Rheumatoid Arthritis (RA) is a systemic inflammatory disorder that commonly presents with polyarthritis but can have multisystemic involvement and complications, leading to increased morbidity and mortality. The diagnosis of RA continues to be challenging due to its varied clinical presentations. In this review article, we aim to determine the potential of PET/CT to assist in the diagnosis of RA and its complications, evaluate the therapeutic response to treatment, and predict RA remission. PET/CT has increasingly been used in the last decade to diagnose, monitor treatment response, predict remissions, and diagnose subclinical complications in RA. PET imaging with [¹⁸F]-fluorodeoxyglucose ([¹⁸F]-FDG) is the most commonly applied radiotracer in RA, but other tracers are also being studied. PET/CT with [¹⁸F]-FDG, [¹⁸F]-NaF, and other tracers might lead to early identification of RA and timely evidence-based clinical management, decreasing morbidity and mortality. Although PET/CT has been evolving as a promising tool for evaluating and managing RA, more evidence is required before incorporating PET/CT in the standard clinical management of RA.

The application of [¹⁸F]-fluorodeoxyglucose ([¹⁸F]FDG) as a radiotracer to detect sites of inflammation (either due to bacterial infection or primary inflammation) has led to exploring the role of PET in visualizing bacteria directly at sites of infection. However, the results from such efforts are controversial and inconclusive so far. We aimed to assess the limitations of PET as an effective modality in the diagnosis of bacterial infections. Inflammation due to bacterial infections can be visualized by using [¹⁸F]FDG-PET. However, the non-specificity of [¹⁸F]FDG makes it undesirable to visualize bacteria as the underlying cause of inflammation. Hence, more specific radiotracers that possibly bind to or accumulate in bacteria-specific receptors or enzymes are being explored. Several radiotracers, including 2-deoxy-2-[¹⁸F]fluorosorbitol ([¹⁸F]FDS), 6-[¹⁸F]-fluoromaltose, [¹¹C]para-aminobenzoic acid ([¹¹C]PABA), radiolabeled trimethoprim (¹¹C-TMP) and its analog fluoropropyl-trimethoprim (¹⁸F-FPTMP), other radiolabeled sugars, and antimicrobial drugs have been used to image microorganisms. Unfortunately, no progress has been made in translating the results to routine human use; feasibility and other factors have constrained their success in clinical settings. In the current article, we discuss the limitations of direct bacterial visualization with PET tracers, but emphasize the important role of [¹⁸F]FDG-PET as the only option for detecting evidence of infection.

Drug-induced gingival overgrowth is an adverse effect of certain drugs, including amlodipine, in genetically susceptible individuals. Although the exact mechanism of gingival hypertrophy remains unclear, a unifying multifactorial hypothesis has been constructed. Gingival hypertrophy causes difficulty in speech and mastication, poor oral hygiene, and poor aesthetic appearance. Here, we present the case of a 49-year-old woman who developed gum hypertrophy following amlodipine use for two years. Maintenance of oral hygiene and substitution of offending agent is commonly the first step in management.

Lung transplantation represents a potential life-extending therapy for patients with advanced CTD-ILD. This study aims to characterize lung transplant listing outcomes among CTD-ILD patients over a 20-year period using the Organ Procurement and Transplantation Network (OPTN) national database. Data analyzed from the OPTN between 2003-2023 included adults ≥18 years of age with CTD-ILD listed for lung transplantation. Patients were categorized into six diagnoses: scleroderma, lupus, rheumatoid arthritis (RA), myositis, Sjögren's, and "Other" (including mixed connective tissue disease, CTD, etc.). Disease and patient specific data were obtained. Trends in listing and outcomes were analyzed in four time periods across the 20 years and among various diagnoses. We used descriptive summary statistics to characterize the sample, and univariate and multivariable logistic regression models to identify factors associated with undergoing lung transplantation. A total of 1977 CTD-ILD patients were listed. Scleroderma constituted the majority (47%). Listings increased fourfold (185 to 744) from the first to last time periods. Listings for all diagnoses increased with time, with rising representation of non-White patients. Trend noted towards listing patients with more advanced lung disease with time. Transplant rates rose, while wait times, and waitlist mortality declined overtime. All diseases received transplants at comparable rates. Older age, lower lung allocation scores, and male sex were associated with higher odds of transplantation, female sex with lower odds. Over two decades, CTD-ILD transplant listings have increased in volume, matched with substantially improved outcomes. This reflects the evolution of listing practices and a growing confidence in lung transplantation as a viable option for CTD-ILD.

Introduction: Moderate to severely ill patients diagnosed with Coronavirus disease 2019 (COVID-19) pneumonia develop a series of complications and less frequently, we might witness cases of Pulmonary Thromboembolism (PE)-refractory to the standard treatment with Low Molecular Weight Heparin (LMWH). The aim of this case series is to report the presentation and management of pulmonary thromboembolism secondary to COVID-19 pneumonia. Method: We report a case series of seven cases aged 40-70 who were presented in Dhulikhel Hospital with COVID-19 symptoms in different stages. The case details were extracted from their medical reports of the hospital. The written informed ethical consents were obtained from all the cases and their voluntary participation was assured. Outcome: The cases in the case series admitted with COVID-19 pneumonia, after diagnostic investigation (Chest x-ray, HRCT, CTPA) were suggestive of COVID-19 Pneumonia with ARDS and pulmonary thromboembolism. The cases received rivaroxaban, a newer anticoagulant-15 mg twice daily for 21 days and after discharge, they were asked to continue once daily doses for 9 weeks. Significant improvement was witnessed, with the presence of additional intervention including rehabilitative chest exercises. Conclusion: Pulmonary thromboembolism secondary to COVID-19 pneumonia is a life-threatening condition. Rivaroxaban is seen to be very effective in the management of this condition when an anticoagulation failure occurs even after the therapeutic dose of low molecular weight heparin. Future studies may require more scientific investigations to prevent complications even in the early stages of COVID-19.

Introduction: Autoimmune gastritis is an immune mediated disorder characterized as anti-intrinsic factor and anti-parietal cell autoantibodies directed against intrinsic factor and parietal cells of the stomach respectively, leading to vitamin B12 deficiency. When the disease remains undiagnosed and untreated, it may lead to neurological complications and even fatal anemia. Case study: We exemplify a non-vegetarian male adolescent case with the neurological symptoms such as bilateral leg weakness, unsteady gait, slurred speech, vertigo, slowed movement, lethargy, and impaired joint sensation. None of his family members had such illness. His hemoglobin was normal with serum vitamin B12 level 105 pg/ mL and anti-intrinsic factor antibody titer positive. A presumed diagnosis of cobalamin deficiency with involvement of the cerebellum, dorsal column and peripheral nerves was made. His symptoms recovered gradually and later completely (after 6 months) after the intramuscular vitamin B12 therapy. Clinical discussion: The indexed rare adolescent case had auto immune gastritis showing neurological manifestation with more pronounced cerebellar features and vitamin B12 deficiency under the non-vegetarian diet consumption. Previous studies had reflected auto immune among adolescents but contrasted some of the clinical features. Conclusion: For the prompt and precise diagnosis of the autoimmune gastritis and to prevent further complications, some of the rare conditions such as deficiency with a non-vegetarian diet, neurological manifestation including cerebellar involvement without anemia should also be considered along with other relevant symptoms. The heightened awareness for timely surveillance and treatment will contribute in reduction of such unusual cases.