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We aimed to investigate the association between habitual tea consumption and the risk of developing cataracts in a large community-based cohort study. We prospectively collected volunteers from 29 recruitment centers that were ≧ 55 years old with no history of cataracts at the beginning of the study. There were 12,080 participants with available information in our study and were divided into two groups according to habitual tea consumption; non-tea-drinking and tea-drinking groups. The mean age was 59 years. Compared to the non-tea-drinking group, the tea-drinking group had a significantly lower incidence of developing cataracts (15.5% vs 12.1%) during follow-up of 46 months. In multivariate Cox proportional hazards regression analysis, the relative risk (RR) of incident cataracts was lower in the tea-drinking group than the non-tea-drinking group (RR = 0.848; 95% confidence interval [CI] = 0.751 to 0.957). Participants with ≧ 2 cups per day were associated with almost 16% reduction in the risk of developing cataracts compared with the non-tea-drinking group (RR = 0.844; 95% CI = 0.741 to 0.961). Our study suggests that habitual tea consumption can reduce the incidence of cataracts and raises the possibility that the tea content may slow the progression of cataracts.

Salmonella enterica serovar Typhimurium is a leading cause of gastroenteritis worldwide and a deadly pathogen in children, immunocompromised patients, and the elderly. Salmonella induces innate immune responses through the Nlrc4 inflammasome, which has been demonstrated to have distinct roles during systemic and mucosal detection of flagellin and non-flagellin molecules. We hypothesized that Nlrc4 recognition of Salmonella flagellin is the dominant protective pathway during infection. To test this hypothesis, we used wild-type, flagellin-deficient, and flagellin-overproducing Salmonella to establish the role of flagellin in mediating Nlrc4-dependent host resistance during systemic and mucosal infection. We observed that during the systemic phase of infection, Salmonella efficiently evades Nlrc4-mediated innate immunity. However, during mucosal Salmonella infection, flagellin recognition by the Nlrc4 inflammasome pathway is the dominant mediator of protective innate immunity. These data establish that recognition of Salmonella’s flagellin by the Nlrc4 inflammasome during mucosal infection is the dominant innate protective pathway for host resistance against the enteric pathogen.

Systemic lupus erythematous (SLE) is a multisystem autoimmune disease, with up to 50% of cases having cardiac involvement.1Myocarditis is one of the cardiac presentations in SLE. Cardiac magnetic resonance imaging (cMRI) is a noninvasive diagnostic technique that provides evidence of acute myocardial inflammation by showing myocardial edema on T2-based imaging and myocardial injury on T1-based imaging.

Dengue virus (DENV) infections may cause life-threatening dengue hemorrhagic fever (DHF). Suppressed protective immunity was shown in these patients. Although several hypotheses have been formulated, the mechanism of DENV-induced immunosuppression remains unclear. Previously, we found that cross-reactive antibodies against tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) receptor 1 (death receptor 4 [DR4]) were elicited in DHF patients, and that anti-DR4 autoantibody fractions were elicited by nonstructural protein 1 (NS1) immunizations in experimental mice. In this study, we found that anti-DR4 antibodies could suppress B lymphocyte function in vitro and in vivo. Treatment with the anti-DR4 immunoglobulin (Ig) induced caspase-dependent cell death in immortalized B lymphocyte Raji cells in vitro. Anti-DR4 Igs elicited by NS1 and DR4 immunizations markedly suppressed mouse spleen transitional T2 B (IgM+IgD+), bone marrow pre-pro-B (B220+CD43+), pre-B (B220+CD43−), and mature B cell (B220+IgD+) subsets in mice. Furthermore, functional analysis revealed that the pre-elicitation of anti-NS1 and anti-DR4 Ig titers suppressed subsequently neutralizing antibody production by immunization with DENV envelop protein. Our data suggest that the elicitation of anti-DR4 titers through DENV NS1 immunization plays a suppressive role in humoral immunity in mice.

Background: Patients who have symptoms of sicca, such as dry eyes and mouth, may have Sjögren’s syndrome (SS). However, the conservative culture makes patients hesitate to undergo an invasive biopsy, which contributes to the difficulty of confirming a diagnosis. We aimed to identify the characteristics of patients with sicca symptoms to develop a better predictive value for each item included in the three different diagnostic criteria for SS and clarify the best diagnostic tools for the local population. Methods: This is a single-center retrospective case-control study from January 2016 to December 2017. Patients who underwent sialoscintigraphy because of clinical symptoms of xerostomia and xerophthalmia at one medical center were reviewed via the patients’ electronic medical records. Results: Of 515 patients enrolled, the severity of results for sialoscintigraphy and Schirmer’s test was correlated with a diagnosis of SS and generated receiver operator characteristic curve. The area under curve (AUC) was 0.603 for positive Schirmer’s test, 0.687 for positive anti-Ro/La results, 0.893 for a positive salivary gland biopsy. The AUC was 0.626 and 0.602 for Schirmer’s test which is redefined as

Yu-Hsiang Chiu,1,2 Chen-Chih Chu,1 Chun-Chi Lu,1 Feng-Cheng Liu,1 Shin-En Tang,3 Shi-Jye Chu,1 San-Yuan Kuo,1 Hsiang-Cheng Chen1 1Division of Rheumatology/Immunology/Allergies, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; 2Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands; 3Division of Thoracic Medicine, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, TaiwanCorrespondence: Hsiang-Cheng Chen, Division of Rheumatology/Immunology/Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec, 2, Cheng-Gong Road, Neihu 114, Taipei, Taiwan, R.O.C, Tel +886 2 87927135, Fax +886 2 87927136, Email hccheng@mail.ndmctsgh.edu.twObjective: Krebs von den Lungen-6 (KL-6) is expressed on regenerating type II pneumocytes and has been recognized as biomarkers in interstitial lung disease (ILD). We aim to identify the role of the serum KL-6 level in patients with newly diagnosed Sjögren syndrome (SS), as well as the correlation between the immunoassays.Methods: Patients with newly diagnosed SS and receiving HRCT for clinical reason during follow-up were included. Baseline KL-6 level was measured via enzyme-linked immunosorbent assay (ELISA) and latex particle-enhanced turbidimetric immunoassay (LETIA).Results: Of the 39 patients, 21 (53.85%) developed interstitial lung disease (ILD) by the conclusion of the follow-up period. The median time to diagnosis of ILD was 2.24 years (IQR 1.15– 4.34) in the ILD group. The median serum KL-6 level, measured using ELISA, was 1232 U/mL (IQR 937– 2242) and 764.5 U/mL (IQR 503.25– 1035.75) in the ILD group and the non-ILD group, respectively (p = 0.001). The median LETIA for serum KL-6 was 329 U/mL (IQR 235– 619) and 245 U/mL (IQR 215.25– 291) in the ILD group and the non-ILD group, respectively (p = 0.074).Conclusion: Serum KL-6 levels were higher in newly diagnosed SS patients with ILD diagnosis during follow-up. Thus, the serum KL-6 level can serve as a valuable biomarker to identify hidden ILD in patients with newly diagnosed SS patients. However, the immunoassay procedure may influence the efficacy of the prediction and its clinical association.Keywords: Sjögren syndrome, interstitial lung disease, KL-6

Quality of life stands for the comprehensive assessment for health conditions and the central concerns in the seniors' care. The inter-relationship between health-related quality of life (HRQoL) and multimorbidity among community-dwelling healthy older adults remains uncertain.Data of 1839 participants from the I-Lan Longitudinal Aging Study were excerpted for analysis. Functional status and HRQoL were measured by the Functional Autonomy Measurement System and the Chinese version of 12-item Short-Form Health Survey version 2. Poor HRQoL was defined as lowest quintile of physical and mental components summaries (PCS and MCS). Multivariable linear and logistic regression analysis were applied to explore associations between variables of interest.Adjusted for potential confounders, multivariable linear regression showed that multimorbidity and functional impairment were negatively associated with PCS (β coefficients -1.8 vs. -8.4) and MCS (β coefficients -1.9 vs. -4.8). Logistic regression affirmed similar associations that the odds of being poor HRQoL were 1.6 (95% CI 1.1-2.2) for multimorbidity, and 5.4 (95% CI 2.8-10.3) for functional impairment in PCS; 1.9 (95% CI 1.4-2.6) for multimorbidity and 6.0 (95%CI 3.2-11.5) for functional impairment in MCS. Adjusted for depressive symptoms and cognitive performance, functional impairment was significantly associated with poor physical component (OR:4.68, 95% CI: 0.35-19.34, p0.001) and mental component in HRQoL (OR:2.4, 95% CI: 1.1-5.5, p=0.032), but the associations were insignificant in multimorbidity.Findings from the study strengthened the importance of functional performance on HRQoL among community-living middle-aged and older adults, which is essential in community health promotion activities and health service programs.

Background Nonradiographic axial spondyloarthropathies (nr-axSpA) are diagnosed by the absence of radiographic sacroiliitis and the presence of bone marrow edema (BME) on magnetic resonance imaging (MRI). According to the classification criteria of the international Assessment of Spondyloarthritis Society (ASAS), structural changes to sacroiliac joints (SIJs) on MRI cannot be used as criteria in the absence of BME. However, less than half the Asian patients with clinically active axSpA show BME. The incidence of human leukocyte antigen (HLA)-B27 is low in Asian populations, which makes it more difficult to identify nr-axSpA. We used MRI to evaluate the structural damage to SIJs in patients with nr-axSpA with and without BME with the aim of identifying the best methodology for accurate diagnosis, especially in populations with less common BME and HLA-B27. Methods One hundred three patients with inflammatory back pain were included in this prospective study. No patient’s radiograph met the definition of positive modified New York criteria. BME and structural damage to SIJ including sclerosis and erosion were assessed independently on coronal and axial short-tau inversion recovery and T1-weighted spin echo MRI scans by two well-trained musculoskeletal radiologists using the Spondyloarthritis Research Consortium of Canada (SPARCC) score. Demographics of patients were collected. Disease characteristics and structural damage were analyzed in patients with and without BME on SIJ MRI. Receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic performance of structural damage. Results All individuals in the cohort had at least one abnormal finding on SIJ MRI, including BME or structural damage; 36 of 103 patients had BME. We identified a significant positive correlation between SPARCC scores and severe erosion assessed by focal joint space widening (fJSW) (p = 0.001) in these 36 patients. Fifty-eight of the 103 enrolled patients fulfilled the ASAS criteria for nr-axSpA in the either absence or presence of BME. Of these 58 patients, 57 and 19 had erosions or fJSW, respectively, and the presence of BME was significantly correlated with fJSW (phi score of 0.319 and p = 0.015). We demonstrated a significant positive correlation between fJSW and either the presence or the severity of BME in patients with nr-axSpA who met the ASAS definition. There was a positive correlation between BME and fJSW across the whole study cohort (phi score of 0.389; p p p = 0.018 and 0.003, respectively) and SPARCC scores were higher in patients with fJSW (p p = 0.005). We also identified a positive correlation between fJSW and BME in patients with nr-axSpA and normal serum levels of C-reactive protein (phi score of 0.362 and p = 0.001). Conclusion Structural damage detected on SIJ MRI, sclerosis, erosions and fJSW may be present in patients without detectable inflammation on SIJ MRI. However, fJSW is significantly correlated with the severity of inflammation seen on SIJ MRI, which contributes to the accurate diagnosis of nr-axSpA, and it could be used as an alternative diagnostic test for nr-axSpA in the general population, especially for those who do not carry the HLA-B27 gene, Asian patients without BME, or patients with normal serum inflammatory biomarkers.

Background Primary carnitine deficiency (PCD) is a rare but potentially life-threatening genetic disorder if left untreated. Although some patients remain asymptomatic lifelong, a few patients present with hepatic encephalopathy, hypoglycemia, cardiomyopathy, dysrhythmia, and even sudden death. Case Report A 25-year-old woman with PCD collapsed suddenly while eating lunch. Bystander cardiopulmonary resuscitation (CPR) was performed for 8 min, with automated external defibrillation once before admission. Upon arrival at our emergency department (ED), she was unresponsive without a pulse or spontaneous breathing. The initial heart rhythm on the electrocardiogram monitor was ventricular fibrillation (VF). The medical staff continued CPR with defibrillation for sustained VF. Return of spontaneous circulation (ROSC) was achieved after a total resuscitation time of 14 min, with defibrillation twice after cardiac arrest. The heart rhythm after ROSC was atrial fibrillation, with a rapid ventricular rate initially and subsequent progression to sinus tachycardia with diffuse ST segment depression and a prolonged QT interval. Her low carnitine level was consistent with her underlying disease. Cardiac magnetic resonance imaging and sonography for detection of cardiomyopathy showed no significant findings. With carnitine supplementation for a few days, her plasma carnitine level returned to 30 μM, with no recurrence of ventricular dysrhythmia. Why Should an Emergency Physician Be Aware of This? PCD is rare but could be life-threatening, and compiling detailed histories may help emergency physicians to determine the cause of sudden cardiac death after resuscitation. This information may be used to correct potential underlying problems and prevent recurrence of the condition after treatment.

Background and Objectives: Thymomas are associated with a high frequency of paraneoplastic manifestations. Paraneoplastic syndrome (PNS) with thymoma presents a challenge to clinicians because of the need to decipher the association between the presenting symptoms and the underlying tumor. The condition most commonly noted in patients with PNS with thymoma is myasthenia gravis. Other common autoimmune diseases that may present as PNS include systemic lupus erythematosus, pure red cell aplasia, and Good syndrome. Seventy-six percent of patients with PNS-associated thymoma experience resolution of PNS after curing thymoma. Materials and Methods: A 37-year-old man with a two-month fever accompanied by polyarthritis accidently found thymoma after contrast computed tomography scans of his chest. He accepted Video assisted thoracoscopic surgery with resection of thymoma. Results: Fever and polyarthritis resolved after operation but recurred in five days due to cytomegalovirus viremia, which might be predisposed by previous antibiotics treatment before the diagnosis of thymoma. Conclusion: Patients with a thymoma also have a high frequency of PNS, and the most frequent condition found in patients with PNS-associated thymoma is myasthenia gravis. Fever with polyarthritis has been rarely reported as a symptom of PNS-associated thymoma. Here we reported an unusual case of PNS mimicking reactive arthritis with thymoma, as diagnosed based on the patient’s clinical progression, imaging examination, and laboratory tests. The patient died of his comorbidities, and his death may have been related to long-term antibiotic use and consequent intestinal dysbiosis. This challenging case may help to inform clinicians of the need for detailed work-up of fever with unknown origin in the presence of chronic polyarthritis to prevent the overdiagnosis of inflammatory arthritis or rheumatic disease and avoid further comorbidities. Detailed work-up should include the patient’s history of infections, inflammation, and malignant or nonmalignant tumors.

Patients with serum anti-melanoma differentiation-associated gene 5 autoantibodies (anti-MDA5) are related to amyopathic dermatomyositis, especially in Asians. Here, we present a 46-year-old woman who was diagnosed with anti-MDA5-mediated demyelinating polyneuropathy clinically mimicking dermatomyositis. She had rapid progression of interstitial pneumonitis complicated with Pneumocystis jirovecii and Aspergillus pneumonia with septic shock. It is rare that patients with anti-MDA5-positive dermatomyositis present as demyelinating polyneuropathy.

Background Sjogren syndrome (SS) is an autoimmune disease presented with exocrine gland inflammation and extra-glandular involvement. The prevalence of pulmonary involvement, including interstitial lung disease (ILD), in patients with primary SS widely varies from 8% to 20%.1, 2Patients with SS with ILD have high morbidity and a fourfold increase in mortality.3 Objectives Krebs von den Lungen-6 (KL-6) is a mucin-like, high-molecular-weight glycoprotein; it is expressed in regenerating type II pneumocytes. Serum KL-6 is highly associated with the activity of ILD in patients with radiation pneumonitis, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, sarcoidosis, rheumatoid arthritis, polymyositis, dermatomyositis and systemic sclerosis.4-8 The increase in serum KL-6 level might reflect the increase in the number of regenerating type II pneumocytes secondary to pulmonary damage.8 We hypothesise that an early pulmonary damage occurs before clinical or radiological evidence of ILD in patients with SS. Methods In this retrospective case-control study, patients who were diagnosed with primary SS and fulfilled the American-European Consensus Group Criteria for Sjogren’s Syndrome were included. Clinical information, laboratory results on inclusion, images and pulmonary functions test results were recorded via electronic medical records review. Pulmonary radiography including chest X-ray and chest computed tomography was reviewed by a chest physician. Results Of the 39 patients with SS, 21 (53.85%) developed ILD at the end of follow-up. The follow-up period was 2.65 ± 1.88 years. The time to diagnosis of ILD was 2.72 ± 1.74 years in the ILD group. The serum KL-6 level was 1920.10 ± 1974.26 U/ml in the ILD group and 894.11 ± 788.53 U/ml in the non-ILD group (p = 0.001). The diffusing capacity of the lungs for carbon monoxide was 70.76 ± 19.63 mmHg and 91.88 ± 12.02 mmHg in the ILD group and non-ILD group, respectively (p Conclusion Serum KL-6 level is significantly higher in patients with primary SS with developing ILD and may represent an early non-radiographic pulmonary damage. Serum KL-6 can be a valuable biomarker in predicting the development of ILD in patients with primary SS. References [1] Roca F, Dominique S, Schmidt J, et al. Interstitial lung disease in primary Sjogren’s syndrome. Autoimmunity reviews. 2017; 16: 48-54. [2] Kreider M and Highland K. Pulmonary involvement in Sjogren syndrome. Seminars in respiratory and critical care medicine. 2014; 35: 255-64. [3] Palm O, Garen T, Berge Enger T, et al. Clinical pulmonary involvement in primary Sjogren’s syndrome: prevalence, quality of life and mortality-a retrospective study based on registry data. Rheumatology (Oxford, England). 2013; 52: 173-9. [4] Hamada H, Kohno N, Akiyama M and Hiwada K. Monitoring of serum KL-6 antigen in a patient with radiation pneumonia. Chest. 1992; 101: 858-60. [5] Kobayashi J and Kitamura S. Serum KL-6 for the evaluation of active pneumonitis in pulmonary sarcoidosis. Chest. 1996; 109: 1276-82. [6] Oyama T, Kohno N, Yokoyama A, et al. Detection of interstitial pneumonitis in patients with rheumatoid arthritis by measuring circulating levels of KL-6, a human MUC1 mucin. Lung. 1997; 175: 379-85. [7] Takanashi S, Nishina N, Nakazawa M, Kaneko Y and Takeuchi T. Usefulness of serum Krebs von den Lungen-6 for the management of myositis-associated interstitial lung disease. Rheumatology (Oxford, England). 2019. [8] Elhai M, Hoffmann-Vold AM, Avouac J, et al. Performance of candidate serum biomarkers for systemic sclerosis-interstitial lung disease. Arthritis & rheumatology (Hoboken, NJ). 2019. Disclosure of Interests None declared

Castleman's disease (CD) is an uncommon lymphoproliferative disorder characterized as either unicentric or multicentric presentation based on the involving sites. The most frequent presentation of CD is a solitary mediastinal mass. We reported a patient with a history of heavy smoking with particular image features of CD, which presented as mediastinal lymphadenopathy and peribronchovascular interstitial thickening mimicking lung cancer or sarcoidosis initially.

Neuropsychiatric Systemic Lupus Erythematosus (NPSLE) refers to neurological or psychological manifestations, in which headaches and seizures are the most common clinical features...

Background:Krebs von den Lungen-6 (KL-6) was recently found to be a serum biomarker for various disease associated interstitial lung disease (ILD) including primary Sjögren syndrome (pSS).1KL-6 is a high-molecular-weight glycoprotein in the Mucin 1 protein group and is majorly expressed by regenerating type II pneumocytes; hence, serum KL-6 levels may reflect the severity of pulmonary damage with regeneration.2Human KL-6 also promotes the proliferation and survival of pulmonary fibroblasts and the differentiation of myofibroblasts, which enhance fibrosis.3, 4Objectives:To evaluate the agreement between the latex particle-enhanced turbidimetric immunoassay with enzyme-linked immunosorbent assay (ELISA) and association with clinical phenotypes.Methods:This retrospective case-control study included 39 patients with pSS, of whom 21 (53.85%) patients developed ILD at the end of follow-up. The serum KL-6 level was compared between latex particle-enhanced turbidimetric immunoassay (Nanopia) and ELISA (MBS2601395; MyBioSource, CA, USA). Electronic medical records were reviewed, including clinical information, images, pulmonary function test, and laboratory results on inclusion, and a chest physician reviewed the results of pulmonary radiography.Results:The two serum KL-6 immunoassays revealed a moderate correlation with a Pearson product-moment correlation coefficient of 0.427. Serum KL-6 levels, measured using ELISA, were 1920.10 ± 1974.26 U/mL and 894.11 ± 788.53 U/mL in the ILD and non-ILD groups, respectively (p = 0.001). The latex particle-enhanced turbidimetric immunoassay for serum KL-6 was 459.62 ± 331.41 U/mL and 265.33 ± 105.37 U/mL in the ILD and non-ILD group, respectively (p = 0.074). The predictive values of serum KL-6 in the area under the receiver-operating characteristic curve were 0.810 and 0.669 in ELISA and latex particle-enhanced turbidimetric immunoassay, respectively.Conclusion:Serum KL-6 is a predicting biomarker in pSS patients who may develop ILD. However, the methodology of immunoassay may influence the efficacy of the prediction and clinical association.References:[1]Chiu Y-H, Lu C-C, Liu F-C, et al. FRI0228 KL-6 AS A BIOMARKER OF DEVELOPING INTERSTITIAL LUNG DISEASE IN PATIENTS WITH SJÖGREN SYNDROME.Ann Rheum Dis. 2019; 78: 793.[2]Yousefi M, Dehghani S, Nosrati R, et al. Aptasensors as a new sensing technology developed for the detection of MUC1 mucin: A review.Biosensors & bioelectronics. 2019; 130: 1-19.[3]Xu L, Yan DR, Zhu SL, et al. KL-6 regulated the expression of HGF, collagen and myofibroblast differentiation.Eur Rev Med Pharmacol Sci. 2013; 17: 3073-7.[4]Ohshimo S, Yokoyama A, Hattori N, Ishikawa N, Hirasawa Y and Kohno N. KL-6, a human MUC1 mucin, promotes proliferation and survival of lung fibroblasts.Biochem Biophys Res Commun. 2005; 338: 1845-52.Acknowledgments:This work was supported by National Defense Medical Center and Tri-Service General Hospital (TSGH-D-109183). The authors thank Kuo’s Yuan In Enterprise co., LTD for supporting Nanopia KL-6 Kit.Disclosure of Interests:None declared

Objective Atopic dermatitis (AD) is a chronic, pruritic, inflammatory skin disease that occurs most frequently in children, but also affects many adults. People with AD have high disease load and poor quality of life, without many treatment options. Dupilumab, a monoclonal antibody, approved for treatment inadequately controlled AD, of which the effect on serum cytokines remains unknown. The aim of this study was to compare serum levels of cytokines in adult patients with atopic dermatitis before and after dupilumab treatment and investigate the possible association between such cytokines and dupilumab. Methods We compared the profiles of cytokines in 5 adults with AD before and after one course of dupilumab treatment. Assessment of serum cytokine concentrations was performed via commercially-available Milliplex® assays. Results Milliplex analysis of cytokines revealed that interleukin 12p70 (IL-12p70), IL-13, IL-21, interferon r (IFN-r) and tumour necrosis factor a(TNF-a) levels were significantly decreased after dupilumab treatment, whereas IL-2, IL-4, IL-6 and IL-10 can not be detected. Conclusions These data indicate that serum interleukin 12p70 (IL-12p70), IL-13, IL-21, interferon r (IFN-r) and tumour necrosis factor a(TNF-a) levels were significantly decreased after dupilumab treatment. Further studies are needed to elucidate the role of cytokines and association with dupilumab in adults with AD.

Introduction: Multidrug-resistant Acinetobacter baumannii (MDRAB) pneumonia with severe sepsis in a patient with rheumatoid arthritis (RA), who is predisposed after treatment with tumor necrosis factor inhibitor (TNFI), is a rare severe infection and can be successfully treated with prompt antibiotics. Case presentation: A 75-year-old woman was diagnosed with RA >30 years previously. After inadequate treatment responses to conventional disease-modifying antirheumatic drugs (DMARDs), she developed progressive RA, including swollen joints in both hands, and had a high disease activity score of 4.96 when presenting at our rheumatology clinic. She had started taking the TNFI, golimumab (50 mg/month), 3 years before and developed a productive cough 4 weeks before this admission. One week after admission, she developed fever, dyspnea, hypoxemia, tachycardia, and increased serum C-reactive protein level. Diagnosis: Chest plain film (CxR) and computed tomography of the chest showed hospital-acquired pneumonia; microbial examination of the sputum showed the presence of MDRAB. Therapeutics: She was prescribed a full course of antibiotics with cefoperazone sulbactam. Outcomes: CxR showed complete remission of pneumonia. Conclusion: Biological DMARDs, such as TNFI, act as a double-edged sword: these drugs are used to treat autoimmune diseases, but they increase the risk of infection. The trend toward antibiotic resistance and persistent environmental survival of MDRAB is an emerging problem in countries with high rates of antibiotic abuse. TNFI may affect intestinal immunity by inducing dysbiosis, which affects T helper 17–mediated mucosal immunity and can contribute to A baumannii colonization and the development of MDRAB in frequently hospitalized patients.

Rationale Asymptomatic Paget disease of bone (PDB) is mostly diagnosed by accidental finding of osteolytic lesion on the plain film. However, in elderly patient with chronic renal insufficiency and weight loss, it is crucial to differentiate PDB from metabolic and metastatic bone diseases for further treatment and better outcome. Patient concerns An 80-year-old man with chronic kidney disease presented to our emergency department due to fever with chillness for a day, while the abdominal fullness, anorexia, and weight loss had been noted for 3 months. Mixed osteoblastic and lytic changes in the pelvic bone were accidentally found on the abdominal plain film. Diagnosis The patient was diagnosed as asymptomatic PDB and urinary tract infection of Pseudomonas aeruginosa. Interventions and outcome The patient received 7 days intravenous and followed by 7 days oral antibiotic treatment, which lead to clinical improvement of his urinary tract infection. No pharmacological treatment was initiated for the asymptomatic and localized PDB. The patient was discharged under stable condition afterward. Lessons In patients with mixed osteolytic and blastic lesions, the differential diagnoses include metabolic and metastatic bone disease. Thorough understanding of the morphology of the bone lesions in high risk patient, not only helps to make differential diagnosis, but it also leads to precise treatment and better outcome.

Rationale: Thromboangiitis obliterans (TAOs, or Buerger's disease) present as a non-atherosclerotic segmental occlusive vasculitis within medium- and small-sized blood vessels. TAO frequently occurs in young adults and is associated with cigarette smoking. At present, there are no accurately defined treatments for TAO. Patient concerns: A 34-year-old Asian woman with a 20-year history of heavy cigarette smoking and recurrent, small, and self-limited lower limb ulcerations since adolescence, presented with persisting unhealed ulcerations on both ankles for 6 months. Her wound healing response was poor following the 2-month administration of colchicine, prednisolone, hydroxychloroquine, and mycophenolic acid. Diagnosis: The patient was diagnosed with TAO with hyperimmunoglobulin E and refractory ulcerations on her ankles. Interventions: The patient received monthly omalizumab (300 mg) and previous medications for 2 months and shifted to omalizumab and colchicine without mycophenolic acid and hydroxychloroquine because of onychomadesis, which was considered to be a possible adverse drug reaction. Outcomes: The wounds healed almost completely. The administration of omalizumab and colchicine will be continued until they the wounds are fully healed. Lessons: Mycophenolic acid has a limited function in TAO treatment, especially in cases of refractory skin ulcerations. Omalizumab can be a valuable treatment option for patients with TAO and hyperimmunoglobulin E.

Aim Mood disorders are a serious issue for patients with rheumatoid arthritis (RA) because poor mental health can exacerbate the disease course. This study aimed to identify the effect of proinflammatory cytokines on the mood of patients with RA. Methods This study was conducted at a rheumatology clinic in Northern Taiwan. In total, 113 patients with RA and 42 healthy controls were assessed for anxiety and depression symptoms using Hospital Anxiety and Depression Scale (HADS). RA was assessed using the Disease Activity Score of 28 joints (DAS28). Serum proinflammatory cytokine levels, including interleukin (IL)-1β, IL-6, IL-17 and tumor necrosis factor alpha (TNF-α) were measured and compared between different patient groups according to disease activity and pain level. Results Serum IL-1β, IL-6, IL-17 and TNF-α levels were significantly higher in patients with RA than in healthy controls, as were the mean anxiety and depression subscale scores. In patients with RA who had different disease activities, pain severity correlated with both anxiety and depression symptoms. When HADS scores were analyzed according to pain levels, age was correlated with depression in the severe pain group. In the mild pain group, patients with higher IL-6 or higher IL-17 had a higher risk of depression. There was no correlation between mood symptoms and cytokine levels in healthy controls. Conclusion Elevated serum IL-6 and IL-17 levels in patients with RA induce arthritis and cause mood symptoms, especially depression symptoms.

Fungal pyomyositis is a rare intramuscular infection characterized by swelling and pain at the site of infection. The most common fungal pathogen is Candida spp1. The risk factors include immunodeficiency, previous fungal infection, and broad-spectrum antibiotic exposure2. In addition, steroid therapy may induce subclinical myopathy and subsequent infectious myositis3. A 48-year-old …

To the Editor: We read with great interest the paper on performance of screening tests for cognitive impairment (CI) in systemic lupus erythematosus (SLE), by Nantes, et al 1. They indicated that CI is highly prevalent in SLE, and that the Montreal Cognitive Assessment (MoCA) is a good tool to screen early CI. In addition, patients with more years of education were less likely to have CI. We agree with the authors’ opinion and would like to emphasize the importance of regular MoCA and imaging examinations in … Address correspondence to Dr. C.C. Lu, No. 325, Sec 2, Cheng-Gong Rd, Neihu Dist., 114, Taipei, Taiwan, ROC. E-mail: jameslutaiwan{at}gmail.com

Objectives: To determine the safety of and immunogenicity induced by A/H1N1 influenza vaccination in patients with systemic lupus erythematosus (SLE). Research design and methods: The study population comprised 21 SLE patients and 15 healthy control subjects who underwent split-virion, inactivated monovalent A/H1N1 vaccination between December 2009 and January 2010. Sera were obtained before, three weeks after, and six months after vaccination. SLE disease activity index (SLEDAI) scores and autoantibodies were measured at every visit in SLE patients. Haemagglutination inhibition and the serum immunoglobulin G (IgG) level were calculated using the World Health Organization (WHO) procedure to evaluate the antibody responses. We also recorded current medications and past seasonal influenza vaccinations to analyse the interactions between vaccinations and the autoimmunity of SLE patients. Results: The mean age of the enrolled population was 34.3 years for SLE patients and 39.4 years for control subjects. The average SLEDAI score for SLE patients was 4.1 at vaccination, 4.5 at three weeks, and 4.3 at six months. The seroprotection rate at three weeks was 76.2% in SLE patients and 80.0% in healthy control subjects; by six months, the seroprotection rate was 66.7% in SLE patients and 60% in healthy control subjects. The seroconversion rate was 76.2% in SLE patients and 80% in healthy controls at three weeks; by six months, the seroconversion rate was 52.4% in SLE patients and 53.3% in healthy controls. The response in SLE patients met the criteria of the European Committee for Proprietary Medicinal Products guidelines at three weeks, while the percentage of seroprotection did not at six months. The clinical disease activity and SLEDAI scores did not differ significantly from before to after vaccination in SLE patients, although the level of anticardiolipin IgG increased at three weeks after vaccination, but with no apparent clinical manifestations. Conclusions: The A/H1N1 influenza vaccine is safe and effective in SLE patients and has no obvious adverse clinical effects. Treatment with a single immunosuppressive agent or combination therapy also leads to effective humoral immunity in these patients.

Rationale:Adult-onset Still disease (AOSD) is a rare systemic inflammatory disease of unknown etiology characterized by evanescent salmon-pink rash, spiking fever, arthralgia/ arthritis, and lymphadenopathy. AOSD sometimes was fatal when it is complicated by macrophage activation syndrome (M