Soluble IL-2 receptor: a biomarker for assessing myositis activity.

OBJECTIVE: To evaluate the clinical significance of serum soluble IL-2R (sIL-2R) in inflammatory myopathies. METHODS: Serum sIL-2R and CK levels were determined in 27 patients with IM during periods of disease exacerbation and inactive disease and were compared to 20 healthy controls and 23 controls with noninflammatory elevated CK. The performance of sIL-2R and CK tests for assessing disease activity was compared. RESULTS: sIL-2R levels were increased in patients with IM. Significantly higher sIL-2R levels were detected in patients with disease exacerbation than in patients with inactive disease. In patients with IM, the sIL-2R levels correlated with the CK levels. Based on ROC analysis, diagnostic accuracy of sIL-2R and CK tests for disease activity was similar. However, when the CK threshold was defined by the upper limit of the normal, the specificity for the CK test dropped to 58%. CONCLUSION: Serum sIL-2R level could be useful to distinguish disease exacerbation from damage in IM, especially in patients with persistent elevated CK levels when a clinical muscular worsening is noted. For discrimination of the disease activity, CK testing requires the use of a different threshold than the upper limit of the normal.

New onset of uveitis during anti-tumor necrosis factor treatment for rheumatic diseases.

UNLABELLED: Uveitis may be associated with various inflammatory diseases. Previous reports suggested that tumor necrosis factor (TNF) blockers, especially anti-TNF monoclonal antibodies, may reduce the incidence of uveitis flares in some inflammatory diseases. Under these circumstances, de novo occurrence, ie, new onset of the first episode of uveitis under anti-TNF therapy, is uncommon. OBJECTIVES: The aim of this study was to collect cases of new onset of uveitis under anti-TNF therapy, using a nationwide network, to describe these cases, and to gather with cases reported in the literature. METHODS: All French rheumatologists, pediatric rheumatologists, and internal medicine practitioners registered on the Club Rhumatismes et Inflammation web site were contacted in an attempt to declare the cases of new onset of uveitis, diagnosed by an ophthalmologist, in patients treated with TNF blockers. The analysis of the literature was performed through PubMed database and manual research. RESULTS: Thirty-one cases were recorded, 19 men, mean age 43 (5-70) years, occurring in ankylosing spondylitis (19 cases), psoriatic arthritis (4 cases), rheumatoid arthritis (6 cases), juvenile idiopathic arthritis (2 cases). The TNF blocker at the time of uveitis was etanercept 23 times, adalimumab 3 times, infliximab 5 times, with a mean total duration of exposure to anti-TNF agents of 27 (4-96) months at uveitis occurrence. Most of the patients were good responders to TNF blockers at the time of uveitis onset. Analysis of the literature revealed 121 similar cases published in English. CONCLUSION: Uveitis occurs de novo under anti-TNF therapy mainly in spondyloarthropathies, but also in rheumatoid arthritis and juvenile idiopathic arthritis patients and more frequently under etanercept.

[Patient education for osteoarthritis]. / Éducation thérapeutique et arthrose.

Therapeutic education is part of the nonpharmacological management of osteoarthritis (OA) both at the medical and surgical phase. The aim of education at an early stage of OA is to change patients' lifestyle, especially the regular practice of physical activity and weight reduction. When a surgical option is considered, the aim of education is to hasten patient recovery, improve autonomy after surgery, facilitate the return home and reduce the rate of transfer to a rehabilitation unit. Like other nonpharmacological treatment, therapeutic education implementation seems insufficient for OA management. One way to improve therapeutic education in the management of OA could be to propose dedicated continuing medical education programs supported by specific economic sources for health care professionals.

Elderly-onset rheumatoid arthritis.

The treatment of elderly-onset rheumatoid arthritis pursues the same objectives as in younger patients: to control the clinical manifestations, to prevent structural damage, to preserve function, and to decrease excess mortality. In the elderly, the presence of co-morbidities and increased rate of drug-related adverse effects raise specific therapeutic challenges. Nonsteroidal anti-inflammatory drugs are associated with cardiovascular, gastrointestinal, and renal adverse events. The role for corticosteroid therapy remains controversial. Although glucocorticoids provide a short-term decrease in clinical activity and probably a medium-term decrease in structural damage, these benefits are offset by numerous adverse effects. Methotrexate was effective in clinical trials and observational studies and did not produce a higher adverse event rate compared to younger patients, provided renal function was normal. Data on the efficacy of TNFalpha antagonists in therapeutic trials are available only for etanercept. Disease activity decreased and function improved. The adverse event rate was higher in older patients, but this was also true of the conventional drugs used as comparators. Registry data confirm that TNFalpha antagonist therapy is effective in RA. An increased rate of infections was found only in some registries. To combat the 2-fold cardiovascular risk increase associated with RA, disease activity should be stringently controlled and all cardiovascular risk factors managed aggressively.

Effects of 14 weeks of TNF alpha blockade treatment on lipid profile in ankylosing spondylitis.

OBJECTIVE: Cardiovascular morbidity and mortality seem to be increased in ankylosing spondylitis, perhaps as the result of biological inflammation and consecutive dyslipidemia. This study aims to investigate the impact of TNF alpha-inhibitors, an effective treatment, on lipid profile. METHODS: Thirty-four ankylosing spondylitis (AS) patients with active disease undergoing anti-TNF alpha therapy (n=20, infliximab; n=7, etanercept; n=7, adalimumab) were recruited. Disease activity parameters, total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were assessed at baseline and after 14 weeks of treatment. RESULTS: After 14 weeks of TNF alpha blockade treatment, there was a significant increase in levels of total cholesterol (5.08+/-1.20 vs. 4.73+/-1.12 mmol/l; p=0.01) and HDL-cholesterol (1.61+/-0.47 vs. 1.47+/-0.35 mmol/l; p=0.008), but no resulting change in the atherogenic index (3.43+/-1.13 vs. 3.35+/-0.93; p=0.87). There was also no change in concentrations of triglycerides (1.33+/-1.22 vs. 1.27+/-0.98 mmol/l; p=0.794) and LDL-cholesterol (3.15+/-0.99 vs. 2.91+/-0.93 mmol/l; p=0.24). TNF alpha inhibitor treatment was followed by a significant improvement in all disease activity parameters: VAS pain or VAS disease activity, BASDAI or BASFI and systemic inflammation. Sub-group analysis showed that monoclonal antibodies increased total and LDL-cholesterol levels but did not change the atherogenic index. Conversely, 14 weeks of etanercept treatment was followed by no change in lipid profile. CONCLUSION: TNF alpha inhibitors may be successful in reducing cardiovascular risk in AS, as in RA, but not by affecting lipid profile. However, there is insufficient documented evidence, and long-term investigations are needed to define the possible protective mechanisms of TNFalpha inhibitor treatment in spondylarthropathies.

Oligo-arthritis and type IV hyperlipoproteinemia.

The increased risk of cardiovascular mortality in patients with inflammatory joint disease indicates a need for routine investigations to detect conventional cardiovascular risk factors. These investigations may provide the classification of the disease. We report a case of oligoarticular arthritis with type IV hyperlipoproteinemia, a condition of which only 15 cases are described in the literature. The patient had oligoarthritis, laboratory signs of severe inflammation, and type IV hyperlipoproteinemia (triglycerides, 24.6 mmol/L; and total cholesterol, 10.7 mmol/L). The clinical and laboratory test abnormalities resolved under fenofibrate therapy.

Polymyositis and pemphigus vulgaris in a patient: successful treatment with rituximab.

Rituximab has been documented to be an effective treatment for autoimmune diseases with contribution of B cells. We report a case of antisynthetase syndrome with a history of EBV-induced lymphoma which developed a pemphigus vulgaris. Rituximab was effective both on polymyositis and on pemphigus. Fifteen months later, the patient died from a septic shock after the first cyclophosphamide infusion for amyloidosis while the B cell population remained depleted. Rituximab may be a good alternative to immunosuppressive drugs in polymyositis and pemphigus especially in lymphoma-risk patients. However, it did not prevent progression to secondary amyloidosis and the fatal infection developed in this patient raises the question of whether a prolonged B cell depletion with rituximab contributes to a greater risk of infection.

Exacerbation of interstitial lung disease during etanercept therapy: Two cases.

We report two cases of interstitial lung disease possibly related to TNF alpha antagonist therapy (etanercept) in patients with rheumatoid arthritis. In both cases, pre-existing interstitial lung disease worsened during etanercept therapy. We found 19 previously published cases of interstitial lung disease in patients who were taking TNF alpha antagonists and had no evidence of infection, raising the possibility of a causal link with the medication. The potential pathophysiological mechanisms remain unknown. Caution is in order when using TNF alpha antagonists in patients with pre-existing lung disease. The development or exacerbation of interstitial lung disease in a patient on TNF alpha antagonist therapy should lead to investigations for a cause. Should these investigations prove negative, the treatment must be discontinued.

Effects of anti-tumor necrosis factor therapy on lipid profile in patients with rheumatoid arthritis.

OBJECTIVES: Analyse the effects of anti-tumor necrosis factor therapy on serum levels of lipid in patients with rheumatoid arthritis (RA). METHODS: Twenty-nine patients (26 females, 3 males) with established RA undergoing anti-TNF therapy (n=12, adalimumab; n=11, infliximab; n=6, etanercept) were recruited. Total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides (TG), and apolipoproteins (apo b and apo a) were assessed at baseline and after 14 weeks of treatment. RESULTS: The disease activity index score (DAS(28)) was 5.19+/-0.90 and decreased to 3.46+/-0.97 at 16 weeks (p<0.001). There was no change neither in the levels of TC (5.65+/-0.98mmol/l vs 5.78+/-1.06mmol/l; p=0.43), TG (1.40+/-0.79mmol/l vs 1.45+/-0.67mmol/l; p=0.59), HDL-C (1.92+/-0.49mmol/l vs 1.97+/-0.49mmol/l; p=0.36), apo a1 (1.92+/-0.28g/l vs 1.99+/-0.29g/l; p=0.06), and LDL-C (3.41+/-0.91mmol/l vs 3.47+/-0.96mmol/l; p=0.66), nor in apo b (1.126+/-0.302g/l vs 1.13+/-0.28g/l; p=0.89), atherogenic index (3.13+/-1.05 vs 3.09+/-0.89; p=0.69) or the apo b/apo a1 ratio (0.58+/-0.25 vs 0.56+/-0.22; p=0.33). CONCLUSION: The favourable effect of anti-tumor necrosis factor therapy on cardiovascular morbidity is not related to effects on lipid metabolism.

Cat scratch disease during etanercept therapy.

Lymphadenopathy in a patient taking TNFalpha antagonist therapy may indicate lymph node tuberculosis or a hematological malignancy. Although histological evidence of granuloma suggests tuberculosis, many other infections responsible for granulomatous reactions have been reported in patients on TNFalpha antagonist therapy. We report a case of granulomatous lymphadenopathy due to Bartonella henselae in a patient taking etanercept to treat ankylosing spondylitis.

Septic arthritis in patients aged 80 and older: a comparison with younger adults.

OBJECTIVES: To compare the frequency and characteristics of septic arthritis in patients younger than 80 and aged 80 and older. DESIGN: Retrospective. SETTING: Single hospital center. PARTICIPANTS: Patients admitted between 1979 and 2002 for septic arthritis. MEASUREMENTS: Age, sex, time to diagnosis, predisposing factors, joint, temperature, white blood cell count, microorganism, and short-term outcome. RESULTS: Of 335 patients, 206 (61.4%) were aged 60 and older, and 42 (12.5%) were 80 and older. The latter had an average age of 84 (range 80-97) and were mainly women (72%). Eighteen of the 42 had at least one risk factor. The mean time to diagnosis was 21 days (range 1 day to 3 months). Twenty patients (47%) had knee involvement, six (14%) shoulder involvement, ten (23.8%) a prosthetic infection, and five (12%) polyarticular infection. Ten (23%) were afebrile. In half of the cases, there was no increase in white blood cell count. The microorganisms isolated were Staphylococcus aureus (n=16, 38%), coagulase negative staphylococci (n=8, 19%), streptococci (n=12, 28%), and gram-negative bacilli (n=6, 14%). The mortality rate increased with age: 0.7% of patients younger than 60, 4.8% of those aged 60 to 79, and 9.5% of those aged 80 and older. CONCLUSION: Advanced age is a risk factor for septic arthritis and poor outcome.

Osteoporosis treatment in postmenopausal women after peripheral fractures: impact of information to general practitioners.

UNLABELLED: A low-impact fracture in a postmenopausal woman should prompt investigations for osteoporosis followed, if needed, by appropriate treatment. OBJECTIVES: To evaluate the impact of information alerting general practitioners to the need for osteoporosis treatment in postmenopausal women with a recent history of peripheral fracture. METHODS: We conducted a prospective 7-month follow-up study of 78 postmenopausal women, with a mean age of 81.5 years, admitted to the emergency department for peripheral fractures. Three months after the fracture, we sent a letter to the general practitioner of each patient emphasizing the probable contribution of osteoporosis to the fracture and the need for osteoporosis treatment. Six months after the fracture, we interviewed the patients by telephone, and one month later we mailed a questionnaire to those physicians who had not followed the treatment recommendation. RESULTS: At emergency room admission, 9 patients were receiving treatment for osteoporosis (hormone replacement therapy in one patient and calcium and vitamin D supplementation in eight patients). Admission to a ward was required in 66 (85%) patients. No treatment for osteoporosis was given at discharge. Six months after discharge, seven patients reported recent initiation of calcium and vitamin D supplementation, and none reported other osteoporosis treatments. The response rate to the physician questionnaire mailed 7 months after discharge was 54% (n=28); responses showed treatment of 11 additional patients, by calcium and vitamin D supplementation in six cases and by bisphosphonates with or without calcium and vitamin D supplementation in five cases. Treatment initiation rates were similar in patients younger and older than 80 years. CONCLUSIONS: Despite information of general practitioners about the need for osteoporosis treatment, such treatment was initiated in only 30.5% of patients. General practitioners may be reluctant to initiate osteoporosis treatment in patients who are very old or have multiple comorbidities.

Streptococcal septic arthritis in adults. A study of 55 cases with a literature review.

OBJECTIVES: To evaluate the rate of occurrence and characteristics of streptococcal septic arthritis. METHODS: Retrospective single-center study of patients with bacteriologically documented septic arthritis admitted to a rheumatology department over a 20-year period. RESULTS: Of 303 cases of septic arthritis, 55 (18%) were due to streptococci and 166 (55%) to Staphylococcus aureus (55%). As compared to patients with S. aureus arthritis, patients with streptococcal arthritis was more likely to be in female (56% vs. 36%, P < 0.006) and older than 60 years of age (71% vs. 58%), less likely to have comorbidities (36% vs. 56%), rheumatoid arthritis (5% vs. 19%, P < 0.01), or diabetes (2% vs. 15%, P < 0.01), and more likely to have cancer (13% vs. 7%). Involved joints and proportions of patients with arthritis in multiple joints were similar in two groups. Mortality was lower in the group with streptococcal infection (3.6% vs. 7.8%). The streptococci were distributed as follows: group A (n = 7), group B (n = 12), group C (n = 4), group D (n = 7), group F (n = 1), group G (n = 2), nongroupable (n = 14), nontypable (n = 1), and Streptococcus pneumoniae (n = 7). Groups A and B and nongroupable strains mainly affected women; group A selectively involved younger patients and group B very elderly patients. Comorbidity, most notably cancer, was common in patients with S. pneumoniae or group D streptococci. The portal of entry was often a skin lesion for groups A and B and a medical procedure for group D. Multiple joint involvement was common with groups A and B and prosthetic joint infection with groups B and C. Group A and S. pneumoniae were associated with severe systemic symptoms and extra articular foci of infection, whereas a smoldering course was more common with groups D and G and with nongroupable strains. Residual joint abnormalities were noted in half the patients, with no differences across groups. CONCLUSIONS: The features of streptococcal septic arthritis vary according to the group of the causative organism and differ from those of S. aureus arthritis.

Insufficiency fracture. A survey of 60 cases and review of the literature.

UNLABELLED: We report findings on the site, risk factors and imaging of insufficiency fractures (IF) in 60 patients admitted to our department between 1989 and 1997. RESULTS: Fifty-five women (mean age 72.5 years) and five men (mean age 59 years) had 91 fractures, accounting for 0.32% of admissions. Fractures occurred most commonly in the pelvic girdle (30.7%, 28/91) and in the sacrum (29.6%, 27/91). In eight patients fractures of the sacrum were associated with fractures of the pelvic girdle. The next most common sites of occurrence were the tibia (16.5%, 15/91: 11 transverse, four longitudinal) and the femoral neck (9.9%, 9/91). There were three subchondral fractures of the femoral head, three fractures of the femoral diaphysis (two longitudinal, one transversal), two of the astragalus, and one each of the ilium, perone, calcaneum and sternum. Thirty patients had osteoporosis: six had received fluoride treatment and five had corticosteroids. Other risk factors were rheumatoid arthritis (4), osteomalacia (4), corticosteroid treatment (4), and hyperparathyroidism (1). Radiography showed a fracture line or osteocondensation in 65% (39/60) of cases. Scintigraphy was positive in 87.5% of cases (21/24), showing a fracture line (15) or a callus (6). Bone computed tomography (CT) scan was positive in 98.1% (54/55) of cases. IF occurs in elderly women with osteoporosis and most commonly in the pelvis. CONCLUSIONS: Since radiologic signs are inconstant, scintigraphy is the choice procedure.

Late-onset spondyloarthropathy mimicking reflex sympathetic dystrophy syndrome.

Atypical presentations are common when spondyloarthropathy develops in older patients. We report two cases initially mistaken for reflex sympathetic dystrophy syndrome (RSDS). Both the patients were men, aged 62 and 75 years, respectively, with marked painful edema of a foot. One patient reported a moderate-energy trauma as the triggering event. Severe diffuse demineralization was noted on radiographs and diffuse hyperactivity on bone scans starting at the early vascular phase. These findings suggestive of RSDS led to treatment with calcitonin, griseofulvin, and pamidronate, all of which were ineffective. Laboratory tests showed severe inflammation, promoting investigations for other conditions. Spondyloarthropathy was diagnosed based on oligoarthritis with sacroiliitis, presence of HLA B27, and a favorable response to non-steroidal antiinflammatory therapy. In older patients, edema of the foot with severe demineralization and the laboratory evidence of inflammation should suggest a spondyloarthropathy.