Active and latent tuberculosis in patients with systemic lupus erythematosus living in the United States.

BACKGROUND: The prevalence and clinical course of tuberculosis infection have not been well described in patients with systemic lupus erythematosus (SLE) in the United States. OBJECTIVE: This study documents the demographic, clinical, and laboratory characteristics and outcomes of patients with SLE and latent tuberculosis infection (LTBI) or active TB in an ethnically diverse clinic. METHODS: We conducted a retrospective review of clinical records of patients with SLE followed during 2005 in a county community hospital rheumatology clinic, with a large immigrant population. Clinical characteristics were analyzed according to the patients' ethnicity, tuberculin skin test (TST) results, and history of treatment for latent or active TB. RESULTS: Data regarding a history of active TB or TST status were available for 187 of 220 patients seen in 2005 (85%). The prevalence of TB infection was highest in patients from TB endemic areas. Fourteen patients (7%) had active TB and 33 patients (18%) had LTBI. Among the 6 patients who developed active TB after the onset of SLE, 2 had pulmonary, 1 had extrapulmonary, and 3 had disseminated TB. Laboratory features and treatment regimens for SLE were similar in patients with a history of TB infection and in patients with a negative TST. CONCLUSIONS: A significant number of patients with SLE in a county clinic population in the United States had LTBI or TB. Treatment of active TB and latent TB yielded good outcomes with no deaths. US clinicians should consider screening SLE patients for LTBI, especially those from TB endemic areas.

Adverse interactions between herbal and dietary substances and prescription medications: a clinical survey.

CONTEXT: Patients often combine prescription medications with herbal and dietary substances (herein referred to as herbal medicines). A variety of potential adverse herb-drug interactions exist based on the pharmacological properties of herbal and prescription medications. OBJECTIVE: To determine the incidence of potential and observed adverse herb-drug interactions in patients using herbal medicines with prescription medications. DESIGN: Consecutive patients were questioned about their use of herbal medicines in 6 outpatient clinics. Patients reporting use of these products provided a list of their prescription medications, which were reviewed for any potential adverse herb-drug interactions using a comprehensive natural medicine database. Any potential adverse herb-drug interactions prompted a review of the patient's chart for evidence of an observed adverse herb-drug interaction. MAIN OUTCOME MEASURE: The rate of potential and observed adverse herb-drug interactions. RESULTS: Eight hundred four patients were surveyed, and 122 (15%) used herbal medicines. Eighty-five potential adverse herb-drug interactions were found in 49 patients (40% of herbal medicine users). Twelve possible adverse herb-drug interactions in 8 patients (7% of herbal medicine users) were observed. In all 12 cases, the severity scores were rated as mild, including 8 cases of hypoglycemia in diabetics taking nopal (prickly pear cactus). CONCLUSIONS: A substantial number of potential adverse herb-drug interactions were detected and a small number of adverse herb-drug interactions observed, particularly in diabetics taking nopal. Screening for herbal medicine usage in 804 patients did not uncover any serious adverse interactions with prescription medications.

Reversible posterior leukoencephalopathy in patients with systemic lupus erythematosus.

BACKGROUND: The development of central nervous system (CNS) symptoms in patients with preexisting systemic lupus erythematosus (SLE) evokes a wide differential diagnosis. Reversible posterior leukoencephalopathy (RPLE) is a rapidly evolving neurologic syndrome with characteristic clinical and radiographic features. Conditions commonly associated with RPLE include hypertensive encephalopathy, eclampsia, immunosuppressive drugs, and inflammatory disorders. OBJECTIVES: To describe our experience with RPLE in patients with concomitant SLE and review the literature. METHODS: The details of 5 novel cases and a MEDLINE review of the literature concerning the development of RPLE in association with SLE are presented. RESULTS: All cases included patients with SLE who developed the acute onset of headache, altered mental status, visual changes, and seizures. Neuroimaging demonstrated posterior white matter edema involving the parietal, temporal, and occipital lobes. Complete clinical and radiographic recovery occurred with prompt antihypertensive treatment and supportive care. Literature review identified 16 additional cases of RPLE occurring in patients with active SLE; the majority of these reports was similar in presentation and outcome to our experience. CONCLUSIONS: It is likely that the clinical manifestations and neuroimages in these lupus patients were the result of the RPLE syndrome. Fortunately, this cause of "secondary" CNS symptoms in patients with SLE is readily reversible when diagnosed early and treated with blood pressure control and supportive care.

Participatory patient-physician communication and morbidity in patients with systemic lupus erythematosus.

OBJECTIVE: To examine associations between active patient-physician communication and measures of morbidity in patients with systemic lupus erythematosus (SLE). METHODS: Audiotapes of routine visits between 79 women with SLE and their rheumatologists were coded for active patient participation and the degree of patient-centered communication of the physician, using a validated coding scheme. Measures of SLE activity, functional disability, and permanent organ damage were recorded at the same visit. Permanent organ damage was reassessed in 68 patients after a median of 4.7 years. RESULTS: Patients who participated more actively in their visits had less permanent organ damage, as measured by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, and tended to accrue less organ damage over time. There were no associations between either active patient participation or physicians' patient-centered communication scores and measures of SLE activity or functional disability. CONCLUSIONS: Patients with SLE who participated more actively in their visits had less permanent organ damage, suggesting that involving patients more in their care may decrease morbidity.

The use of disease modifying antirheumatic drugs in women with rheumatoid arthritis of childbearing age: a survey of practice patterns and pregnancy outcomes.

OBJECTIVE: To describe the practices of rheumatologists when prescribing the disease modifying antirheumatic drugs (DMARD) methotrexate (MTX), leflunomide (LF), etanercept (ET), and infliximab (IN) to women of childbearing age with rheumatoid arthritis (RA) and the pregnancy outcomes of patients who become pregnant while taking these medications. METHODS: A questionnaire was mailed to 600 members of the American College of Rheumatology inquiring about their perception of fetal risk, their recommendations regarding the use of birth control in women of childbearing age taking DMARD, and the pregnancy outcomes of women with DMARD exposure. RESULTS: One hundred seventy-five rheumatologists (29%) returned completed surveys. Respondents were more likely to agree that pregnancy is contraindicated in women taking MTX (95%) or LF (92.7%) than for women taking ET (38.6%) or IN (46.5%). Accordingly, most required birth control for women taking MTX (95.7%) and LF (97.3%), and fewer for women taking ET (75.4%) or IN (73.4%). A total of 65 pregnancies exposed to these DMARD were reported (MTX 38, LF 10, ET 14, IN 2, MTX and ET 1). Only 3 congenital malformations, all in the MTX group, were reported among the 52 pregnancies with known outcomes. CONCLUSION: Rheumatologists agree that there is a risk of teratogenicity with MTX and LF and usually require the use of reliable methods of birth control in women taking these medications. There is no consensus about ET and IN; however, physicians still tend to discuss reliable birth control methods with their female patients. We have confirmed there is a risk of congenital malformations with in utero exposure to MTX. No malformations were reported in infants exposed to LF, ET, or IN, but the number of reported pregnancy outcomes was small.