Screening for latent TB in patients with rheumatic disorders prior to biologic agents in a 'high-risk' TB population: comparison of two interferon gamma release assays.

Patients with rheumatic disorders treated with TNF inhibitors are at increased risk of developing TB. There is no 'gold-standard' for the diagnosis of latent TB prior to initiation of biologic agents. We report our own experience of comparing two interferon gamma release assays (IGRAs) in screening for latent TB in a 'high-risk' TB area in patients with rheumatic disorders. The study demonstrated good concordance between the two tests. We believe the additional cost of these assays is justified in high-risk populations prior to biologic agents, with 16% of the current study population with at least one positive IGRA assay.

Biologics for treating axial spondyloarthritis.

INTRODUCTION: Spondyloarthritis (SpA) encompasses a heterogeneous group of diseases sharing genetic, immunological, clinical and imaging features. Axial spondyloarthritis (axSpA) refers to a subgroup characterised predominately by inflammation of the axial skeleton with subsequent symptoms of chronic (often inflammatory) back pain and sacroiliitis. There is a strong association with the major histocompatibility complex (MHC) class I allele human leukocyte antigen (HLA) B27. In the last decade, there has been significant progress in earlier detection of the disease and the molecular mechanisms involved in its pathogenesis. The subsequent introduction of anti-tumour necrosis factor (TNF) has revolutionised the treatment of patients with axSpA. AREAS COVERED: In this article, we review the current biologic therapies for axSpA, the emergence of biosimilars, predictors of response, primary and secondary failure and new biologics on the horizon. EXPERT OPINION: There have been significant advances in the treatment of axSpA. Beyond the clear efficacy of anti-TNF inhibition, IL-17 offers an alternative therapeutic target and there is promise from inhibition of the IL-17/IL-23 pathway and small molecules, such as Janus kinase (JAK) inhibitors. Biosimilars have offered greater affordability and choice within this increasingly growing field of therapeutics.

New therapeutic avenues in SLE.

Although the use of corticosteroids and immunosuppressive agents such as cyclophosphamide and mycophenolate has led to reduced mortality in systemic lupus erythematosus (SLE), there is a need for development of new biologic agents to improve outcomes further. The pathogenesis of SLE involves many components of the immune system, notably B cells, T cells, cytokines and innate immunity, which are potential targets for the new biologic therapies. In this study, the rationale for the development of new therapies in SLE and the progress that has been made in each direction of therapy are described. Most progress has been made with agents directed against B cells, especially rituximab and belimumab and the latter has been the subject of two successful randomised clinical trials (RCTs). Anti-T-cell and anti-cytokine therapies are further back in the development process, but promising advances can be anticipated over the next decade.

Sarcoidosis presenting as massive splenic infarction.

Sarcoidosis is a multisystem granulomatous disease of unknown aetiology. Granulomatous inflammation involving the spleen is common and associated with splenomegaly. However, massive splenomegaly is a rare occurrence. Infrequently massive splenomegaly can result in splenic infarction. Massive splenic infarction in sarcoidosis has, to our knowledge, not been previously reported. We present a case of a woman presenting with massive splenic infarction and sarcoidosis confirmed by granulomatous inflammation of the liver.