Ghina Haidar’s research while affiliated with Damascus University and other places

Introduction Systemic Lupus Erythematosus is a systemic immune disease that classically occurs in young to middle-aged women and may present with cutaneous, renal, hematologic, neurological, and/or other symptoms at the time of diagnosis. Late-onset Systemic Lupus Erythematosus or Systemic Lupus Erythematosus in the elderly is a subtype that differs from classic Systemic Lupus Erythematosus in terms of age group, clinical symptoms, organ involvement and severity. Case presentation A 63 years old female noted to have pancytopenia. The patient was diagnosed with lupus upon obtaining clinical presentations and serological marker, along with high titers of the antinuclear antibody and/or anti-double-stranded DNA antibody. The patient was managed with glucocorticoids and mycophenolate mofetil therapy, which led to a rapid response. Discussion Late-onset SLE accounts for 2–12% of SLE patients with a minimum age of onset of 50 years and older, leading to significant delays in diagnosis. Late-onset SLE differs from early-onset SLE in terms of gender and ethnicity prevalence, clinical symptoms and signs, development of organ damage, disease activity and severity, and prognosis .Some studies have also shown that late-stage SLE patients have higher rates of RF and anti-Ro/anti-La antibody positivity, lower complement titer, and higher incidence of elevated creatinine and decreased creatinine clearance .First-line treatment of pancytopenia is glucocorticoid. In refractory cases, rituximab and immunosuppressants can be used. Conclusion It is important to assess any unusual presentation of Systemic Lupus Erythematosus when clinical suspicion remains high and conducting further laboratory and imaging investigation.

Introduction The problem of infertility is common worldwide. IVF remains the most widely used technique of assisted reproductive technology. Embryo implantation failure is a common cause of unexplained infertility and recurrent miscarriages, thus the relationship between antiphospholipid antibodies and embryo implantation failure after IVF and embryo transfer is an important problem in fertility medicine that must be studied. Patients and methods A retrospective and prospective (bidirectional) cohort study were conducted at the Laboratory Department of the Faculty of Medicine, and Hospital from June 2017 to June 2021. The sample size was 1000 participants, 900 of them were retrospective (2017–2020), and 100 were prospective (2020–2021). Data was collected, including patients’ demographics, type and duration of fertility, and antiphospholipid antibody values. Inclusion criteria-Women <40 years old, undergoing IVF, and in the retrospective study, patients who undergo IVF and who have antibody data, positivity of phospholipids, and/or anticardiolipin, and/or B2 glycoprotein I, and the presence of the gestational sac on ultrasound as a criterion for pregnancy. We performed a PTT LA for the control group in a cohort study (20 healthy women), then a PTT LA test, and the blending test were performed, and the values were considered positive if the correction was not made. The PTT LA test is a screening test. Results The average age of the women was 31.91, the success rate of assisted fertilization in inducing pregnancy in the last trial was 52.8%, the prevalence was 4.4% of anticardiolipin IgG, 2.6% of anticardiolipin IgM, and 4% of Lupus anticoagulant. No relation was found between the antiphospholipid value and the age of the women, the number of times the experiment was conducted, the rate of success and failure, the type of infertility, and the number of oocytes induction, while the duration of sterility was affected by positive values of IgG and lupus coagulant antibodies. Conclusion There is no need for a routine antiphospholipid assay for female candidates for IVF, and when it is confirmed, treatment is required by Anticoagulants.

Introduction:Psoriatic Arthritis (PsA) is an immune-mediated disease. The effectiveness of biologics has changed therapeutic strategies for psoriasis. We report a case of leukopenia in a patient with psoriatic arthritis (PsA) who was treated with Ustekinumab. Case presentation: A 36- year- old Syrian female presented for a follow up concerning treatment of psoriatic arthritis. She was diagnosed with psoriatic arthritis according to the CASPAR criteria. She was treated with Methotrexate, then Sulfasalazine. On presentation, the physical examination revealed tender in metacarpals, proximal interphalengal joints and distal interphalengal joints of both hands. Laboratory analysis showed: white blood cells (WBC) :3500 /mm3, (Neut:23% n = 40-65%, Lymp:65% n= 25-40%), erythrocyte sedimentation rate (ESR): 40 mm/h1, and C-reactive protein (CRP): 9.3 mg/L . Given the patient’s ongoing disease activity, and the presence of leukopenia, we started with Ustekinumab 45 mg subcutaneous. After the third dose of Ustekinumab, evaluation showed improvement in her peripheral arthritis and normal laboratory findings. Discussion: Patients with psoriasis had higher total white blood cell and neutrophil. Ustekinumab has good efficacy against disease activity as well as a favourable safety profile. In literature, we found a case of myelodysplastic syndrome associated with inflammatory bowel disease treated with Ustekinumab. Another case of constitutional neutropenia and psoriasis vulgaris treated with Ustekinumab. Conclusion: This is the first case of leukopenia associated with PsA successfully treated with Ustekinumab. UST treatment might be recommended for leukopenia associated with PsA, but further researches are recommended.

Introduction and Importance The use of cyclophosphamide in women of childbearing age with severe systemic lupus erythematosus is normally indicated. However, cyclophosphamide is generally avoided during pregnancy due to the risk of teratogenicity, especially since its effect on fetal survival is poorly understood. This is a case report of a lupus patient exposed to cyclophosphamide during pregnancy. Case Presentation A 35-year-old woman with a history of lupus presented to our outpatient clinic in the 12th week of pregnancy for her 6 th routine cyclophosphamide bolus. The fetal echocardiogram result with gynecology consultation was normal with the recommendation for a medical termination of pregnancy, which has been refused by the patient. Shared decision-making with the patient included a discussion of maternal risks of continuation of pregnancy in the setting of worsening systemic function and the fetal risks of definitive treatment with cyclophosphamide for a lupus flare and the patient decided to proceed with the pregnancy. Treatment with immunosuppressants, including azathioprine was initiated replacing cyclophosphamide with close monitoring of her and the fetus every month. Clinical Discussion The first trimester of pregnancy seems to be particularly susceptible to fetal malformations, although CPA effects on fetuses in later stages of pregnancy are also reported occasionally. Nonetheless, its repercussions on fetal survival remain poorly comprehended. Conclusion In conclusion, exposing pregnancy to cyclophosphamide could end with pregnancy loss. Based on our experience, the survival of the fetus is strongly in doubt when cyclophosphamide is required to treat lupus in the mother. However, in rare cases, it could be without complications.

Introduction and importance Rhupus syndrome is a very rare combination of systemic lupus erythematosus and rheumatoid arthritis. It is characterized by the presence of erosive arthritis with symptoms and signs of systemic lupus erythematosus. Rheumatoid nodules and neurological and renal involvement are further complications of Rhupus syndrome, leading to a worse prognosis. Case presentation We presented a young female patient diagnosed with lupus erythematosus, who laterally, developed clinical signs and biomarkers that led to the diagnosis of Rhupus syndrome. This is believed to be of relevance to the knowledge of the medical community. Conclusion Despite being a rare entity, it is important to know its early diagnosis, and treatment to reduce the complications

Introduction: Primary Sjögren syndrome (pSS) is an immune systemic disease, that may affect the central nervous system. A severe headache unresponsive to treatment is the headache which is persistently nonresponsive to narcotic analgesics. Case presentation: A 48-year-old woman with a 10-year history of pSS was seen in January 2021, complaining of a headache one week previously. The headache was characterised by a dull persistent pressing intensity and was not responding to paracetamol, NSAIDs or codeine. She had no previous history, nor family history. Physical examination revealed bilateral parotid glands enlargement. Laboratory tests showed anaemia, and elevated levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), with positive anti-La and anti-Ro antibodies. She was given topical treatment and different doses of Predlone, in addition to methotrexate10 mg/week. She had received three pulses of methylprednisolone and was started on azathioprine with a mild response to the headaches, so she received two initial IV doses of rituximab 375 mg/m2, then every 2 weeks, with a clinical and laboratory response. Two years later, she had no headache. Discussion: Headache that may presented in pSS are tension headaches, migraines and cluster headaches. The therapy is disease-modifying antirheumatic drugs, hydroxychloroquine, glucocorticoids and biotherapeutics. Rituximab is used in the treatment of some patients with pSS, especially where it can affect systemic symptoms. Conclusion: Rituximab treatment may be an option for severe headache in patients with pSS. The mechanism is unknown but may be due to depletion of brain auto-reactive B cells. Further research is needed.

Introduction: Erythema nodosum (EN) is a self-limited septal panniculitis that presents with fever, arthralgia, and arthritis. Tumor necrosis factor alpha (TNF-α) inhibitor such as golimumab has been found to treat EN in inflammatory bowel diseases (IBD). We herein report the paradoxical occurrence of EN following golimumab for ankylosing spondylitis. Case presentation: A 34-year-old female presented in June 2022 with a complaint of 'sores' on her feet that intermittently presented for approximately 5 months but that had worsened dramatically in the last 24 h. The patient had an 8-year history of ankylosing spondylitis for 7 years. Subcutaneous golimumab was administered every 4 weeks as she had not responded to other treatments. Twenty-four hours after the fifth subcutaneous injection, painful, erythematous nodules appeared, histologically compatible with EN. Despite this side effect, we continue therapy due to the good response and efficacy. Discussion: Skin reactions were associated with the treatment with golimumab, including warm tender skin around the injection site, eruptions, itchiness, and sometimes a full-body rash. Golimumab was successfully used in treating EN in Crohn's disease. Because our patient continued on golimumab, the temporal association of EN flares with therapeutic injection and the lack of any etiology support a direct causal relationship between EN and golimumab treatment. Conclusion: TNF-α inhibitors are useful in treating Crohn's disease patients with EN, although it may present as an adverse effect of this treatment. Further work is needed.

Unlabelled: Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease that affects many organs. In this report, we discuss the case of a patient with SLE who presented to an out-hospital clinic, complaining of fever and pain with genital ulcers. Negative evaluations for other causes of genital ulcers, indicated these ulcers as related to SLE. This case highlights the importance of including SLE ulcers in the differential diagnosis of genital ulcers. Learning points: Determining the cause of genital ulceration is a clinical challenge, especially in sexually active individuals.Genital ulcers associated with SLE are often underdiagnosed. Any patient with a history of SLE presenting with genital discomfort and/or pain must be evaluated for genital ulcers without delay.