Clinical Research in Infectious Diseases

Desquamative Inflammatory Vaginitis as an extra-articular Manifestation of Rheumatoid Arthritis?

Case Report | Open Access | Volume 5 | Issue 1

  • 1. Department of Internal Medicine, Wayne State University School of Medicine, USA
+ Show More - Show Less
Corresponding Authors
Jack D. Sobel, Wayne State University School of Medicine 540 E. Canfield St 1241 Scott Hall Detroit MI 48201, USA.

We report four women with seropositive Rheumatoid Arthritis (RA) presenting with concomitant Desquamative Inflammatory Vaginitis (DIV). No convincing evidence emerged establishing a causal connection between RA and DIV, or indicating that DIV was an extra- articular manifestation of RA. Similarly, use of rituximab was not shown to be a causal factor in pathogenesis of vaginitis.


• Desquamative inflammatory vaginitis

• Rheumatoid arthritis

• Rheumatoid diseases

• Rituximab


Shukla A, Sobel JD (2020) Desquamative Inflammatory Vaginitis as an extra-articular Manifestation of Rheumatoid Arthritis? Clin Res Infect Dis 5(1): 1055.


Rheumatoid arthritis (RA) affects 1-2% of the population worldwide. It is the most common inflammatory joint disease, affecting women two to three times more commonly than men [1]. It is a complex disease with a combination of risk alleles from different susceptibility genes predisposing to development of the disease, following exposure to unknown environmental factors [2].

Extra-articular manifestations of RA not directly related to the locomotor system are by no means uncommon [1-5]. Several studies have shown that presence of extra-articular manifestations varies directly with the severity and manifestations of rheumatoid disease [6,7]. Extra-articular manifestations in RA include vasculitis, neuropathy, pericarditis, pleuritis, Felty’s syndrome, ophthalmologic manifestations (e.g. kerato- conjunctivitis sicca, scleritis, episcleritis and peripheral ulcerative keratitis), glomerulonephritis, rheumatoid lung disease, amyloidosis, and rheumatoid nodules [1-8]. However, there are no studies about the vaginal manifestations of rheumatoid arthritis.

Desquamative inflammatory vaginitis (DIV) is an uncommon and severe form of chronic vaginitis causing purulent discharge, vestibulo-vaginal irritation, and dyspareunia [9,10,11]. It predominantly occurs in Caucasians and although diagnosed in a wide age range, its occurrence peaks in perimenopausal women [12,13]. DIV syndrome has unknown etiology and is frequently undiagnosed. It is characterized by vaginal inflammation with a vaginal rash and purulent discharge with microscopy revealing a marked increase in inflammatory cells, predominantly polymorphonuclear leukocytes and parabasal epithelial cells, together with abnormal vaginal flora or dysbiosis [9,10,14,15]. The term desquamative inflammatory vaginitis first was introduced by Gray and Barnes in 1965 when they described six women with a “reddened” vagina and “numerous pus cells with oval and round parabasal cell” [14]. Gardner published the first case series three years later with eight patients who had similar clinical presentation and no response to antimicrobial treatment [9]. It was only after three decades that Sobel described desquamative inflammatory vaginitis in 51 women and successful treatment with 10% hydrocortisone and 2% clindamycin [10]. DIV is now considered as, by no means uncommon and thought to represent an autoinflammatory or autoimmune disease precipitated by estrogen deficiency.

There have been no studies documenting the association of RA with DIV. We report four women with diagnosed RA seen at a university- based vaginitis clinic presenting with vaginal symptoms and manifestations of DIV.


Case 1

A 46-year-old female with longstanding RA well controlled on rituximab, presented to the clinic in December 2014 with purulent vaginal discharge. She was diagnosed with pyoderma gangrenosum and desquamative inflammatory vaginitis and was prescribed 10% hydrocortisone 5 g intravaginal once daily. Her DIV, purulent vaginitis was thought to be due to rituximab and the possibility was discussed with her Rheumatologist. Her symptoms responded to vaginal hydrocortisone for 3 months, but she had a relapse of DIV and clobetasol ointment BID was added to the regimen. At this point, she was still on rituximab for RA. 3 Months later, hydrocortisone and clobetasol doses were reduced due to weight gain and facial puffiness and well controlled vaginal symptoms. However, her DIV relapsed while on reduced doses of 10% hydrocortisone and clobetasol. She had also switched from rituximab to tocilizumab. In the following 5 months on increased topical steroid therapy, she reported continuous improvement in DIV leading to full remission, allowing vaginal corticosteroid medications to be gradually discontinued.

Comment: This patient suffered from severe longstanding but well controlled rheumatoid arthritis benefitting from rituximab. She made a successful transition from rituximab to tocilizumab and after prolonged local vaginal steroid therapy achieved full resolution of her DIV. The role of rituximab in causation of DIV was never established.

Case 2 A 60-year-old female with past medical history of rheumatoid arthritis well controlled on rituximab infusions, methotrexate and folic acid was referred for chronic vaginal discharge and pain. She presented to the clinic in December 2011 with abnormal discharge. Examination findings showed vestibular erythema and erosion and diffuse vaginal rash. DIV was suspected on the basis of microscopic findings and patient was started on 10% hydrocortisone vaginal cream once daily and topical estradiol twice weekly. Her past medical history also included Hashimotos thyroiditis and Sjogren’s syndrome. On 1 month follow up, her vaginal symptoms were considerably improved with accompanying improvement in examination findings. Vaginal hydrocortisone was reduced to 5 x week and topical vestibular steroids was started. For the next 11 months, DIV remained in controlled remission and the same regimen was continued, however acute vulvovaginal candidiasis developed, treated with induction and maintenance therapy with oral fluconazole. Months later, she had a mild DIV relapse presenting with burning and irritation. Clobetasol ointment was added to her regimen. However, her DIV remained uncontrolled with florid vestibulitis in the following 3 months and discontinuation of rituximab was recommended. Even after trying tacrolimus and intramuscular Kenalog for 12 months later her DIV remained uncontrolled. She was started on intravaginal sulfanilamide and niacin amide 4 g once daily x 6 months and DIV showed moderate improvement only. At the time, she was treated with methotrexate and hydroxychloroquine for RA. Subsequently she restarted rituximab for RA flare up. She discontinued her medications for DIV, with her only symptom being residual dyspareunia. Currently, RA is moderately well controlled while still receiving rituximab. Full remission of DIV was never achieved in spite of all local modalities of therapy.

Comment: Longstanding RA, never completely controlled on hydroxychloroquine, methotrexate and rituximab, simultaneously developing florid, severe DIV. Later demonstrating incomplete DIV resolution in spite of topical and systemic steroid therapy and discontinuation of rituximab. Once more, causal relationship between RA, rituximab and DIV was never established.

Case 3:

A 50-year-old female with past medical history of RA, well controlled on rituximab infusion (1 x year) was referred in October 2017 for uncontrolled DIV present for 18 months, she had been treated with clindamycin, boric acid and 10% hydrocortisone in the past. At the time of presentation, her dominant symptoms were copious discharge, burning, pain and itching. Examination findings showed vestibular inflammation and diffuse rash in the upper third of vagina. Saline microscopy showed 4+ increase in white cells, 3+ parabasal cells, absence of normal flora and a pH of 5.5. DIV secondary to rituximab was suspected and she was advised to start intravaginal clindamycin 2% and HC once a day. She was also advised to consider discontinuing rituximab. At 1 month follow up, she was asymptomatic with improved vaginal physical examination and microscopic findings. DIV was in controlled remission and she was advised to decrease clindamycin and hydrocortisone dosage. Two months later, however she presented with DIV relapse after discontinuing local anti-inflammatory therapy. She restarted 10% hydrocortisone 4 g per vagina and two months later, her symptoms had dramatically improved, examination as well as pH and microscopy findings were normal and DIV was in controlled remission. She was advised to discontinue vaginal hydrocortisone and her DIV has entirely resolved and RA is well controlled on rituximab.

Comment: This patient presented with DIV of 18 months duration and RA well controlled on rituximab infusion. Although a causal relationship between DIV and RA was suspected, the role of rituximab in causation of DIV is unlikely.

Case 4

A 56-year-old female presented to the clinic in November 2013 complaining of burning on micturition, copious vaginal discharge, itching and dyspareunia. Examination findings showed erythematous vagina, edematous vulva with bilateral fissures while saline microscopy showed 2+ increase in white cells, +parabasal cells, absence of normal flora and a pH of 5, compatible with diagnosis of DIV. She was started on intravaginal 2% clindamycin. At her 2 months follow up, she was asymptomatic, DIV had dramatically improved with residual focal vestibulitis and the same regimen was continued at lower dose and estradiol per vagina twice weekly was added. One month later, clindamycin was decreased to three times weekly and estradiol per vagina added. She remained asymptomatic with well controlled DIV over the next 1 year. During this period, she was diagnosed with seropositive Rheumatoid arthritis and was started on etanercept (TNF inhibitor) which was followed by DIV relapse while on low dose 2% clindamycin maintenance. Clindamycin dose was increased to once weekly and her examination findings responded. Over the next 5 years, her DIV remained controlled, asymptomatic but smoldering with declining dose of maintenance clindamycin.

RA was well controlled on tofacitinib. Her last visit was in February 2020 and although entirely asymptomatic, low grade smoldering DIV was present based upon pH and saline microscopy and the same regimen was continued. Currently she is asymptomatic in terms of DIV, on vaginal clindamycin 2% cream twice monthly.

Comment: Her initial presentation of DIV preceded onset of RA and therapy thereof. Severe DIV responded well to vaginal anti- inflammatory therapy with 2% clindamycin but has never completely resolved although now asymptomatic. Her RA responded well to tofacitinib. Relationship between DIV and RA possible but unproven.


Despite the fact that extra-articular manifestations have been studied in numerous RA cohorts, there is no uniformity in their definition or classification. Extra articular manifestations occur in 17.8–40.9% of RA patients and 1.5%–21.5% of them present in the most severely affected [16,17].

The prevalence of extra—articular manifestations of RA has declined in recent years, with the timing and pattern of the decline indicating that disease-modifying RA treatments may be changing the natural history of the disease [18-20]. Trends for specific extra-articular manifestations varied, showing linear declines in fibromyalgia syndrome, increases in RA lung disease, possibly reflecting increased diagnostic sensitivity with early recognition and treatment being the key to decrease mortality [19,21]. Nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs) are primarily used for treatment of RA. This was followed by methotrexate and a major advance followed the advent of infliximab, which targets tumor necrosis factor α (TNFα). Thereafter numerous biological drugs inhibiting interleukin-6 (IL-6) and cytotoxic T-lymphocyte associated antigen 4 (CTLA-4), and Janus kinase (JAK) inhibitors, were approved in succession. These drugs being highly effective against RA, made it possible to raise the treatment goals for RA [22].

In order to establish whether DIV represents an extra-articular complication of RA, a number of criteria need to be satisfied. High prevalence of DIV in RA greater than what one may anticipate. In the last two decades, more than 200 patients with DIV have been seen at the Vaginitis clinic [11]. Accordingly, 4 patients in the last 9 years failed to meet the criteria of increased occurrence suggesting a causal link. In a review of 200 patients in our clinic as reported by Reichman and Sobel, a search for associated clinical diagnostic entities was undertaken and no association between DIV and other autoimmune and autoinflammatory conditions emerged [10-12]. Another factor suggesting an association could be a temporal relationship particularly in relation to activity and control of RA, correlating with occurrence, expression or activity of DIV. On the basis of the four cases reported here, no clear association was evident. DIV could present, exacerbate or relapse without any change in RA activity. Likewise, no improvement in DIV necessarily followed improved management of RA.

Complicating any association between RA and DIV is the role of rituximab and other biologics now in use for the treatment of RA. No other biologics have been associated with vulvovaginal disease; however, several case series and case reports have implicated rituximab in causation of vulvovaginitis including pyoderma [23,24]. Although, three of the four RA patients reported in the current series received rituximab prior to onset of DIV, a clear causal relationship could not be established, in that DIV never resolved or improved with discontinuation of rituximab alone. Stopping rituximab in women with active symptomatic DIV simultaneously intensively treated with DIV specific anti-inflammatory agents precludes establishing a causal role.


Although both rheumatoid arthritis and DIV are considered non- infectious, auto-inflammatory diseases, no causal relationship could be established. In patients with RA well controlled on rituximab in whom DIV is newly diagnosed, there appears no convincing evidence that rituximab should be discontinued and an alternative biologic initiated. Such action may be considered only when DIV is refractory to appropriate vaginal anti-inflammatory treatment.


1. Cojocaru M, Cojocaru IM, Silosi I, Vrabie CD, Tanasescu R. Extra-articular Manifestations in Rheumatoid Arthritis. Maedica. 2010; 5: 286–291.

2. Pawlik A, Paradowska-Gorycka A, Safranow K, Dziedziejko V, Dutkiewicz G, S?ucznowska-G?abowska S, Juzyszyn Z, Drozdzik M. SLC22A5 polymorphism associated with risk of extra- articular manifestations in rheumatoid arthritis patients. Reumatologia. 2019; 57: 3-7.

3. Mielants H, Van den Bosch F. Extra-articular manifestations. Clin Exp Rheumatology. 2009; 27: S56–S61.

4. Bongartz T, Cantaert T, Atkins SR, P Harle, Myers JL, Turesson C, et al. Cirullination in extra- articular manifestations of rheumatoid arthritis. Rheumatol (Oxford). 2007; 46: 70–75.

5. Sahatçiu-Meka V, Rexhepi S, Manxhuka-Kerliu S, Rexhepi. Extra-articular manifestations of seronegative and seropositive rheumatoid arthritis. Bosnian Journal of Basic Medical Sciences. 2010; 10: 26–31.

6. Schmid FR, Cooper NS, Ziff M. Arteritis in rheumatoid arthritis. Am J Med. 1961; 30: 56.

7. Thompson M. The clinical features of rheumatoid disease, in Dixon AStJ (ed): Progress in Clinical Rheumatology. London, Churchill. 1965.

8. Epidemiology of extra-articular manifestations in Rheumatoid arthritis; Turesson, C; Jacobsson, LT Scand J Rheumatol. 2004; 33: 65- 72.

9. Gardner HL. Desquamative inflammatory vaginitis: a newly defined entity. Am J Obstet Gynecol. 1968; 102: 1102-1105.

10. Sobel JD. Desquamative inflammatory vaginitis: a new subgroup of purulent vaginitis responsive to topical 2% clindamycin therapy. Am J Obstet Gynecol. 1994; 171: 1215-1220

Shukla A, Sobel JD (2020) Desquamative Inflammatory Vaginitis as an extra-articular Manifestation of Rheumatoid Arthritis? Clin Res Infect Dis 5(1): 1055

Received : 15 Jul 2020
Accepted : 12 Sep 2020
Published : 14 Sep 2020
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X