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IntroductionOral isotretinoin is commonly prescribed for acne vulgaris. Several case reports and observational studies have reported serious musculoskeletal side effects; however, the incidence, imaging findings, and longitudinal follow-up data are limited for patients who develop inflammatory back pain (IBP).ObjectiveTo assess the incidence of isotretinoin-triggered axial spondyloarthropathy (SpA) in acne vulgaris patients based on clinical features and MRI findings and to examine clinical and radiological outcomes following drug withdrawal.MethodsFive hundred thirteen acne patients receiving isotretinoin were screened for IBP; IBP patients were assessed for CRP, plain radiographs, and MRI of the sacroiliac joint. MRI-proven sacroiliitis was scored semi-quantitatively. Patients were followed longitudinally to assess SpA clinical course and longitudinal MRI sacroiliac joints, and CRP levels were reassessed 3 weeks after patients were symptom-free, following isotretinoin discontinuation.ResultsOf the 513 patients, 23.98% developed IBP. MRI-proven sacroiliitis was detected in 42.3% of the symptomatic patients or 10.1% of the cohort. Among MRI-proven sacroiliitis cases, 51.9% fulfilled the Assessment of Spondyloarthritis International Society criteria for axial SpA. Mean CRP level was 32.05 ± 17.23 mg/L at pain onset and 3.4 ± 2.7 mg/L after symptom resolution. MRI findings completely resolved within 9 months (mean 6.27 ± 1.7) after isotretinoin discontinuation. MRI scores positively correlated with baseline CRP levels and global acne grading system score, pain, and the Ankylosing Spondylitis Disease Activity Score.ConclusionIsotretinoin-induced axial SpA is a prevalent side effect in acne vulgaris patients. Early detection and follow-up of isotretinoin-induced sacroiliitis can be facilitated by MRI. Cessation of isotretinoin resulted in complete resolution in all affected patients.Key Points• Detection of underdiagnosed isotretinoin side effects which are common but not always correctly diagnosed and managed.• Incidence, diagnosis, and management of these side effects in a real-world setting.• This is the first large prospective longitudinal cohort study to report on axial manifestations in patients treated with isotretinoin as well as the effect of drug cessation upon the clinical, laboratory, and radiological findings.

Background Neuromyelitis optica spectrum disorders (NMOSD) are considered as an autoantibody-mediated disorder that targets aquaporin-4 (AQP4); other autoantibodies could be detected in such spectrum of diseases, including anti-nuclear antibody and antibodies to extractable nuclear antigens. Systemic autoimmune diseases such as systemic lupus erythematosus (SLE), Sjogren’s syndrome (SS), and other autoimmune diseases can overlap with NMOSD. We aimed in this review to address the current evidence describing the relation of NMOSD to systemic autoimmunity diseases, its controversy of being co-association or the same etiology, and its practical implications. Main body The current review was done using a search for related articles or case reports on PubMed until 2019. The keywords included neuromyelitis optica spectrum disorders in combination with autoimmune disease nomenclature. We described the literature background of this controversy, to summarize the evidence of NMOSD relationship to systemic autoimmune diseases. Conclusion NMOSD associated with systemic autoimmune diseases is more common in SLE and Sjogren’s syndrome rather than other autoimmune diseases, frequently affects females more than males; AQP4 antibodies should be tested for all NMOSD like manifestations associated with an autoimmune disorder; however, the clinical diagnosis of NMOSD regardless of the cord lesion length and the presence of positive AQP4 antibody can occur in systemic autoimmune diseases.

Background: The values of electroencephalography (EEG) in neonatal hypoxic-ischemic encephalopathy (HIE) during therapeutic hypothermia (TH) are still uncertain. Aims: The aim of this study is to detect EEG background, the prevalence of seizures during cooling, and to determine different EEG patterns that can predict brain injury in magnetic resonance imaging (MRI). Patients and Methods: Thirty-nine newborns with HIE were subjected to TH. Continuous monitoring by video-EEG was carried out throughout cooling and during rewarming. MRI was done for all newborns after rewarming. The predictive value of EEG background for MRI brain injury was evaluated at 6-h intervals during cooling and rewarming. Results: At all-time intervals, normal EEG was associated with no or mild MRI brain injury. At the beginning of cooling, normal background was more predictive of a favorable MRI outcome than at later time points. After 24 h of monitoring, diffuse burst suppression and depressed patterns had the greatest prognostic value. In most patients, a discontinuous pattern was not associated with poor prognosis. Thirty-one percent developed electrical seizures, and 8% developed status epilepticus. Seizures were subclinical in 42%. There is a significant association between duration of seizure patterns detected on the EEG and severity of brain injury on MRI. Conclusions: Continuous EEG monitoring in newborns with HIE under cooling has a prognostic value about early MRI brain injury and identifies electrographic seizures, approximately 50% of which are subclinical. Treatment of clinical and subclinical seizure results in a reduction of the total duration of seizure pattern supports the hypothesis that subclinical seizures should be treated.

ObjectiveTo evaluate ultrasonographic subclinical inflammatory synovitis and enthesitis in psoriasis patients, without clinical arthritis or enthesitis compared with healthy controls, with a 2-year follow-up to study the associated incidence of psoriatic arthritis (PsA).MethodsA total of 109 consecutive psoriasis vulgaris patients without clinical signs of PsA and 90 healthy controls were included from two tertiary medical centers. Subjects underwent dermatological examination, PASI score evaluation for severity of psoriasis, musculoskeletal examination using 68/66 joints count for tenderness and swollen joints. Patients were assessed for CRP, musculoskeletal ultrasound (MSUS) in the form of grayscale ultrasound (GSUS), and power Doppler ultrasound (PDUS) for eight entheses and 34 joints to detect MSUS subclinical enthesitis and synovitis. All patients were followed-up for 2 years to detect evolving PsA.ResultsSubclinical enthesitis and synovitis were detected in 39.5% of psoriasis patients and 10% of controls (P < 0.001). CRP was significantly higher in psoriasis patients with MSUS manifestations (P < 0.01). PDUS and GSUS subclinical synovitis and/or enthesitis were detected at least in one site in psoriatic patients more than in controls (P < 0.05). During a 2-year follow-up of patients, the annual PsA incidence was 4.3%. Psoriasis patients who developed PsA showed a higher prevalence of baseline enthesitis, higher PDUS and GSUS synovitis scores, and higher baseline CRP level than those who did not develop PsA.ConclusionsMSUS subclinical synovitis and enthesitis are quite common in psoriasis patients. The incidence of PsA in Saudi’s psoriasis patients was slightly higher than worldwide reports. Subclinical enthesitis, PDUS, and GSUS synovitis could predict PsA development.

Background: Adrenal leiomyoma is a very rare benign soft tissue tumor, it is even more unusual if presenting bilaterally; 21 cases have been reported in the literature and only six had bilateral involvement; 5 in the pediatric population and only one in an adult patient. Radiological appearance may frequently be confused with malignancy especially if large, calcified and with central necrosis. We report a rare case of bilateral, large, calcified, non-functioning adrenal leiomyoma in a 20-year-old female, who was suspected for a malignancy preoperatively. Clinical Case: A 20 year-old-female presented with chronic abdominal discomfort, fatigue, and inability to gain weight. On examination, she was normotensive, underweight with BMI of 15.6 kg/m2, and there were no stigmata of Cushing’s syndrome, Addison’s disease or pheochromocytoma. A contrast CT scan of the abdomen revealed the presence of bilateral well-defined suprarenal lesions measuring 8.5 x 8.5 x 7.2 cm and 4.7 x 4.2 x 3.5 cm on the right and left side, respectively. The lesions showed large central areas of necrosis with multiple punctate calcifications and heterogenous peripheral enhancement. The radiological differential diagnosis included adrenal cortical carcinoma, adrenal metastasis, infectious etiology, and bilateral pheochromocytoma. Her hormonal assays showed normal free cortisol and catecholamine metabolites in the urine and normal serum androgens. Thus, the tumors were concluded to be non-functioning. Adrenal insufficiency was ruled out after a short Synacthen test. The patient underwent a successful right adrenalectomy. Resected specimen measured 10 x 9.5 x 7.5 cm. Histology revealed a well-circumscribed and pseudo-encapsulated smooth muscle tumor comprised of bland, spindle-shaped cells. The panel of immunohistochemical stains supported the diagnosis of leiomyoma. Postoperatively, the symptoms improved, she gained 4 kg weight over the following 4 months, and short Synacthen test confirmed an intact adrenal function. To avoid lifelong adrenal insufficiency and after discussion with the patient, we agreed to leave the left adrenal mass and follow it by serial imaging. There was only a minimal increase in the size over the following 4 years (5.5 x 4.5 x 3.8 cm). Conclusion: Adrenal leiomyoma is an extremely rare adrenal tumor and can be confused with adrenal malignancy. Therefore, it should be considered in the differential diagnosis of adrenal incidentalomas. In the case of bilateral etiology, permanent adrenal insufficiency and longterm replacement therapy can be avoided in certain population by removing the larger tumor and continuous follow-up for the other side.