Mira Merashli

War and violence have become part of daily life in many areas of the Middle East and North Africa (MENA), including some Arab countries, with profound consequences for both mental and physical health. Civil wars, prolonged political instability, large-scale refugee crises, the COVID-19 pandemic, and escalating economic challenges in several low- and middle-income countries across the region have had catastrophic effects on population health. Physicians working in conflict settings have been forced to fundamentally alter their practice, often rationing limited resources, working in primitive conditions, and adapting treatment approaches under extreme constraints. Data specifically addressing rheumatic diseases in the Arab world during periods of war and conflict remains scarce. Nevertheless, rates of non-communicable diseases and their associated risk factors, including musculoskeletal disorders, have steadily increased across the MENA region over recent decades. Rheumatologists in conflict-affected Arab countries frequently report increases in post-infectious reactive arthritis, complex regional pain syndrome, post-traumatic musculoskeletal injuries, and stress-related fibromyalgia. However, these trends remain insufficiently documented in the literature. Treatment interruptions, disruption of vaccination programs, destruction of sanitation infrastructure, increased disease burden, reduced access to healthcare facilities, and shortages of healthcare professionals due to migration have collectively had devastating effects on already fragile health systems. Public health policies and responses by international health organizations have often been slow and insufficiently aligned with the complex social, economic, and political realities faced by countries in the MENA region. To mitigate the health consequences of war, each country requires a tailored and adaptable healthcare strategy, supported by continuous monitoring and evaluation. At the same time, sustained diplomatic efforts remain essential to prevent conflict and to protect populations from the profound and lasting health consequences of war.

Background: It is becoming increasingly recognized that rheumatologic diseases and sensorineural hearing loss (SNHL) are linked. These autoimmune disorders can affect the auditory system through both disease-related immune dysregulation and medication-induced ototoxicity. The latest findings on auditory involvement in patients with autoimmune rheumatologic conditions are summarized in this review Methods: This narrative review was conducted using PubMed, focusing on articles published in English between 2010 and 2024. Clinical, experimental, and epidemiological studies describing hearing outcomes in autoimmune conditions were included. MeSH and keywords related to autoimmune diseases, SNHL, auditory dysfunction, and cochlear implantation were used. Results: Autoimmune-mediated SNHL results from immune complex deposition, vasculitis, antibody- mediated cytotoxicity, and inflammatory injury to cochlear structures. Rheumatoid arthritis, systemic lupus erythematosus, primary Sjögren’s syndrome, vasculitis, juvenile idiopathic arthritis, IgG4-related disease, and Behçet’s disease all demonstrate variable yet significant auditory involvement. Commonly used medications for these diseases, such as calcineurin inhibitors, methotrexate, cyclophosphamide, and antimalarials, may also cause ototoxicity. Cochlear implantation offers effective rehabilitation for severe or refractory SNHL. However, autoimmune- related cochlear fibrosis or ossification may limit outcomes, highlighting the need for prompt diagnosis. Conclusion: Hearing is affected in patients with rheumatologic disease and those using immunosuppressants as treatment. Routine audiologic monitoring, early identification of auditory symptoms, and personalized therapeutic planning are essential. Further prospective research is needed to clarify the mechanisms and optimize treatment protocols for autoimmune-associated hearing loss.

Introduction and importance: Behçet’s disease (BD) is a rare, autoimmune vasculitis usually characterized by oral and genital ulcers with systemic involvement of multiple organ systems. Its diagnosis is usually clinical as it lacks the disease-specific markers seen in other autoimmune pathologies. Avascular necrosis (AVN) is extremely rare in BD and if it were to occur, it would usually be unifocal. Case presentation: This case report presents an odd case of BD that was complicated by bilateral AVN of the knees in a 36-year-old man. His diagnosis was confirmed by MRI of both knees after he started complaining of knee pain while on rituximab. The patient’s treatment was adjusted and he has reported relief from pain and clinical improvement while on Infliximab, which he is currently maintained on. Clinical discussion: AVN is usually observed with chronic steroid use or with diseases such as sickle cell disease. The vasculitis associated with BD may result in an ischemic insult to the bone and joints; however, the pathophysiology is still unclear. Hence, joint pain in BD patients may be a warning sign to AVN which thus needs to be considered among the differential diagnosis in these immunosuppressed patients. Conclusion: This is case of bilateral AVN of the knees in a patient with BD warrants investigation of joint pain or symptoms in patients with BD and other autoimmune diseases even if not on corticosteroid treatment. Prompt evaluation of patients’ symptoms decreases risks of development of serious complications and preserves their health.

Immune-complex small-vessel vasculitis (ICSVV) is a subtype of vasculitis characterized by inflammation and necrosis of small blood vessels caused by deposition of circulating immune complexes in vessel walls, followed by complement activation and recruitment of inflammatory cells. It typically targets postcapillary venules in the skin, but other small vessels in muscles, kidneys, gastrointestinal tract, and other organs can also be affected. Vasculitic myositis is usually bilateral and symmetric, with only a few reports of muscle-limited disease. Hepatitis A virus (HAV) is an uncommon trigger of vasculitis, in contrast to the well-recognized associations of hepatitis B with polyarteritis nodosa and hepatitis C with cryoglobulinemic vasculitis. We report a case of a woman in her early 30s who experienced intense discomfort in her left groin and thigh, accompanied by swelling and fever, two months after a confirmed acute HAV infection. Laboratory studies demonstrated severe systemic inflammation (WBC 30×10³/µL, C-reactive protein (CRP) 348 mg/L, erythrocyte sedimentation rate (ESR) >100 mm/h) with normal creatine kinase (CK). Axial fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) and coronal MRI revealed diffuse left-thigh inflammation without abscess. MRI-guided biopsy of the vastus lateralis demonstrated transmural inflammation and fibrinoid necrosis of intramuscular arteries with mixed CD4+/CD20+ infiltrates and C5b-9 deposition, consistent with ICSVV. The patient received oral prednisone 1 mg/kg daily (tapered over 10 weeks) and methotrexate 15 mg weekly; CRP decreased to 3.4 mg/L within four weeks. Remission was achieved by six months, with only mild residual numbness. This case represents the first report of biopsy-proven unilateral immune-complex vasculitic myositis temporally associated with HAV infection. It emphasizes the importance of considering vasculitic myositis in the differential diagnosis of focal limb swelling with systemic inflammation, even when CK levels are normal. It also highlights the role of MRI-guided biopsy in establishing the diagnosis. Early immunosuppressive therapy can improve outcomes in this rare but treatable condition.

Background: Behçet’s Disease (BD) is a complex vasculitis affecting multiple organ systems, with Neuro-Behçet’s Disease (NBD) representing a rare yet severe manifestation. Data on NBD are limited, particularly in Middle Eastern populations. Methods: This retrospective observational study, spanning from 2000 to 2021, involved 262 BD patients at a tertiary medical center in Lebanon. NBD was diagnosed based on International Consensus Recommendation diagnostic criteria. Clinical data, including demographics, manifestations, inflammatory blood markers, genetics, and treatments, were collected. The modified Rankin Scale (mRS) was used to assess disease severity. Results: Among the cohort, 27 (10.3%) had NBD, with headaches, weakness, and dizziness as the most common presenting symptoms. The prevalence of NBD was similar across genders, which differs from some regional studies. HLA-B51 positivity was found in 50 out of 60 (83.3%) tested BD patients. Parenchymal NBD cases exhibited greater disease severity than non-parenchymal cases, with female patients experiencing a more severe course compared to males. Elevated inflammatory markers (CRP and ESR) were more common in patients with severe NBD. Corticosteroids and colchicine were the most commonly used therapies overall, while patients with better disease severity were more frequently prescribed methotrexate, mycophenolate, cyclophosphamide, adalimumab, and rituximab. An analysis of disease progression showed that at presentation, 57.1% (n = 12) of NBD patients had mild to moderate disability, which increased to 76.2% (n = 16) at the last follow-up, including 10 patients who showed an improvement in their mRS score. Conclusions: This study provides valuable insights into the prevalence and clinical characteristics of NBD in a Middle Eastern population. These findings enhance our understanding of NBD in the Middle East, highlighting the need for further research to improve diagnosis and management.

Sarcoidosis is an inflammatory multisystem disease characterised by non-necrotising granulomas that typically affect the lungs, lymph nodes, eyes, skin, liver, spleen, heart, bones and joints. Although rare, necrotising granulomas can also occur. In this report, we present a case of a healthy woman in her 60s who presented with a 1-year history of fatigue and generalised body aches. A comprehensive diagnostic workup, including a detailed history, physical examination, blood tests, imaging studies (CT and positron emission tomography-CT) and biopsies, was conducted to identify the underlying cause. Biopsy results confirmed the presence of necrotising granulomas, leading to a diagnosis of extrapulmonary sarcoidosis after excluding other aetiologies. The patient was treated with a multiregimen therapeutic approach, including adalimumab, which resulted in significant clinical improvement.

Background Behçet Disease (BD) is a complex, multi-systemic vasculitis characterized by inflammatory processes in blood vessels. Neuro-Behçet's Disease (NBD) represents a rare yet debilitating manifestation of BD, demanding a comprehensive understanding of its clinical features, prevalence, and distinction between parenchymal and non-parenchymal involvement. Methods and Results A retrospective observational study was conducted, spanning the years 2000 to 2022, involving 262 patients diagnosed with BD at a tertiary medical center in Lebanon. Neurological involvement was diagnosed based on International Consensus Recommendation criteria. Patients were stratified into groups based on NBD severity and subtypes, and clinical data, including demographics, manifestations, and genetic factors collected. The modified Rankin Scale (mRS) was used to assess NBD severity. Among the BD cohort, 10.3% were diagnosed with NBD. Clinical manifestations in NBD included prevalent neurological symptoms, with headaches, weakness, and dizziness being most frequent. The study found a similar prevalence of NBD between genders, contrary to some regional studies. Interestingly, HLA B51 positivity was observed in 83.3% of patients tested which were only sixty. Further stratification revealed a higher proportion of severe disease in parenchymal NBD compared to non-parenchymal cases. Conclusion This study provides valuable insights into the prevalence and clinical characteristics of NBD in a Middle Eastern population. Despite challenges in diagnosis and limited prevalence, the findings underscore the need for ongoing research to enhance the understanding, diagnosis, and management of NBD. These insights contribute to the broader comprehension of BD, particularly in the context of the Middle East, emphasizing the significance of tailored approaches for effective patient care.

Objectives. Illustration of a case of systemic mastocytosis mimicking reactive arthritis in the absence of an infectious etiology. Methods. Review of the patients medical records. Results. We report a case of systemic mastocytosis relapse, presenting with pancytopenia accompanied by knee monoarthritis, cystitis, and bilateral conjunctivitis occurring simultaneously at the same time interval within 24days, mimicking reactive arthritis in the absence of an infectious etiology. Conclusion. Our case demonstrated reactive arthritis features (triad of urethritis, conjunctivitis, and arthritis) without an infectious trigger but rather a relapse of mastocytosis. We should think outside the box when faced with such a clinical scenario in the absence of an infectious etiology. Paraneoplastic reactive arthritis is to be considered after excluding an underlying infection.

Eosinophilic fasciitis (EF) is a rare connective-tissue disorder that is characterised by subacute onset of erythema, oedema, and induration of the skin and soft tissues of the limbs and trunk. Although several triggers have been hypothesised to be associated with EF, the aetiology of eosinophilic fasciitis (EF) is still unclear, and several treatment regimens have been proposed to treat this disease. In this article, we report a case of a 72-year-old gentleman with multiple comorbidities who presented to the clinic for diffuse skin thickening present on his forearms, thighs, legs bilaterally, and over the pelvis. The patient was diagnosed with EF and failed multiple treatment regimens including prednisone, methotrexate, rituximab, but finally responded and was maintained on tocilizumab. In this article, we will review the current understanding of EF, diagnostic approach, popular treatments and review other cases of EF in which tocilizumab was used.