Clinical Manifestations and Treatment of Vogt-Koyanagi-Harada Disease during Pregnancy and after Birth: A Case Report.

PURPOSE: To describe the clinical manifestations of Vogt-Koyanagi-Harada (VKH) disease during pregnancy and after birth and the therapeutic challenge of treating patients with this condition. METHODS: We describe the clinical manifestations of this disease, as well as the diagnostic tests and treatments performed. RESULTS: The patient was referred for evaluation due to a persistent headache. Examination revealed bilateral anterior uveitis, papillitis and yellowish-white choroidal lesions in both eyes. A tentative diagnosis of VKH disease was made. A multimodal imaging study was performed at the time of presentation and throughout the disease course. The patient was initially treated with intravenous corticosteroids, and subsequently, oral corticosteroids and cyclosporine were administered. Clinical manifestations increased in severity after childbirth. CONCLUSIONS: The clinical course of VKH disease can be modified by pregnancy. While clinical manifestations during gestation may be mild, these may be exacerbated after birth. Treatment with corticosteroids and cyclosporine can be effective.

Efficacy of Tocilizumab in Patients With Moderate-to-Severe Corticosteroid-Resistant Graves Orbitopathy: A Randomized Clinical Trial.

OBJECTIVE: To demonstrate the efficacy of the anti-interleukin-6 receptor monoclonal antibody tocilizumab in patients with moderate-to-severe corticosteroid-resistant Graves orbitopathy (GO). DESIGN: Double-masked randomized clinical trial. METHODS: Setting and Participants: Thirty-two adults with moderate-to-severe corticosteroid-resistant GO from 10 medical centers in Spain were randomized (1:1). INTERVENTION: Randomization to either 8 mg/kg body weight tocilizumab or placebo administered intravenously at weeks 0, 4, 8, and 12, and follow-up for an additional 28 weeks. Main Outcomes and Measures: The primary outcome was the proportion of patients with a change from baseline to week 16 of at least 2 in the clinical activity score (CAS). RESULTS: The primary outcome was met by 93.3% (95% confidence interval [CI] 70.1%-98.8%) of the patients receiving tocilizumab and 58.8% (36%-78.3%) receiving placebo (P = .04; odds ratio, 9.8 [CI 1.3-73.2]). A significant difference was also observed in the proportion of patients achieving a CAS < 3 (86.7% [CI 62.1%-96.2%] vs 35.2% [CI 17.3%-58.7%], P = .005; OR 11.9 [CI 2.1-63.1]) at week 16. Additionally, a larger proportion of patients with improvement in the European Group on GO-proposed composite ophthalmic score at week 16 (73.3% [CI 48%-89.1%] vs 29.4% [CI 13.2%-53.1%]; P = .03), and exophthalmos size change from baseline to week 16 (-1.5 [-2.0 to 0.5] mm vs 0.0 [-1.0 to 0.5] mm; P = .01) were seen with tocilizumab. One patient experienced a moderate increase in transaminases at week 8; another had an acute pyelonephritis at week 32 in the tocilizumab-treated group. CONCLUSION: Tocilizumab offers a meaningful improvement in activity and severity in corticosteroid-resistant GO. This trial justifies further studies to characterize the role of tocilizumab in GO.