2,991 results match your criteria Mixed Connective-Tissue Disease

Options in the treatment of superficial and deep venous disease in patients with Klippel-Trenaunay syndrome.

J Vasc Surg Venous Lymphat Disord 2022 Jun 29. Epub 2022 Jun 29.

The RANE Center for Venous and Lymphatic Diseases, MS 39216, USA.

Objective: Klippel-Trenaunay syndrome (KTS) is a congenital mixed mesenchymal malformation syndrome that includes varicose veins, capillary and venous malformations, lymphatic abnormalities and hypertrophy of various connective tissue elements. The purpose of this study was to describe clinical characteristics and outcomes in a subset of patients with KTS in whom venous interventions, including iliofemoral venous stenting, were performed after the failure of conservative therapy.

Methods: A single center retrospective data review of 34 patients with KTS who underwent interventions for venous disease between January, 2000 and December, 2020 was carried out. Read More

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Myelodysplastic syndrome and autoimmune disorders: two sides of the same coin?

Lancet Haematol 2022 Jul;9(7):e523-e534

Division of Hematologic Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address:

Systemic inflammatory and autoimmune diseases and myelodysplastic syndromes have been linked in individual patients and in larger case series for at least 25 years. These associations frequently include thyroid disease, neutrophilic dermatoses, polyarthritis, connective tissue diseases, vasculitis, and autoimmune cytopenias. Studies have found that autoimmune disease (or its therapy) is a risk factor for the development of myelodysplastic syndromes, but such syndromes might also be an instigator of autoimmune disease. Read More

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Clinical and radiological features of lung disorders related to connective-tissue diseases: a pictorial essay.

Insights Imaging 2022 Jun 29;13(1):108. Epub 2022 Jun 29.

Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", 95123, Catania, Italy.

Connective tissue diseases (CTDs) include a spectrum of disorders that affect the connective tissue of the human body; they include autoimmune disorders characterized by immune-mediated chronic inflammation and the development of fibrosis. Lung involvement can be misdiagnosed, since pulmonary alterations preceded osteo-articular manifestations only in 20% of cases and they have no clear clinical findings in the early phases. All pulmonary structures may be interested: pulmonary interstitium, airways, pleura and respiratory muscles. Read More

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STAT3-confusion-of-function: beyond the loss and gain dualism.

J Allergy Clin Immunol 2022 Jun 21. Epub 2022 Jun 21.

Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.

Background: Germline mutations of signal transducer and activator of transcription 3 (STAT3) are responsible for two distinct human diseases: autosomal-dominant hyper-immunoglobulin E syndrome (AD-HIES) caused by STAT3 loss-of-function (STAT3-LOF) mutations and STAT3 gain-of-function (STAT3-GOF) disease. So far, these entities have been regarded as antithetic, with AD-HIES mainly associated with characteristic infections and a connective tissue phenotype and STAT3-GOF characterized by lymphoproliferation and poly-autoimmunity. The R335W substitution in the DNA binding domain of STAT3 was initially described in 2 patients with typical AD-HIES, but paradoxically, recent functional analysis demonstrated a GOF effect of this variant. Read More

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Mixed Connective Tissue Disease with Severe Axonal Polyneuropathy: A Case Report.

Oman Med J 2022 May 31;37(3):e376. Epub 2022 May 31.

Rheumatology Unit, Department of Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman.

Mixed connective tissue disease (MCTD) is a unique disorder characterized by the presence of a high titer of anti-U1 ribonucloprotein antibody with overlapping features of various connective tissue disorders including systemic lupus erythematosus, scleroderma, and myositis. Severe renal or neurological involvement is unusual with this disorder. We describe a case of biopsy-confirmed severe sensorimotor axonal polyneuropathy in a middle-aged gentleman as his first presentation for MCTD. Read More

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Predisposition of HLA-DRB1*04:01/*15 heterozygous genotypes to Japanese mixed connective tissue disease.

Sci Rep 2022 Jun 15;12(1):9916. Epub 2022 Jun 15.

Department of Clinical Research, National Hospital Organization Tokyo National Hospital, 3-1-1 Takeoka, Kiyose, 204-8585, Japan.

Mixed connective tissue disease (MCTD) is a rare systemic autoimmune disease characterized by the production of anti-U1 ribonucleoprotein antibodies and systemic symptoms similar to those of some other autoimmune diseases. HLA-DRB1 polymorphisms are important genetic risk factors for MCTD, but precise associations of DRB1 genotypes with MCTD have not been reported in Japanese people. Genotyping of HLA-DRB1 and -DQB1 was performed in Japanese MCTD patients (n = 116) and controls (n = 413). Read More

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Successful Treatment of Thrombotic Thrombocytopenic Purpura in a Patient with Mixed Connective Tissue Disease.

Clin Lab 2022 Jun;68(6)

Background: Although the survival rate of thrombocytopenic purpura (TTP) has increased significantly due to the introduction of therapeutic plasma exchange (TPE). TTP in patients with mixed connective tissue disease (MCTD) has a very high mortality rate and a very small number of reported cases. In TTP, daily TPE is administered until a treatment response is achieved; however, in practice, TPE is often not performed for such long durations. Read More

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Lupus Cerebritis as a Rare Neuropsychiatric Manifestation of Systemic Lupus Erythematosus.

Cureus 2022 May 13;14(5):e24973. Epub 2022 May 13.

General Surgery, West Suburban Medical Center, Chicago, USA.

Mixed connective tissue disease (MCTD) is a rare autoimmune condition that shows an overlap of at least two connective tissue diseases (CTD) including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), scleroderma, Sjögren's syndrome, polymyositis, or dermatomyositis. From a laboratory standpoint, MCTD is associated with high titers of anti-U1-RNP antibodies, which makes it difficult to determine whether it is a variant of each of the respective CTDs or a different entity altogether. Our objective is to report the case of a patient with MCTD presenting with status epilepticus who was ultimately diagnosed with lupus cerebritis. Read More

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The Relationship between 9/11 Exposure, Systemic Autoimmune Disease, and Post-Traumatic Stress Disorder: A Mediational Analysis.

Int J Environ Res Public Health 2022 May 27;19(11). Epub 2022 May 27.

New York City Department of Health and Mental Hygiene, New York, NY 11101, USA.

The relationship between 9/11 exposure, systemic autoimmune disease (SAD) and mental health remains poorly understood. This report builds on a prior analysis of World Trade Center Health Registry data to determine whether 9/11 exposure is associated with higher risk of SAD, and if so, whether post-traumatic stress disorder (PTSD) is a mediating factor and whether the association varies by responder/community member status. The final analytic sample comprised 41,656 enrollees with 123 cases of SAD diagnosed post 9/11 through November 2017. Read More

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Clinical relevance of rheumatoid factor and anti-citrullinated peptides in fibrotic interstitial lung disease.

Respirology 2022 Jun 2. Epub 2022 Jun 2.

Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Background And Objective: Rheumatoid arthritis (RA) is a frequent cause of interstitial lung disease (ILD); however, the impact of rheumatoid factor and anti-citrullinated peptide antibody seropositivity in ILD without connective tissue disease (CTD) is unclear. We examined the association of seropositivity with ILD progression, mortality and response to immunosuppression in non-CTD ILD.

Methods: A total of 1570 non-CTD patients (with idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, interstitial pneumonia with autoimmune features or unclassifiable ILD) and 181 RA-ILD patients were included from a prospective registry. Read More

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Increased levels of sirtuin-1 in systemic lupus erythematosus.

Int J Rheum Dis 2022 May 29. Epub 2022 May 29.

Department of Rheumatology and Immunology, Affiliated Hospital of Southwest Medical University, Luzhou, China.

Aim: We investigated plasma sirtuin-1 (SIRT1) levels in systemic lupus erythematosus (SLE) patients, and discussed potential of plasma SIRT1 as a biomarker for SLE.

Methods: A total of 359 subjects, including 299 patients (89 SLE, 50 rheumatoid arthritis, 30 osteoarthritis, 30 gout, 38 Sjögren's syndrome, 20 ankylosing spondylitis, 30 mixed connective tissue disease, 12 systemic sclerosis) and 60 healthy controls were recruited. SIRT1 in plasma of SLE patients was detected by enzyme-linked immunosorbent assay. Read More

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A Case of Cryptococcal Meningitis and Fungemia With Relapse in an HIV-Negative, Non-transplant Patient on Azathioprine Therapy for Mixed Connective Tissue Disorder.

Cureus 2022 Apr 21;14(4):e24356. Epub 2022 Apr 21.

Infectious Disease, Yale New Haven Bridgeport Hospital, Bridgeport, USA.

Cryptococcal meningitis typically occurs in immunocompromised patients. Approximately 80% of cryptococcal infections occur in HIV patients. Non-HIV, non-transplant recipient patients are the least numerous population groups affected by cryptococcal infections. Read More

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Nailfold capillaroscopy for the early diagnosis of the scleroderma spectrum of diseases in patients without Raynaud's phenomenon.

J Scleroderma Relat Disord 2022 Jun 21;7(2):144-150. Epub 2022 Apr 21.

Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.

Background: The utility of nailfold capillaroscopy in the evaluation of patients without Raynaud's phenomenon is unclear.

Objective: This study aims to compare the utility of nailfold capillaroscopy for the early diagnosis of the scleroderma-spectrum of diseases in patients who present with Raynaud's phenomenon, undifferentiated non-Raynaud's phenomenon features and positive systemic sclerosis-associated antibodies without scleroderma-spectrum of disease features.

Methods: Eligible patients were divided into three referral criteria groups: (I) Raynaud's phenomenon; (II) Undifferentiated non-Raynaud's phenomenon features and (III) Positive systemic sclerosis-associated autoantibodies without features to suggest scleroderma-spectrum of diseases. Read More

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Health-related quality of life in patients with mixed connective tissue disease: a comparison with matched systemic sclerosis patients.

Clin Exp Rheumatol 2022 05 2;40 Suppl 134(5):66-70. Epub 2022 May 2.

Department of Rheumatology, Leiden University Medical Center, The Netherlands.

Objectives: Health-Related Quality of Life (HRQoL) in adult patients with mixed connective tissue disease (MCTD) has not been described so far. Therefore, we performed an explorative study to evaluate HRQoL in MCTD patients.

Methods: MCTD patients fulfilling the Kahn criteria and participating in the prospective follow-up cohort for MCTD of the Leiden University Medical Center were included; and matched to systemic sclerosis (SSc) patients based on age, sex and disease duration. Read More

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Management of calcinosis cutis in rheumatic diseases.

J Rheumatol 2022 May 15. Epub 2022 May 15.

Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348. Email:

Calcinosis (hydroxyapatite and calcium phosphate crystal deposition) within the extracellular matrix of the dermis and subcutaneous tissue is a frequent manifestation of adult and pediatric systemic autoimmune rheumatic diseases, specifically systemic sclerosis, dermatomyositis, mixed connective tissue disease and systemic lupus erythematosus. In this article, we review classification of calcinosis, highlight mechanisms that may contribute to the pathogenesis of calcinosis and summarize the evidence evaluating non-pharmacologic and pharmacologic interventions for the treatment of calcinosis. Read More

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Systemic Lupus Erythematosus vs. Mixed Connective Tissue Disease Disguised As Scabies.

Cureus 2022 Mar 29;14(3):e23621. Epub 2022 Mar 29.

Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that involves numerous body systems and may initially present as a malar or discoid rash. When there are features of other autoimmune disorders present, such as scleroderma or polymyositis, the term mixed connective tissue disorder (MCTD) may be used. The current literature illustrates that the diagnostic criteria for MCTD are unclear. Read More

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Autoimmune diseases after allogeneic stem cell transplantation: a clinician's guide and future outlook.

Expert Rev Clin Immunol 2022 May 12:1-14. Epub 2022 May 12.

Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy.

Introduction: Autoimmune disease (AD) may occur after allogeneic hematopoietic stem cell transplantation (HSCT). The autoimmune mechanism seems to be related to an imbalance of the immune regulation effect of T-regulatory lymphocytes on autoreactive T-lymphocytes.

Areas Covered: ADs include hematological ADs (HADs) and nonhematologic ADs (NHADs) involving organs such as thyroid, peripheral and central nervous system, skin, liver, connective tissue, gastrointestinal tract, and kidney. Read More

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A novel case of lupus nephritis and mixed connective tissue disorder in a COVID-19 patient.

Ann Med Surg (Lond) 2022 Jun 23;78:103653. Epub 2022 Apr 23.

RCSI University of Medicine and Health Sciences, Dublin, Ireland.

Introduction: Mixed connective tissue disease (MCTD) is a rare autoimmune condition characterized by Scleroderma, Polymyositis, and Systemic Lupus Erythematous (SLE). Though a possible relationship between COVID-19 and autoimmune diseases has been recently reported, its pathophysiological mechanism behind flares in Lupus Nephritis (LN), a complication of SLE, remains unknown.

Case Presentation: A 22-year-old COVID-19 positive female presented with anemia, bilateral pitting edema, periorbital swelling, and posterior cervical lymphadenitis. Read More

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[Basophils and IgE in autoimmunity: Mechanisms and therapeutic targets].

Med Sci (Paris) 2022 Apr 29;38(4):366-373. Epub 2022 Apr 29.

Université Paris Cité, Centre de recherche sur l'inflammation, Inserm UMR1149, CNRS ERL8252, Faculté de médecine site Bichat, Paris, France - Université Paris Cité, Laboratoire d'excellence Inflamex, Paris, France.

Understanding the pathophysiology of antibody-driven autoimmune diseases (AAID) represents a major challenge for the biomedical community to develop innovative therapeutic strategies that are still lacking to control these diseases. If the reason why AAID are developing still needs to be defined, loss of tolerance to self-antigens leads to the development of an autoimmune chain reaction in some individuals. However, autoreactive antibodies are present in a large proportion of the general population without any associated pathological condition. Read More

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Case of Moxifloxacin-Induced Black Hairy Tongue.

Am J Case Rep 2022 Apr 25;23:e936235. Epub 2022 Apr 25.

Department of Infectious Diseases, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan.

BACKGROUND Black hairy tongue (BHT) is a relatively uncommon acquired benign condition, with a prevalence ranging from 0.6% to 11.3%. Read More

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Connective tissue disease-related interstitial lung disease (CTD-ILD) and interstitial lung abnormality (ILA): Evolving concept of CT findings, pathology and management.

Eur J Radiol Open 2022 7;9:100419. Epub 2022 Apr 7.

Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine (SKKU-SOM), ChangWon, Gyeongsangnam-do, South Korea.

Connective tissue diseases (CTDs) demonstrating features of interstitial lung disease (ILD) include systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc), dermatomyositis (DM) and polymyositis (PM), ankylosing spondylitis (AS), Sjogren syndrome (SS), and mixed connective tissue disease (MCTD). On histopathology of lung biopsy in CTD-related ILDs (CTD-ILDs), multi-compartment involvement is an important clue, and when present, should bring CTD to the top of the list of etiologic differential diagnoses. Diverse histologic patterns including nonspecific interstitial pneumonia (NSIP), usual interstitial pneumonia (UIP), organizing pneumonia, apical fibrosis, diffuse alveolar damage, and lymphoid interstitial pneumonia can be seen on histology in patients with CTD-ILDs. Read More

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Collapsing glomerulopathy in a patient with mixed connective tissue disease.

Am J Med Sci 2022 Jul 14;364(1):99-105. Epub 2022 Apr 14.

Division of Nephrology and Hypertension, School of Medicine, Tulane University, New Orleans, LA, USA.

Collapsing glomerulopathy (CG) is a form of podocytopathy that is challenging to manage. CG can be idiopathic or associated with other conditions including autoimmune connective tissue diseases. In the setting of autoimmune connective tissue diseases, there are no current guidelines to guide therapy. Read More

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Associations between quality of health care and clinical outcomes in patients with rheumatic and musculoskeletal diseases: a rehabilitation cohort study.

BMC Musculoskelet Disord 2022 Apr 15;23(1):357. Epub 2022 Apr 15.

National Advisory Unit on Rehabilitation in Rheumatology, Division of Rheumatology and Research, Diakonhjemmet Hospital, PO Box 23, Vinderen, N-0319, Oslo, Norway.

Background: The quality of provided health care may be an important source of variation in rehabilitation outcomes, increasing the interest in associations between quality indicators (QIs) and improved patient outcomes. Therefore, we examined the associations between the quality of rehabilitation processes and subsequent clinical outcomes among patients with rheumatic and musculoskeletal diseases (RMDs).

Methods: In this multicentre prospective cohort study, adults with RMDs undergoing multidisciplinary rehabilitation at eight participating centres reported the quality of rehabilitation after 2 months and outcomes after 2, 7, and 12 months. Read More

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Non HCV-Related Mixed Cryoglobulinemic Vasculitis With Biopsy-Proven Renal Involvement: The Effects of Rituximab.

Front Med (Lausanne) 2022 28;9:819320. Epub 2022 Mar 28.

Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy.

In the countries where HCV infection is still endemic, about 90% of subjects with mixed cryoglobulinemia had previously been infected with HCV and about 80% are RNA positive. Remarkable results in severe HCV-related cryoglobulinemic vasculitis have been obtained with Rituximab. Details of the clinical characteristics and effective treatment of non HCV-related cryogloulinemic syndromes are presently lacking. Read More

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Fundoplication after lung transplantation in patients with systemic sclerosis-related end-stage lung disease.

J Scleroderma Relat Disord 2021 Oct 25;6(3):247-255. Epub 2021 May 25.

Department of Surgery, Section of General Thoracic Surgery, Columbia University Irving Medical Center, New York, NY, USA.

Introduction: Gastroesophageal reflux and aspiration are risk factors for chronic lung allograft dysfunction in lung transplant recipients. Patients with systemic sclerosis are at an increased risk of aspiration due to esophageal dysmotility and an ineffective lower esophageal sphincter. The aim of this study is to understand the effect of fundoplication on outcomes in systemic sclerosis recipients. Read More

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October 2021

An uncommon cause of myalgia: A case report on systemic lupus erythematous myopathy.

Ann Med Surg (Lond) 2022 Mar 2;75:103450. Epub 2022 Mar 2.

Faculty of Medicine and Health Science, Universiti Malaysia Sabah (UMS), Jalan UMS, 88400, Kota Kinabalu, Sabah, Malaysia.

Introduction: Myositis in systemic lupus erythematous may present in a wide range of clinical spectrum. It can be part of an overlap syndrome, or mixed connective tissue disease or a musculoskeletal manifestation of systemic lupus erythematous itself.

Case Presentation: Here, we present a young girl with an underlying systemic lupus erythematous presented with the typical manifestation of severe proximal myopathy in the background of normal creatine kinase values. Read More

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Long-term evaluation of pulmonary function and survival of patients with interstitial pneumonia with autoimmune features.

Clin Exp Rheumatol 2022 03 30. Epub 2022 Mar 30.

Division of Rheumatology, MedStar Georgetown University Hospital, Washington, DC, USA.

Objectives: Interstitial pneumonia with autoimmune features (IPAF) includes patients with interstitial lung disease with autoimmune features who do not meet criteria for a connective tissue disease (CTD). Previous studies showed a wide variation in the radiologic pattern, pulmonary function and prognosis but there is still limited data on longitudinal outcomes. We aim to describe the long-term pulmonary function, radiological patterns, and survival of IPAF patients and explore a classification based on CTD-like subgroups by using clinical/serologic data. Read More

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Turning walking pneumonia into recurrent abscesses: a curious case of CVID and review of the literature.

Allergy Asthma Clin Immunol 2022 Apr 5;18(1):31. Epub 2022 Apr 5.

University of Illinois College of Medicine, One Illini Drive, Peoria, IL, 61605, USA.

Background: Common variable immunodeficiency (CVID) is a primary immunodeficiency disorder associated with a broad symptom presentation that is still being characterized. We report a rare case of recurrent mycoplasma skin abscesses in a patient with a history of autoimmune disorders and prolonged mycoplasma pneumonia who was diagnosed with CVID.

Case Presentation: A 34-year-old woman presented with a history of recurrent abscesses previously confirmed positive for Mycoplasma pneumoniae. Read More

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Evaluation of the European League Against Rheumatism/American College of Rheumatology-2019 classification criteria in patients with childhood-onset systemic lupus erythematosus: a single-center retrospective study.

Clin Rheumatol 2022 Apr 4. Epub 2022 Apr 4.

Department of Infection and Immunology, Aichi Children's Health and Medical Center, 7-426 Morioka-cho, Obu, Aichi, 474-8710, Japan.

This study aimed to compare the sensitivity and specificity of the European League Against Rheumatism/American College of Rheumatology-2019 (EULAR/ACR-2019) classification criteria with prior classification schemes for patients with childhood-onset systemic lupus erythematosus (cSLE). This single-center retrospective study examined 53 patients with cSLE and 53 patients having antinuclear antibody (ANA) titers ≥ 1:80 but not cSLE as controls. Sensitivity and specificity were calculated for the EULAR/ACR-2019 criteria, original criteria reported earlier in 2019, the ACR-1997 criteria, and the Systemic Lupus International Collaborating Clinics-2012 (SLICC-2012) criteria. Read More

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Capillaroscopic analysis of the microvascular status in mixed versus undifferentiated connective tissue disease.

Microvasc Res 2022 07 29;142:104367. Epub 2022 Mar 29.

Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DiMI), University of Genova, IRCCS San Martino Polyclinic, Genoa, Italy. Electronic address:

Introduction: Raynaud phenomenon (RP), typically, precede the clinical onset of systemic manifestations in several connective tissue diseases (CTDs). These autoimmune disorders usually share a microvascular damage whose alterations can be detected by nailfold videocapillaroscopy (NVC). The aim of the study was to compare the NVC microvascular status in Mixed Connective Tissue Disease (MCTD) versus the Undifferentiated Connective Tissue Disease (UCTD), and to search correlations between NVC findings and specific autoantibodies in UCTD patients. Read More

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