Relationships between eosinophilia, anti-Fasciola IgG, and IgM rheumatoid factors, in urban and rural areas of north-western Spain.

A study was carried out, among adult patients attending a hospital in Lugo, in north-western Spain, to investigate possible relationships between eosinophilia, IgG antibodies against the parasitic helminth Fasciola hepatica, and IgM rheumatoid factors (IgM-RF). Blood samples were collected from 1264 individuals and divided into three groups according to eosinophil count: normal (<0.5 x 10(9) eosinophils/litre), eosinophilic (0.5 x 10(9)-3 x 10(9)/litre) or hyper-eosinophilic (>3 x 10(9)/litre). Each sample was checked for IgG against F. hepatica, in an ELISA in which the excretory/secretory products of the trematode were used as the antigens, and for IgM-RF, in a latex agglutination test. Overall, 21% of the cases were found seropositive for fascioliasis and 15% were found to have IgM-RF. Women from rural areas not only showed the highest seroprevalence of fascioliasis but also the highest frequency of IgM-RF carriage. Men from rural areas were more likely to be eosinophilic than the other patients. Curiously, the patients found seronegative for fascioliasis were more likely (but not significantly more likely) to be eosinophilic than their seropositive counterparts, and the eosinophilic patients were significantly more likely (P=0.001) to be carrying IgM-RF auto-antibodies than the non-eosinophilic. It appears that, in the study area, those living in rural regions have a higher risk of F. hepatica infection (as indicated by IgG antibodies against the parasite) than those living in urban settings. The risk of developing eosinophilia appears to be positively associated with the presence of IgM-RF auto-antibodies.

Influence of anti-TNF-alpha infliximab therapy on adhesion molecules associated with atherogenesis in patients with rheumatoid arthritis.

OBJECTIVE: Chronic systemic inflammation plays a pivotal role in the development of atherosclerosis in rheumatoid arthritis (RA). Soluble (s) adhesion molecules were found significantly increased in RA patients with active disease. Since increased levels of some adhesion molecules were closely linked to the development of endothelial dysfunction and atherosclerosis and administration of anti-TNF-alpha-infliximab resulted in a rapid and dramatic improvement of endothelial function in long-term infliximab treated RA patients, we assessed whether infusion of the chimeric anti-TNF-alpha infliximab might also yield a rapid and favorable effect on serum levels of soluble adhesion molecules in RA patients periodically treated with this drug because of severe disease. METHODS: We recruited patients with RA refractory to conventional therapy seen over a period of 2 months at Hospital Xeral-Calde, Lugo, Spain, who were on periodical treatment with infliximab for at least 14 weeks. Blood samples for determination of sICAM-1, sICAM-3, sVCAM-1, sE-selectin, and sP-selectin levels by ELISA were taken immediately before and after infliximab infusion. RESULTS: Thirty-four RA patients (25 women; mean age: 55.4 years; mean DAS28: 4.27) fulfilled the inclusion criteria. Following infliximab infusion a reduction of the overall mean values of the five adhesion molecules was observed. However, when a Wilcoxon signed-rank test was used, only significant differences for sICAM-3 and sP-selectin were observed. In this regard, sICAM-3 and sP-selectin levels fell in 26 (77%) and 28 (82%) of the 34 patients. CONCLUSION: Our study confirms a rapid and beneficial effect of infliximab infusion on expression of some adhesion molecules in RA patients treated periodically with this anti-TNF-alpha monoclonal antibody because of severe disease.

Short-term adalimumab therapy improves endo-thelial function in patients with rheumatoid arthritis refractory to infliximab.

OBJECTIVE: Endothelial dysfunction has been found in patients with rheumatoid arthritis (RA). In this study we aimed to assess whether adalimumab, a fully human monoclonal antibody directed against TNF-alpha, was able to improve endothelial function in RA patients with long-standing disease refractory to infliximab. METHODS: Eight RA patients (7 women; range: 24- 74 years) were studied. They had been treated with the chimeric monoclonal anti-TNF-alpha antibody-infliximab for at least 1 year and were switched to adalimumab therapy because of loss of efficacy following periodical treatment with infliximab. Endothelial dependent (EDV) and independent vasodilatation (EIV) were measured by brachial ultrasonography. Patients were assessed prior to (day 0) and at day 2, and weeks 2 and 12 after the onset of adalimumab therapy. RESULTS: Following adalimumab administration a rapid increase in the percentage (%) of EDV was found in all patients (mean +/- SD: 10.1 +/- 5.1% at day 2 compared to 5.8 +/- 4.1% at day 0). At weeks 2 and 12 the %EDV was also significantly increased compared to day 0. All patients showed decrease in the disease activity score 28 and C-reactive protein levels (P = 0.012). Moreover, at week 12 the atherogenic index was reduced in all patients (P = 0.012). CONCLUSION: Our study confirms that short-term adalimumab therapy yields an active and positive effect on endothelial function in long-standing RA patients with severe disease. This observation emphasizes the potential role of the TNF-alpha blockade in the mechanisms implicated in the development of atherogenesis in RA.

Anti-tumor necrosis factor-alpha blockade improves insulin resistance in patients with rheumatoid arthritis.

OBJECTIVE: Systemic inflammation, insulin resistance, and endothelial dysfunction have been implicated in the development of cardiovascular disease in rheumatoid arthritis (RA). Since insulin resistance can promote endothelial dysfunction and anti-TNF-alpha blockade yield a rapid improvement of endothelial function, we have sought to assess whether TNF-alpha blockade may also result in a reduction of insulin serum levels and improvement of insulin resistance in RA patients who require this therapy because of severe and refractory disease. METHODS: We recruited patients with RA seen over a period of 1 month at Hospital Xeral-Calde, Lugo, Spain, that were on treatment with anti-TNF-alpha monoclonal antibody-infliximab. Patients with diabetes mellitus or plasma glucose > 110 mg/dl were excluded. Fasting blood samples were taken for determination of plasma glucose and serum insulin levels immediately prior to and after infliximab infusion. RESULTS: Twenty-seven RA patients (21 women; mean age: 57.1 years; mean DAS28: 4.43) fulfilled the inclusion criteria. Dramatic reduction in the serum insulin levels and insulin/glucose index was observed following infliximab infusion. Also, a significant improvement of insulin resistance and insulin sensitivity was found. CONCLUSION: Our study confirms a rapid beneficial effect of infliximab on insulin resistance and insulin sensitivity in RA patients treated periodically with this drug. It may support the long-term use of drugs that act blocking TNF-alpha function to reduce the mechanisms implicated in the development of atherosclerosis in patients with RA.

Successful therapy with danazol in refractory autoimmune thrombocytopenia associated with rheumatic diseases.

The objective was to assess the efficacy of therapy with danazol in refractory immune thrombocytopenia associated with different rheumatic diseases. Patients with severe immune thrombocytopenia (platelet counts < 40 x 10(9)/l) with a bone marrow biopsy showing megakaryocytes in normal or increased number and normal morphology were included if they fulfilled at least one of the following criteria: (a) thrombocytopenia refractory to prednisone (> or = 1 mg/kg/day during > or = 4 weeks); (b) patients requiring an unacceptably high dose of prednisone for > 2 months (prednisone dose > or = 20 mg/day); (c) no response to at least another drug besides corticosteroids. Other causes of thrombocytopenia were excluded. They were treated with danazol (100-200 mg q.i.d.) and followed for at least 12 months. Four patients diagnosed with systemic lupus erythematosus, two with rheumatoid arthritis and one with primary antiphospholipid syndrome met the inclusion criteria. All of them achieved acceptable platelet counts within the first 4 weeks of danazol therapy that allowed the prednisone dosage to be tapered. No important side-effects related to danazol therapy were observed. Danazol therapy seems to be a useful and well-tolerated treatment for refractory immune thrombocytopenia associated with different rheumatic diseases.

Giant cell arteritis in Lugo, Spain: a more frequent disease with fewer classic features.

OBJECTIVE: Progressive increases in the incidence rate of giant cell arteritis (GCA) have been observed in different geographic areas. The incidence of GCA in Lugo, Northwestern Spain, was previously considered low. Our aim was to analyze trends in incidence and clinical features of GCA in Lugo. METHODS: Retrospective study of biopsy proven GCA diagnosed from January 1, 1986 through December 31, 1995. The average annual incidence rate of GCA for population age > or = 50 years was analyzed at 5 year intervals from 1986 to 1995, inclusive. A comparative study of clinical features and laboratory findings of GCA in patients diagnosed 1991-1995 with those diagnosed 1986-1990 was performed. RESULTS: Forty-one and 52 Lugo residents were diagnosed with GCA in the 1986-1990 and 1991-1995 time periods, respectively. For each period the average annual incidence rate for population age > or = 50 years was 8.26 and 10.49/10(5), respectively. A lower frequency of classic features of GCA such as constitutional symptoms (67.3 vs 95.1%) and polymyalgia rheumatica (30.8 vs 51.2%) was observed in patients diagnosed 1991-1995. Other typical findings were less common than in the 1986-1990 period, namely, headache (82.7 vs 87.8%), abnormal examination of temporal artery (61.5 vs 70.7%), jaw claudication (36.5 vs 43.9%), and amaurosis fugax (9.6 vs 14.6%). There was a longer delay to diagnosis 1991-1995 than 1986-1990 (12.7 +/- 12.1 wks vs 8.9 +/- 6.2). Also, at the time of diagnosis, anemia, thrombocytosis, and elevated alkaline phosphatase were less frequently observed in the period 1991-1995. CONCLUSION: In recent years, we observed a progressive increase in the incidence of GCA in our area. Such an increase correlates with lower frequency of classic manifestations of GCA.

Giant cell arteritis in Lugo, Spain, is associated with low longterm mortality.

OBJECTIVE: To assess the longterm survival of patients with giant cell arteritis (GCA) in a well defined area in Northwestern Spain. METHODS: A followup study of consecutive biopsy proven patients with GCA diagnosed in Lugo, Spain January 1, 1982-March 31, 1996 was performed. Patients were followed from time of diagnosis until either their death or October 1, 1996. Time and cause of death were reviewed. Statistical methods included standardized mortality ratio (SMR), and Kaplan-Meier product-limit survival analysis. Cox proportional hazard models were used to identify clinical features and laboratory findings associated with survival. RESULTS: By October 1, 1996, full information about 109 biopsy proven patients with GCA (59 men/50 women) was available. The mean age +/- SD at the time of diagnosis was 73.9 +/- 7.3 years for women and 74.1 +/- 5.8 for men (p = NS). After a median followup of 54 months, 22 patients (20.2%) had died. Three died within the first month after diagnosis due to either vascular complications related to GCA or therapy complications. Apart from a history of severe underlying diseases (comorbid condition unrelated to GCA), neither sex nor any clinical features of GCA were significantly associated with an increase in mortality. As in the general population of the same age in Lugo, the majority of deaths were due to cardiovascular and cerebrovascular complications. SMR was 0.80 (95% CI 0.47-1.13). One, 2, 5, and 10 year survival rates were 95, 91, 81, and 62%, respectively. Hazard function was 1.8% at Day 30 after diagnosis and remained low until the end of the first year of treatment. Thereafter, mortality increased slightly. As this function was constant, we applied an exponential model. The estimated risk of death with this model was 5.3% per year. CONCLUSION: Longterm mortality of GCA in our area is low. However, it may be possible to further lower the mortality rate through early diagnosis and careful followup.

[Poststreptococcal reactive arthritis: a benign complication of a common infection]. / Artritis reactiva postestreptocócica: una complicación benigna de una infección común.

Poststreptococcal reactive arthritis (PSRe A) is a sterile synovitis associated to the evidence of previous streptococcal infection. PSRe A has different clinical features from those observed in rheumatic fever. Regarding systemic complications, PSRe has in general a good prognosis. A new case is described and the literature is reviewed in this article.

Pyomyositis and septic arthritis from Fusobacterium nucleatum in a nonimmunocompromised adult.

We describe a case of pyomyositis of the quadriceps associated with septic arthritis of the knee that developed after Fusobacterium nucleatum septicemia in a healthy man. The primary foci was presumed to be the oral cavity. Pyomyositis from Fusobacterium nucleatum is uncommon, and to our knowledge its association with septic arthritis has not been described.