Dear Editor, I read with interest the systematic review by Mohamadzadeh et al., which synthesized evidence on autoantibodies associated with rheumatic diseases in active tuberculosis...

Mixed connective tissue disease (MCTD) represents a complex autoimmune condition characterized by vasculopathy, fibrosis, and immune dysregulation. Autoimmune cytopenias are rare but clinically significant complications that increase morbidity and complicate management of these diseases. Current therapies, including glucocorticoids and conventional immunosuppressants, may be limited by intolerance or inadequate hematologic response. Type I interferon (IFN) signaling has emerged as a key pathogenic pathway, and its blockade represents a novel therapeutic approach. We describe a 39-year-old woman with MCTD and clinical features of systemic sclerosis, presenting with Raynaud's phenomenon, digital ischemic ulcers, esophageal involvement, and pulmonary arterial hypertension. Her disease course was complicated by progressive cytopenia, including leukopenia, severe lymphopenia, mild anemia, and thrombocytopenia. Azathioprine therapy led to worsening pancytopenia, necessitating discontinuation, while glucocorticoids provided only partial hematologic recovery. Subsequent treatment with mycophenolate was ineffective. Introduction of anifrolumab (300 mg IV every 4 weeks) resulted in hematologic improvement, with normalization of hemoglobin and stabilization of leukocyte and platelet counts, without infusion-related adverse events. The findings support type I IFN blockade as a promising therapeutic avenue in refractory hematologic manifestations of connective tissue disease, warranting further investigation in larger studies.

Hypocomplementemic urticarial vasculitis (HUV) is a rare small-vessel vasculitis that may occur as a primary form or secondary to systemic disease. Its concurrent association with systemic lupus erythematosus (SLE) and Sjögren's disease (SD) remains exceptional. Diagnosis is particularly challenging due to overlapping clinical and immunological features among these entities. We report the case of a 46-year-old woman with no significant medical history, presenting with recurrent chronic urticaria resistant to antihistamines. Clinical, biological, and histological investigations led to the diagnosis of HUV associated with SLE and SD without severe organ involvement. Treatment with colchicine and hydroxychloroquine resulted in complete remission of symptoms. This case highlights the importance of considering HUV in any patient with chronic or refractory urticaria and of systematically screening for associated autoimmune diseases, particularly SLE and SD.

Dear Editor, Cristopher Columbus's voyages have undoubtedly changed the history of humankind. Despite already being a public figure in his lifetime, several facts concerning Columbus's life, including his final illness, are still under debate...

Melanoma differentiation-associated gene 5 dermatomyositis (MDA-5 DM) is a rare subtype of dermatomyositis. Cytomegalovirus (CMV) retinitis is an opportunistic ocular infection that has historically been linked to HIV infection. Herpes simplex virus (HSV) uveitis is caused by the reactivation of the varicella-zoster virus. We present the case of a 69-year-old woman diagnosed with aggressive MDA-5 DM associated with interstitial lung disease, who received multiple immunosuppressive therapies and subsequently developed left eye CMV retinitis and right eye acute herpetic, hypertensive, anterior uveitis with dendritic keratitis. After the diagnosis of MDA-5 DM, she was treated with glucocorticoids (GC), followed by rituximab and triple therapy (cyclosporine, cyclophosphamide, and GC); however, she did not improve and multiple adverse effects occurred. The patient then started tofacitinib (TOF) and improved. While being on TOF, she developed right eye acute herpetic, hypertensive, anterior uveitis, followed by left eye CMV retinitis. TOF was stopped, and the patient started oral acyclovir and intravenous and intravitreal ganciclovir, which was later changed to maintenance therapy with oral valganciclovir. Cyclical intravenous immunoglobulin (IVIG) administration was started, resulting in an overall improvement in disease activity associated with MDA-5 DM. This case underscores the uncommon link between CMV retinitis in a non-HIV patient and HSV anterior uveitis in a patient undergoing immunosuppressive therapy and the challenge of treating MDA-5 DM with IVIG, which led to favorable results.

Neuropsychiatric systemic lupus erythematosus (NPSLE) encompasses a wide range of neurological manifestations, including, though rarely, myasthenia gravis (MG). We report the case of a 47-year-old woman with long-standing systemic lupus erythematosus (SLE) who developed diplopia and fluctuating muscle weakness. Electromyography revealed a decremental response to low-frequency stimulation in the absence of MG-specific autoantibodies. These neurological features were interpreted as manifestations of NPSLE and were initially treated with azathioprine and then rituximab, the latter discontinued due to an adverse reaction. Several years later, immunosuppressive therapy with mycophenolate mofetil and voclosporin was initiated following a renal flare. Although renal remission was achieved, the patient experienced a concomitant relapse of neurological symptoms. After multidisciplinary consultation with neurologists, the patient underwent 3 monthly cycles of plasma exchange combined with corticosteroid pulses, resulting in marked clinical improvement of neurologic symptoms and sustained serological and clinical stability during the follow-up. The coexistence of SLE and MG is uncommon; distinguishing between an overlap syndrome or lupus-related myasthenic manifestations and choosing the optimal therapeutic strategy remain challenging. In this case, plasma exchange proved to be an effective rescue therapy, highlighting the importance of a multidisciplinary approach and individualized treatment strategies in managing complex NPSLE presentations.