Classical Rheumatoid Arthritis Research Articles

ASIA syndrome after BNT162b2 vaccination: Is it a distinct rheumatoid arthritis phenotype?

Vaccines are an identified cause of autoimmune/inflammatory syndrome induced by adjuvants (ASIA syndrome). In this research, we aimed to investigate the remarkable features of patients, whom we classified as ASIA syndrome, developing rheumatoid arthritis (RA) after BNT162b2 vaccination. Patients who were asymptomatic before the BNT162b2 vaccination, developed chronic arthritis within 3months after the vaccination, and fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism RA classification criteria were enrolled in the study. Demographic, laboratory, clinical, and treatment characteristics were reviewed retrospectively. We identified ten patients developing RA following BNT162b2 vaccination. The median age was 54.5years and six of them were female. The median time between vaccination and onset of symptoms was 7days; seven patients had acute arthritis, and four had intermittent arthritis at the onset of the disease. Only three patients had a disease onset in the small joints of the hands. All patients had radiological erosions on hand X-rays. We reported a case series of patients, classifiable as having ASIA syndrome, who developed RA with radiological erosions after the BNT162b2 vaccine. The onset of the disease in joints different from the typically expected ones, along with the early development of erosions in hand X-rays, suggests that these cases may follow a course distinct from classic RA. RA that develops following mRNA vaccination may have an aggressive course, but studies with larger sample sizes are needed.

Elderly-Onset Rheumatoid Arthritis: Characteristics and Treatment Options.

Elderly-onset rheumatoid arthritis (EORA) is a distinct clinical entity defined as the onset of rheumatoid arthritis (RA) in individuals aged over 60 years. EORA presents unique clinical features, including a more equitable distribution of sexes, a potential predilection for male involvement, a higher incidence of acute onset characterized by constitutional symptoms, a propensity for systemic manifestations, elevated sedimentation rates at disease onset, a reduced occurrence of rheumatoid factor positivity, increased titers of anti-citrullinated protein antibodies, a preference for involvement of large joints, elevated disease activity, the presence of bone erosions, and heightened patient disability. RA is recognized to consist of three partially overlapping subsets. One subset mirrors the classical RA clinical presentation, while the remaining subsets exhibit either a polymyalgia rheumatica-like phenotype or present with remitting seronegative symmetrical synovitis accompanied by pitting edema syndrome. In the initial stages of EORA management, non-steroidal anti-inflammatory drugs (NSAIDs) are not typically the first-line treatment choice, because seniors are much more prone to develop side effects due to NSAIDs, and the use of NSAIDs is in reality contraindicated to the majority of seniors due to comorbidities. Disease-modifying antirheumatic drugs (DMARDs), frequently methotrexate, are introduced immediately after the diagnosis is made. In cases where elderly patients demonstrate resistance to conventional DMARD therapy, the introduction of biological or targeted synthetic DMARDs becomes a viable treatment option. EORA presents a unique clinical profile, necessitating tailored treatment strategies. Our study emphasizes the challenges of NSAID use in seniors, highlighting the imperative shift toward DMARDs such as methotrexate. Future research should explore personalized DMARD approaches based on disease activity, comorbidities, and safety considerations, aiming to optimize treatment outcomes and minimize glucocorticoid reliance, thereby enhancing the quality of care for EORA patients.

Patterns of Involvement of the Hand Joints in Classical Rheumatoid Arthritis.

Symmetrical involvement of the hand joints is described as characteristic of rheumatoid arthritis (RA). Quantitative data on specific patterns of involvement are lacking. The Brigham Rheumatoid Arthritis Sequential Study was created for observational studies of patients with RA and afforded a unique opportunity to answer these questions. Of 1598 subjects in the Brigham Rheumatoid Arthritis Sequential Study cohort, 535 met the following criteria: (1) disease duration of 7 years or greater, (2) seropositive, and (3) hand radiographs available. Patterns in specific hand joints based on physical examination and radiographic findings obtained at entry were identified. The level of symmetry of involvement of the metacarpophalangeal (MCP) and wrist joints was determined, as was the correlation between findings on physical examination and radiographic changes in the hand joints. The prevalence of joint space narrowing and/or erosions in each proximal interphalangeal (PIP) joints ranged between 11% and 18%. Joint space narrowing and/or erosions in the MCPs increased radially from the fifth to the second finger. Swelling and tenderness on physical examination of both the PIPs and MCPs also increased radially although the positive predictive value of physical examination as an indicator of joint damage decreased radially. The wrist was the most common joint involved both by physical examination (67%) and radiographically (70%). The right side was more involved radiographically. Analysis of radiographic changes in individual patients revealed that symmetrical findings in the wrists and MCPs occurred in only 67% of patients. The study describes the pattern of involvement of the hand joints in patients with long standing RA. Findings of interest include symmetrical involvement in only 67% of patients and a discordancy between physical findings and radiographic changes most marked in the more radial PIP joints.

Adult-onset Still’s Disease after COVID 19 Infection: Case Report

Abstract Adult-onset Still's disease (AOSD) is an inflammatory disorder that presents by quotidian fevers, arthritis, an evanescent rash and even life-threatening conditions like Macrophage activation syndrome. Still's disease in the adult was used to describe a series of adult patients who had features similar to the children with systemic juvenile idiopathic arthritis and did not fulfil criteria for classic rheumatoid arthritis. We reported a case of Adult-onset Still’s Disease where the patient presented with frequent high grades of fever associated with sore throat, cough and intermittent sharp chest pains not responding to regular pain killers. Keywords: Adult-onset Still's disease, Macrophage activation syndrome.

Case report and disease’ review: tophaceous gouty arthropathy

Gout is a common inflammatory and metabolic disorder of the joints and probably other organs, especially the kidneys. It has a definitive genetic and environmental background, making it mainly a disease of middle-aged and elderly males, infrequently inflicting postmenopausal and elderly women who usually have arterial hypertension, renal impairment, and usually on diuretics. Excessive tissue urate turnover and persistent hyperuricemia is the hallmark of the disease. A typical algorithm is characterized by acute attack of the monoarticular joint, the metatarsophalangeal joint of the big toe often is involved (podagra), but tarsal joints, ankles, and knees might also be affected. Chronic asymmetric polyarticular arthritis that might be confused with classical Rheumatoid Arthritis might be encountered in some patients and in recurrent and relapsing diseases. In this setting, many organs and tissues are affected by the deposition of monosodium urate (MSU) crystals other than synovium, bursae, tendons, and periarticular tissues. The risk of involvement of renal interstitium or uric acid nephrolithiasis has a particular interest in the course of the disease. By the inflammation and collection of MSU crystals in form of tophi that might involve many tissues and occasionally the pinna of the ears, this kind of tophaceous gout is rarely observed nowadays, especially in our community (Middle East region). The patient who is presented here has exhibited acute attack on the top of chronic tophaceous gouty arthritis. The recent epidemiologic reports revealed that gout has given different results. This wide variation is attributed to the population studied and methods employed, but overall, for the prevalence of <1% to 6.8% and an incidence of 0.58-2.89 per 1,000 person per year. The most noticeable risks for gout are obesity and associated metabolic syndrome (insulin resistance, hypertension, dyslipidaemia), dietary factors, high fructose-containing diet, high purine diet (red meat, internal organ’s meat ,seafood) high consumption of alcohol, and exclusively beer ( as in our patient’s case ), a wide variety of disorders that are characterized by high urate turnover like myeloproliferative disorders, neoplasms, psoriasis, haemolytic anaemias, medications , to under-secretion of urate like renal insufficiency.

Patterns of Involvement of the Hand Joints in Classical Rheumatoid Arthritis

Patterns of Involvement of the Hand Joints in Classical Rheumatoid Arthritis

Patients with checkpoint inhibitor-induced inflammatory arthritis do not become seropositive for anti-cyclic citrullinated peptide when followed over time.

Patients with checkpoint inhibitor-induced inflammatory arthritis do not become seropositive for anti-cyclic citrullinated peptide when followed over time.

Features and Outcomes of Elderly Rheumatoid Arthritis: Does the Age of Onset Matter? A Comparative Study From a Single Center in China.

IntroductionThe aim of this work is to investigate the clinical and radiological characteristics of elderly rheumatoid arthritis and compare the outcomes between the two subgroups, elderly- and young-onset rheumatoid arthritis (EORA and YORA, respectively).MethodsWe conducted a retrospective case-control study on the elderly rheumatoid arthritis patients in our medical center. EORA was defined as the patient whose onset age was above 60.ResultsA total of 142 elderly rheumatoid arthritis patients were admitted, with 79 patients in EORA and 63 in YORA group. Inflammatory parameters including C-reactive protein, D-dimer, serum ferritin, and platelet count levels were all higher in the EORA group than those in YORA. EORA patients showed a higher score of health assessment questionnaire's disability index (p = 0.01) and patient global health assessment (p = 0.049), but a lower status of modified total sharp score (p = 0.001). Bivariate logistic regression analysis revealed that elderly onset of the disease (OR 2.30, 95% CI [1.45–3.77]), age (OR 2.04, 95% CI [1.22–3.41]), high disease activity (OR 1.90, 95% CI [1.17–3.32]), and red blood cell distribution width (OR 1.81, 95% CI [1.03–3.19]) were independent prognostic factors of disability. Age (OR 0.25, 95% CI [0.07–0.91]), disease duration (OR 2.73, 95% CI [0.97–7.70]), and co-morbid diabetes mellitus (OR 118.10, 95% CI [3. 50–3985.57]) independently contributed to radiographic joint damage in the elderly population. EORA patients showed increased death incidents and worse prognosis than YORA. Cox regression analysis reveals that comorbid hypertension (HR 12.02, 95% CI [1.08–133.54]), interstitial lung disease (ILD) (HR 85.04, 95% CI [4.11–1759.19]), and compressive fracture (HR 85.04, 95% CI [4.11–1759.19]) are independent predictors of mortality, and that ILD (HR 50.21, 95% CI [5.56–335.33]) and pulmonary hypertension (HR 25.37, 95% CI [3.03–265.81]) are independent predictors of no disease remission in the EORA patients.ConclusionsThe distinct features of EORA patients make EORA a unique entity different from “classic rheumatoid arthritis”. EORA patients develop an upgraded systemic inflammatory status, more declined life quality, and worse prognosis than the elderly YORA. Better control of the comorbidities like ILD and diabetes mellitus may benefit the management of elderly rheumatoid arthritis. Further investigation regarding the pathogenesis and therapeutic strategies of EORA is urgently warranted.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40744-020-00267-8.

The importance of differences; On environment and its interactions with genes and immunity in the causation of rheumatoid arthritis.

The current review uses rheumatoid arthritis (RA) as a prominent example for how studies on the interplay between environmental and genetic factors in defined subsets of a disease can be used to formulate aetiological hypotheses that subsequently can be tested for causality using molecular and functional studies. Major discussed findings are that exposures to airways from many different noxious agents including cigarette smoke, silica dust and more interact with major susceptibility genes, mainly HLA-DR genetic variants in triggering antigen-specific immune reactions specific for RA. We also discuss how several other environmental and lifestyle factors, including microbial, neural and metabolic factors, can influence risk for RA in ways that are different in different subsets of RA.The description of these processes in RA provides the best example so far in any immune-mediated disease of how triggering of immunity at one anatomical site in the context of known environmental and genetic factors subsequently can lead to symptoms that precede the classical inflammatory disease symptoms and later contribute also to the classical RA joint inflammation. The findings referred to in the review have led to a change of paradigms for very early therapy and prevention of RA and to efforts towards what we have named 'personalized prevention'. We believe that the progress described here for RA will be of relevance for research and practice also in other immune-mediated diseases.

Can rheumatoid vasculitis predate a diagnosis of rheumatoid arthritis?

We report regarding a male patient who presented with a systemic vasculitis that was consistent with a diagnosis of polyarteritis nodosa. At presentation, he had no features of inflammatory arthritis but had a high rheumatoid factor titer and low C4 level. Withdrawal of immunosuppression after 6 years resulted in the development of classical rheumatoid arthritis (RA). This case supports previous reports that revealed that vasculitis may predate the development or occur very early in the course of articular RA.

The Additive Value of Femoral Ultrasound for Subclinical Atherosclerosis Assessment in a Single Center Cohort of 962 Adults, Including High Risk Patients with Rheumatoid Arthritis, Human Immunodeficiency Virus Infection and Type 2 Diabetes Mellitus.

BackgroundPresence of femoral atheromatic plaques, an emerging cardiovascular disease (CVD) biomarker additional to carotid plaques, is poorly investigated in conditions associating with accelerated atherosclerosis such as Rheumatoid Arthritis (RA), Human Immunodeficiency Virus (HIV) infection and Type 2 Diabetes Mellitus (T2DM).Objective/MethodsTo assess the frequency of femoral/carotid subclinical atheromatosis phenotypes in RA, HIV and T2DM and search for each disease-specific probability of either femoral and/or carotid subclinical atheromatosis, we examined by ultrasound a single-center cohort of CVD-free individuals comprised of consecutive non-diabetic patients with RA (n=226) and HIV (n=133), T2DM patients (n=109) and non-diabetic individuals with suspected/known hypertension (n=494) who served as reference group.ResultsSubclinical atheromatosis - defined as local plaque presence in at least on arterial bed - was diagnosed in 50% of the overall population. Among them, femoral plaques only were found in 25% of either RA or HIV patients, as well as in 16% of T2DM patients and 35% of reference subjects. After adjusting for all classical CVD risk factors, RA and HIV patients had comparable probability to reference group of having femoral plaques, but higher probability (1.75; 1.17 - 2.63 (odds ratio; 95% confidence intervals), 2.04; 1.14 - 3.64, respectively) of having carotid plaques, whereas T2DM patients had higher probability to have femoral and carotid plaques, albeit, due to their pronounced dyslipidemic profile.ConclusionRA and HIV accelerate predominantly carotid than femoral. A “two windows” carotid/femoral, rather than carotid alone ultrasound, screening improves substantially subclinical atheromatosis detection in patients at high CVD risk.

Balneotherapy (or spa therapy) for rheumatoid arthritis.

Balneotherapy (or spa therapy) for rheumatoid arthritis.

Importance of Electrocardiogram for Detection of Preclinical Abnormalities in Patients with Rheumatoid Arthritis without Cardiovascular Events

Introduction: In patients with rheumatoid arthritis, cardiovascular involvement is common, may have serious consequences, and can contribute to worsening of patient’s outcome. The realization of systematic electrocardiogram can help to detect earlier cardiac abnormalities and place in a logical secondary prevention. Our purpose of this study was to investigate the electrocardiographic abnormalities in a population of Senegalese patients with rheumatoid arthritis without clinically evident cardiovascular manifestations. Patients and methods: The study was performed as a cross-sectional study, which included prospectively 73 patients of both sexes aged at least 18 years in the internal medicine department of University Hospital Center Aristide Le Dantec in Dakar, Senegal, fulfilling the criteria for definite or classical rheumatoid arthritis according to the criteria of the American Rheumatism Association. It focused on a sample of following clinical examination, we conducted laboratory tests (CRP, fibrinogen, ESR, Rheumatoid factors, Latex and Waaler Rose, Anti-CCP, antinuclear factors and antibodies anti-ENA), a standard ECG. Data were analyzed using a descriptive study of the different variables with the calculation of proportions for categorical variables, and the positional parameters and dispersion for quantitative variables. Results: All patients had normal ECG and no cardiac symptoms or dyspnoea on effort. The study included 73 patients (68 females and 5males) with rheumatoid arthritis without obvious cardiac events meet the criteria of definition of the ACR 1987. The mean age was 44.17 ± 14.43 years with extremes of 18 and 75 years. The mean duration of RA was 5.93 ± 4.78 years. The concept of family inflammatory arthritis was reported in 35.60% of cases and almost one in six patients had at least a factor of cardiovascular risk (16.96%). Electrocardiographic abnormalities found were dominated by left ventricular hypertrophy encountered in 34 patients (46.57%), left atrial enlargement in 32.90% of cases, 16.44% of patients had left axis deviation. The myocardial hyper excitability was present in 8 patients (11.19%), including 6 (8.45%) ventricular premature beats found in patients with active RA. Twenty-six patients had signs consistent with an ischemia and/or myocardial injury is a rate of 35.61%. Conclusion: The realization of the electrocardiogram in patients with rheumatoid arthritis without clinically evident cardiovascular manifestations allows highlighting cardiovascular abnormalities related to the natural course of the disease.

A Rare Presentation of Adult Onset Still’s Disease

Introduction: Adult onset Still’s disease is an inflammatory disorder that includes a triad of daily fever, arthritis and rash. This disease was first described by George Still in 1896 [1]. In other words it can be described as, systemic onset juvenile idiopathic arthritis. This still’s disease is most common in paediatric population. This same condition is described as adult onset still’s disease when adult patients who are not fulfilling criteria for classic rheumatoid arthritis, but having presentation similar to children with systemic onset idiopathic juvenile arthritis. This is a rare case report of patient who presented with a different presentation and how we diagnosed the same condition. Case Blog A 52 year old male patient presented to ENT department with complaints of hyperplastic candidiasis of oral cavity. The patient was given management for candiasis, with oral and local antifungal. Simultaneously rapid ELISA was performed two at an interval of 6 weeks was done and results turned out to be negative. The candidiasis was not getting better even after a treatment of four weeks. After four weeks patient presented with history of arthritis of two weeks duration and fever for past seven days. Then patient was referred to medicine department for further workup. In medicine department routine blood investigations were done. Total count was twenty thousand nine hundred with eighty percent polymorphs. Erythrocyte sedimentation rate was one hundred and sixty seven mm/hour. Blood urea was ninety one, creatinine 3.5 mg/dl. Liver function test was showing normal bilirubin, SGOT 56 IU/L, SGPT 57 IU/L, alkaline phosphatase 149, total protein 5.3 gm/dl, albumin 2.9 gm/dl. Urine routine was found to be normal. Blood and urine culture and sensitivity revealed no growth. Ultrasound of the abdomen showed hepatospleenomegaly. Blood smear for malarial parasite came negative. HBsAg and anti HCV were non reactive. Chest X ray was within normal limits. to rule out associated macrophage activation syndrome bone marrow biopsy was done and the report showed reactive marrow with microcytic hypochromic RBC morphology.

Felty's Syndrome, Insights and Updates.

Felty’s syndrome (FS) is characterized by the triad of seropositive rheumatoid arthritis (RA) with destructive joint involvement, splenomegaly and neutropenia. Current data shows that 1-3 % of RA patients are complicated with FS with an estimated prevalence of 10 per 100,000 populations. The complete triad is not an absolute requirement, but persistent neutropenia with an absolute neutrophil count (ANC) generally less than 1500/mm3 is necessary for establishing the diagnosis. Felty’s syndrome may be asymptomatic but serious local or systemic infections may be the first clue to the diagnosis. FS is easily overlooked by parallel diagnoses of Sjӧgren syndrome or systemic lupus erythematosus or lymphohematopoietic malignancies. The role of genetic (HLA DR4) is more prominent in FS in comparison to classic rheumatoid arthritis. There is large body of evidence that in FS patients, both cellular and humoral immune systems participate in neutrophil activation, and apoptosis and its adherence to endothelial cells in the spleen. It has been demonstrated that proinflammatory cytokines may have inhibitory effects on bone marrow granulopoiesis. Binding of IgGs to neutrophil extracellular chromatin traps (NET) leading to neutrophil death plays a crucial role in its pathophysiology. In turn, "Netting" neutrophils may activate auto-reactive B cells leading to further antibody and immune complex formation. In this review we discuss on basic pathophysiology, epidemiology, genetics, clinical, laboratory and treatment updates of Felty’s syndrome.

Rheumatoid Arthritis: Clinical Manifestations and Diagnosis

The onset and course of rheumatoid arthritis (RA) can be highly variable, and the lack of a specific biologic marker can make diagnosis difficult in early disease. A careful history and physical examination and the integration of clinical and laboratory data are often required. The presence of anti-citrullinated peptide antibodies (ACPAs) is one of the best predictors of progression to establish RA. This review describes the clinical manifestations used to diagnose RA, such as physical examination of the hands and wrists, elbows and shoulders, hips, knees, ankles and feet, and cervical spine. Extra-articular manifestations related to rheumatoid nodules, eyes, lungs, heart, blood and blood vessels, and neuromuscular involvement are reviewed. Laboratory tests and differential diagnosis are also discussed. Figures show synovitis in the hand and wrist, rheumatoid nodules near the extensor surface of the elbow, a pelvic radiograph of a patient with classic seropositive RA, erosions in the metatarsal heads and phalanges of the foot of a patient with classic seropositive RA, the anterior edge of the odontoid process, and a typical rheumatoid nodule. This review contains 6 highly rendered figures and 20 references.

Rheumatoid Arthritis: Etiology and Pathogenesis

Rheumatoid arthritis (RA) is among the most common forms of chronic inflammatory arthritis. It affects approximately 1% of adults and is two to three times more prevalent in women than in men. There are no specific laboratory tests for RA; diagnosis depends on a constellation of signs and symptoms that can be supported by serology and radiographs. The disease evolves over many years as a consequence of repeated environmental stress causing inflammation and immune activation followed by a breakdown of tolerance in individuals with a specific genetic background. This review describes the definition of RA; its etiology, including genetics, infections, the role of smoking and citrullination of proteins, and epigenetic mechanisms; and its pathogenesis, including synovial histopathology, bone and cartilage damage, adaptive and innate immunity, and the role of cytokines and intracellular signaling. Tables include the 1987 American Rheumatism Association criteria for the classification of RA and the 2010 American College of Rheumatology/European League Against Rheumatism classification for RA. Figures show citrullinated proteins in airway cells, a section of a proliferative synovium from a patient with a classic RA, and scalloped regions of erosion at the junction between a proliferative inflamed rheumatoid synovium and the bone. This review contains 3 highly rendered figures, 2 tables, and 71 references.

Epidemiología de la artritis Rematoide en el Hospital de La Fuerza Aérea del Perú*. Mayo 1976 – Junio 1992

El objetivo de este estudio fue conocer algunos aspectos epidemiológicos de la artritis reumatoide (clásica) en el Servicio de Reumatología del hospital Central de la Fuerza Aérea del Perú (HCFAP) entre los años 1976 y 1992. El estudio fue descriptivo, longitudinal y retrospectivo. Se estudió 206 casos, de pacientes con el diagnóstico de artritis reumatoidea clásica. La demora en el diagnóstico fue definida como el período de tiempo comprendido entre el inicio de los síntomas y el momento del diagnóstico. Se encontró 169 mujeres (82,03%) y 37 hombres (17,97%). La edad promedio fue 65 ± 14,43 años (media ± DE) en los varones y 61 ± 14,44 años en las mujeres. El grupo etáreo más comprometido fue el de 46-55 años (23,30%) y el menos comprometido el de 16-25 años. Al momento del ingreso al servicio, el 48,75% de los casos presentaba grado funcional II. El factor Reumatoideo (FR) fue positivo en el 70% de los pacientes (p<0,001). La mayor frecuencia de casos nuevos se registró en el año 1988 (11,65%) y la menos en el año 1978 (2,42%). El 52,38% evolucionó a la incapacidad en un intervalo de 0 – 5 años. Con relación a la ocupación, se observó que la mayor frecuencia correspondió a las amas de casa (71,21%). Se concluye que los resultados encontrados concuerdan con los datos referidos en la literatura nacional y extranjera, siendo posible que el mayor número de casos observados en 1988 esté relacionado a la modificación de los criterios de la Asociación Americana de Reumatología (ARA) en 1987.

A Case of Etoposide Therapy in a Patient Newly Diagnosed with Classic Kaposi's Sarcoma and Rheumatoid Arthritis

본 저자들은 류마티스관절염을 처음 진단받고 면역저하의 증거가 없으며 HHV-8 음성이며 전신상태가 좋지 않은 고령의 환자에서 전신 피부에 발생한 4병기 고전형 카포시 육종을 진단하였고 지속적인 저용량 경구 에토포사이드 단독요법으로 좋은 임상경과를 얻은 증례가 있어 보고하는 바이다.

A role for b-cell-depleting agents in treating psoriatic skin lesions induced by tumor necrosis factor-alpha antagonists: A case report and literature review

Despite recent advances in understanding the pathological pathways, clinical pattern and management opportunities for new-onset psoriasis as a paradoxical adverse event in patients receiving TNF inhibitors for their immune-mediated disorder, there is a subset of patients who are either partial responders or non-responders, whatever the therapeutic scenario. We present the case of new-onset psoriasis and severe alopecia development in a case study of long-standing rheumatoid arthritis (RA) treated with adalimumab (ADA) and leflunomide. Since skin lesions and alopecia are resistant to the classic protocol (topical treatment, ADA discontinuation) and RA becomes highly active, rituximab (RTX) was started. Dramatic improvement in joint disease, total remission of alopecia and partial remission of pustular psoriasis were described after the first RTX cycle. Although B-cell-depleting agents result in controversial effects on psoriatic skin lesions, this is the first case of ADA-induced psoriasis and alopecia that improved under RTX, suggesting a possible role in treating such a patient population.