. Of the cases, 20/27 (75%) were mild to moderate in severity. Over 80% of cases had excellent resolution of inflammatory features, mostly with the use of corticosteroid therapy. Other immune-mediated conditions included idiopathic pericarditis (n = 2), neurosarcoidosis with small fiber neuropathy (n = 1), demyelination (n = 1), and myasthenia gravis (n = 2). In 22 cases (81.5%), the insurgence of Adverse event following immunization (AEFI)/IMD could not be explained based on the drug received by the patient. In 23 cases (85.2%), AEFI development could not be explained based on the underlying disease/co-morbidities. Only in one case (3.7%), the timing window of the insurgence of the side effect was considered not compatible with the time from vaccine to flare. INTERPRETATION Despite the high population exposure in the regions served by these centers, IMDs flares or onset temporally-associated with SARS-CoV-2 vaccination appear rare. Most are moderate in severity and responsive to therapy although some severe flares occurred. FUNDING none.
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Affiliation(s)
- Abdulla Watad
- Department of Medicine ‘B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 10457, Israel; (A.W.); (Y.S.); (H.A.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; (H.M.); (A.D.); (M.B.); (Y.C.); (P.L.); (M.L.)
- Rheumatology Unit, Sheba Medical Center, Tel-Hashomer 10457, Israel
- NIHR, Leeds Biomedical Research Centre, The Leeds Teaching Hospitals NHS Trust & Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (G.D.M.); (C.B.); (H.M.-O.); (E.V.)
| | - Gabriele De Marco
- NIHR, Leeds Biomedical Research Centre, The Leeds Teaching Hospitals NHS Trust & Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (G.D.M.); (C.B.); (H.M.-O.); (E.V.)
| | - Hussein Mahajna
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; (H.M.); (A.D.); (M.B.); (Y.C.); (P.L.); (M.L.)
- Gastroenterology Department, Sheba Medical Center, Tel-Aviv 10457, Israel
| | - Amit Druyan
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; (H.M.); (A.D.); (M.B.); (Y.C.); (P.L.); (M.L.)
- Rheumatology Unit, Sheba Medical Center, Tel-Hashomer 10457, Israel
| | - Mailam Eltity
- Department of Neurology, Sheba Medical Center, Tel-Aviv 10457, Israel;
| | - Nizar Hijazi
- Rheumatology Unit, Carmel Medical Center, Michal Street, Haifa 3436212, Israel; (N.H.); (A.H.); (M.E.); (D.Z.); (M.A.E.)
| | - Amir Haddad
- Rheumatology Unit, Carmel Medical Center, Michal Street, Haifa 3436212, Israel; (N.H.); (A.H.); (M.E.); (D.Z.); (M.A.E.)
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Muna Elias
- Rheumatology Unit, Carmel Medical Center, Michal Street, Haifa 3436212, Israel; (N.H.); (A.H.); (M.E.); (D.Z.); (M.A.E.)
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Devy Zisman
- Rheumatology Unit, Carmel Medical Center, Michal Street, Haifa 3436212, Israel; (N.H.); (A.H.); (M.E.); (D.Z.); (M.A.E.)
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Mohammad E. Naffaa
- Department of Rheumatology, Galilee Medical Center, Azrieli Faculty of Medicine, Bar-Ilan University, Safed 22100, Israel;
| | - Michal Brodavka
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; (H.M.); (A.D.); (M.B.); (Y.C.); (P.L.); (M.L.)
- Rheumatology Unit, Sheba Medical Center, Tel-Hashomer 10457, Israel
| | - Yael Cohen
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; (H.M.); (A.D.); (M.B.); (Y.C.); (P.L.); (M.L.)
- Rheumatology Unit, Sheba Medical Center, Tel-Hashomer 10457, Israel
| | - Arsalan Abu-Much
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Tel Aviv 10457, Israel;
| | - Muhanad Abu Elhija
- Rheumatology Unit, Carmel Medical Center, Michal Street, Haifa 3436212, Israel; (N.H.); (A.H.); (M.E.); (D.Z.); (M.A.E.)
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Charlie Bridgewood
- NIHR, Leeds Biomedical Research Centre, The Leeds Teaching Hospitals NHS Trust & Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (G.D.M.); (C.B.); (H.M.-O.); (E.V.)
| | - Pnina Langevitz
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; (H.M.); (A.D.); (M.B.); (Y.C.); (P.L.); (M.L.)
- Rheumatology Unit, Sheba Medical Center, Tel-Hashomer 10457, Israel
| | - Joanna McLorinan
- Department of Rheumatology, Mid Yorkshire Hospitals, West Yorkshire WF8 1PL, UK;
| | - Nicola Luigi Bragazzi
- Centre for Disease Modelling, Department of Mathematics and Statistics, York University, Toronto, ON M3J 1P3, Canada
- Fields-CQAM Laboratory of Mathematics for Public Health (MfPH), York University, Toronto, ON M3J 1P3, Canada
- Correspondence: (N.L.B.); (D.M.)
| | - Helena Marzo-Ortega
- NIHR, Leeds Biomedical Research Centre, The Leeds Teaching Hospitals NHS Trust & Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (G.D.M.); (C.B.); (H.M.-O.); (E.V.)
| | - Merav Lidar
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; (H.M.); (A.D.); (M.B.); (Y.C.); (P.L.); (M.L.)
- Rheumatology Unit, Sheba Medical Center, Tel-Hashomer 10457, Israel
| | - Cassandra Calabrese
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A50, Cleveland, OH 44195, USA; (C.C.); (L.C.)
| | - Leonard Calabrese
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A50, Cleveland, OH 44195, USA; (C.C.); (L.C.)
| | - Edward Vital
- NIHR, Leeds Biomedical Research Centre, The Leeds Teaching Hospitals NHS Trust & Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (G.D.M.); (C.B.); (H.M.-O.); (E.V.)
| | - Yehuda Shoenfeld
- Department of Medicine ‘B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 10457, Israel; (A.W.); (Y.S.); (H.A.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; (H.M.); (A.D.); (M.B.); (Y.C.); (P.L.); (M.L.)
| | - Howard Amital
- Department of Medicine ‘B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 10457, Israel; (A.W.); (Y.S.); (H.A.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; (H.M.); (A.D.); (M.B.); (Y.C.); (P.L.); (M.L.)
- Rheumatology Unit, Sheba Medical Center, Tel-Hashomer 10457, Israel
| | - Dennis McGonagle
- NIHR, Leeds Biomedical Research Centre, The Leeds Teaching Hospitals NHS Trust & Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (G.D.M.); (C.B.); (H.M.-O.); (E.V.)
- Correspondence: (N.L.B.); (D.M.)
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9
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Nissim L, Lieber SB, Naffaa ME, Fowler ML, Shmerling RH, Paz Z. The impact of gender on the clinical presentation, management, and surgical outcomes of patients with native-joint septic arthritis. J Eval Clin Pract 2021; 27:371-376. [PMID: 32613746 DOI: 10.1111/jep.13437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/31/2020] [Accepted: 06/04/2020] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Approximately 20 000 cases of septic arthritis (SA) occur in the U.S. yearly. We examined whether gender-related differences exist in the presentation, management, and outcomes of patients with native joint septic arthritis (NJSA). METHODS This was a retrospective study of medical files of patients aged 18 years and older admitted between 1998 and 2015 to a single tertiary care hospital and diagnosed with NJSA. All study subjects had positive synovial fluid or blood cultures and each was managed surgically. Patients' charts were reviewed for demographics, comorbidities, clinical presentations, microbiology profiles, management, and outcomes. Cases of osteomyelitis, septic bursitis, prosthetic joint, and culture-negative SA were excluded. RESULTS Of 324 NJSA patients, those who were female (n = 130; 40.1%) were significantly older at presentation than males (mean age: 63.6 vs 58.3; P = .006). Prior joint pathology was more common amongst females, including osteoarthritis (20.8% vs 12.9%; P = .04) and rheumatoid arthritis (10% vs 3.6%; P = .03). Female patients had a higher frequency of hip involvement (17.7% vs 10.8%; P = .05). No differences were observed in clinical presentations, culture results, medical management, or outcomes between genders. CONCLUSIONS Compared to men, women with NJSA presented at an older age and had more prior joint pathology and a higher frequency of hip involvement. These differences, however, had no significant impact on the clinical presentation, medical management, or outcomes of NJSA.
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Affiliation(s)
- Lior Nissim
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Sarah B Lieber
- Department of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohammad E Naffaa
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,Department of Rheumatology, Galilee Medical Center, Nahariya, Israel
| | | | - Robert H Shmerling
- Department of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ziv Paz
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,Department of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Rheumatology, Galilee Medical Center, Nahariya, Israel
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10
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Naffaa ME, Rosenberg V, Watad A, Tiosano S, Yavne Y, Chodick G, Amital H, Shalev V. Adherence to metformin and the onset of rheumatoid arthritis: a population-based cohort study. Scand J Rheumatol 2020; 49:173-180. [PMID: 32208872 DOI: 10.1080/03009742.2019.1695928] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: The aim of this retrospective cohort study was to examine whether adherence to metformin treatment may be associated with lower onset of rheumatoid arthritis (RA).Method: Using the computerized databases of a 2.3-million state-mandated health services organization in Israel, we identified incident RA cases among a cohort of 113 749 adult patients who initiated metformin therapy between 1998 and 2014. Adherence was assessed by calculating the mean proportion of follow-up days covered (PDC) with metformin.Results: During the 18 year study period, there were 558 incident RA cases (61 per 100 000 person-years). Adherence to metformin treatment was associated with a lower risk of developing RA, with the lowest risk recorded among patients with a PDC of 40-59% [adjusted hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.45-0.84] compared with non-adherent patients (PDC < 20%). A mean daily metformin dose of 2550 mg or more was also associated with a lower risk of developing RA (adjusted HR 0.62, 95% CI 0.46-0.84) compared to a daily dose of 850 mg or less. In stratified analyses by gender, the negative association between adherence and the risk of RA was limited to women alone.Conclusions: Adherence to metformin treatment is associated with a reduced risk of developing RA in women. Further studies are needed to assess the effect of metformin on RA development in other patient populations.
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Affiliation(s)
- M E Naffaa
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
| | - V Rosenberg
- Epidemiology and Database Research, Maccabi Healthcare Services, Tel Aviv, Israel
| | - A Watad
- Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Tiosano
- Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Y Yavne
- Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - G Chodick
- Epidemiology and Database Research, Maccabi Healthcare Services, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - H Amital
- Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - V Shalev
- Epidemiology and Database Research, Maccabi Healthcare Services, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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11
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Nasser R, Naffaa ME, Mashiach T, Azzam ZS, Braun E. The association between serum magnesium levels and community-acquired pneumonia 30-day mortality. BMC Infect Dis 2018; 18:698. [PMID: 30587164 PMCID: PMC6307202 DOI: 10.1186/s12879-018-3627-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/17/2018] [Indexed: 11/17/2022] Open
Abstract
Background Community acquired pneumonia (CAP) is a common illness affecting hundreds of millions worldwide. Few studies have investigated the relationship between serum magnesium levels and outcomes of these patients. We aimed to study the association between serum magnesium levels and 30-day mortality among patients with CAP. Methods Retrospective overview of patients hospitalized with CAP between January 1, 2010 and December 31, 2016. Participants were analyzed retrospectively in order to identify the risk factors for a primary endpoint of 30-day mortality. Normal levels of magnesium levels in our laboratory varies between 1.35 and 2.4 mg/dl. Results 3851 patients were included in our cohort. Age > 75 years, blood urea nitrogen (BUN) > 20 mg/dl, hypoalbuminemia, and abnormal levels of magnesium were all associated with increased risk of 30-day mortality. Normal magnesium levels were associated with the lowest mortality rate (14.7%). Notably, within the normal levels, high normal magnesium levels (2–2.4 mg/dl) were correlated with higher mortality rates (30.3%) as compared to levels that ranged between 1.35–2 mg/dl (12.9%). Hypomagnesemia and hypermagnesemia were both associated with excess of 30-day mortality, 18.4 and 50%, respectively. Conclusion Hypomagnesemia and hypermagnesemia on admission were associated with an increased rate of 30-day mortality among adult patients hospitalized with CAP. Interestingly, magnesium levels within the upper normal limits were associated with higher mortality.
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Affiliation(s)
- Roni Nasser
- Department of Internal Medicine "B", Ramabm Health Care Campus, HaAliya HaShniya St 8, 3109601, Haifa, Israel.
| | | | - Tanya Mashiach
- Epidemiology and Biostatistics Unit, Rambam Health Care Campus, Haifa, Israel
| | - Zaher S Azzam
- Department of Internal Medicine "B", Ramabm Health Care Campus, HaAliya HaShniya St 8, 3109601, Haifa, Israel.,The Rappaport's Faculty of Medicine, The Technion Institute, Haifa, Israel
| | - Eyal Braun
- The Rappaport's Faculty of Medicine, The Technion Institute, Haifa, Israel.,Department of Internal Medicine "H", Ramabm Health Care Campus, Haifa, Israel
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12
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Naffaa ME, Nasser R, Manassa E, Younis M, Azzam ZS, Aronson D. Cardiac troponin-I as a predictor of mortality in patients with first episode acute atrial fibrillation. QJM 2017; 110:507-511. [PMID: 28340049 DOI: 10.1093/qjmed/hcx060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recent-onset atrial fibrillation (AF) is a frequent cause for presentation to the emergency department. Recent studies proposed that the addition of biomarker information might improve the prediction of clinical outcomes by enabling identification of patients at high risk. AIM We aimed to examine the role of cardiac troponin I as a predictor of clinical outcome in patients with first episode acute AF. DESIGN Patients, 18 years or older, presenting to our hospital with a primary diagnosis of first episode acute AF were included in this retrospective study. METHODS The association between elevated cTnI with mortality or the composite endpoint (mortality, stroke or heart failure) was examined in a univariate Cox regression model. RESULTS Of the 274 study patients, 111 had elevated cTnI levels (41%). Increased cTnI was associated with older age, history of myocardial infarction, higher creatinine levels and higher heart rate (All P < 0.01). Elevated cTn was associated with an adjusted hazard ratio of 1.86 [95% confidence interval (CI) 1.17-2.96; P = 0.009] for mortality and 1.89 (95% CI 1.27-2.84; P = 0.002) for the combined endpoint. CONCLUSIONS Elevated cardiac Troponin I is a significant predictor of mortality and a composite endpoint of mortality, stroke or heart failure in patients presenting with first episode acute AF.
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Affiliation(s)
- M E Naffaa
- Department of Internal Medicine "H", Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - R Nasser
- Department of Internal Medicine "B"
| | | | - M Younis
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Z S Azzam
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
- Department of Internal Medicine "B"
| | - D Aronson
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
- Division of Cardiology, Rambam Health Care Campus, Haifa, Israel
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13
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Eyal A, Braun E, Naffaa ME. [SYNCOPE CAUSED BY INTRA-OCULAR TIMOLOL]. Harefuah 2015; 154:701-742. [PMID: 26821501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Timolol eye-drops are commonly used for the treatment of glaucoma. Despite being topically applied, some systemic absorption occurs with the resulting adverse reactions related to its beta-adrenoreceptor blocking activity CASE PRESENTATION We report the case of a 68 years old healthy male who was admitted to our department for further workup following two episodes of syncope. Medical history taking revealed that the episodes of syncope occurred soon after beginning treatment with intra-ocular timolol for glaucoma. An electrocardiogram demonstrated a sinus bradycardia rhythm and a prolonged PR interval, consistent with the negative effects of a beta adrenergic receptor antagonist on the heart's electrical generation and conduction system. DISCUSSION This case demonstrates the potential for dangerous systemic side effects of a topically-applied medication. It also highlights the importance of thorough medical history taking in the evaluation of syncope, including inquiry regarding the use of all, especially new, medications. CONCLUSION Detailed medical history taking can help in avoiding the performance of an expensive and unnecessary workup.
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14
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Naffaa ME, Mustafa M, Azzam M, Nasser R, Andria N, Azzam ZS, Braun E. Serum inorganic phosphorus levels predict 30-day mortality in patients with community acquired pneumonia. BMC Infect Dis 2015; 15:332. [PMID: 26268323 PMCID: PMC4535260 DOI: 10.1186/s12879-015-1094-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 08/06/2015] [Indexed: 11/20/2022] Open
Abstract
Background Community acquired pneumonia is a major cause of morbidity and mortality. The association between serum phosphorus levels on admission and the outcome of patients with community acquired pneumonia has not been widely examined. We aimed to investigate the prognostic value of serum phosphorus levels on admission on the 30- day mortality. Methods The cohort included patients of 18 years old or older who were diagnosed with community acquired pneumonia between 2006 and 2012. Patients were retrospectively analyzed to identify risk factors for a primary endpoint of 30-day mortality. Binary logistic regression analysis was used for the calculation of the odds ratios (OR) and p values in bivariate and multivariate analysis to identify association between patients’ characteristic and 30-day mortality. Results The cohort included 3894 patients. In multivariate regression analysis, variables associated with increased risk of 30-day mortality included: age >80 years, increased CURB-65 score, RDW >15, hypernatremia >150 mmol/l, hypoalbuminemia <2 gr/dl and abnormal levels of phosphorus. Levels of <1.5 mg/dl and >4.5 mg/dl were significantly associated with excess 30-day mortality, 38 % (OR 2.9, CI 1.8-4.9, P = 0.001) and 39 % (OR 3.4, CI 2.7-4.2, P = 0.001), respectively. Phosphorus levels within the upper normal limits (4-4.5 mg/dl) were associated with higher mortality rates compared to levels between 1.5-3.5 mg/dl, the reference group, 24 % (OR 1.9, CI 1.5-2.4, P = 0.001). Conclusions Abnormal phosphorus levels on admission are associated with increased mortality rates among patients hospitalized with Community acquired pneumonia.
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Affiliation(s)
- Mohammad E Naffaa
- Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel. .,B. Shine Rheumatology Unit, Rambam Health Care Campus, Haifa, Israel. .,The Rappoport's Faculty of Medicine, Technion, Haifa, Israel.
| | - Mona Mustafa
- Department of Internal Medicine E, Rambam Health Care Campus, Haifa, Israel.
| | - Mohje Azzam
- The Rappoport's Faculty of Medicine, Technion, Haifa, Israel.
| | - Roni Nasser
- Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel.
| | - Nizar Andria
- Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel.
| | - Zaher S Azzam
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel. .,The Rappoport's Faculty of Medicine, Technion, Haifa, Israel.
| | - Eyal Braun
- Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel. .,The Rappoport's Faculty of Medicine, Technion, Haifa, Israel. .,Department of Internal Medicine H and Infectious Diseases Unit, Rambam Health Care Campus, Haa'leya Hashneyya 8, Haifa, 31096, Israel.
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