Ana Cristina Vanderley Oliveira

Vacinação contra febre amarela em pacientes com diagnósticos de doenças reumáticas, em uso de imunossupressores

Yellow fever is endemic in some countries. The anti-yellow fever vaccine is the only effective means of protection but is contraindicated for immunocompromised patients. The aim of this paper was to report on a case series of rheumatological patients who were using immunosuppressors and were vaccinated against this disease. This was a retrospective study by means of a questionnaire applied to these patients, who were vaccinated 60 days before the investigation. Seventy patients of mean age 46 years were evaluated. Most of them were female (90%). There were cases of rheumatoid arthritis (54), systemic lupus erythematosus (11), spondyloarthropathy (5) and systemic sclerosis (2). The therapeutic schemes included methotrexate (42), corticosteroids (22), sulfasalazine (26), leflunomide (18), cyclophosphamide (3) and immunobiological agents (9). Sixteen patients (22.5%) reported some minor adverse effect. Among the eight patients using immunobiological agents, only one presented a mild adverse effect. Among these patients using immunosuppressors, adverse reactions were no more frequent than among immunocompetent individuals. This is the first study on this topic.

Yellow fever revaccination during infliximab therapy

Yellow fever vaccinations in patients receiving immunosuppressive therapy have been shown to be contraindicated due to the increased risk of viscerotropic disease in nonimmunocompetent patients (1). Biologic therapy such as anti–tumor necrosis factor (anti-TNF) has the capacity to block antibody development postvaccination, which is of concern to clinicians (2). Yellow fever vaccination is important in controlling this disease. Immunization of the native population and travelers is advisable in countries where this disease is endemic. Yellow fever vaccination uses a live attenuated virus (17-D strain) that induces low-grade viremia in 50% of the vaccinated people and elicits neutralizing antibody levels in 99% of all the vaccinated individuals (3,4). Recently an outbreak of yellow fever occurred in Brazil and, following a massive advertising campaign by the health authorities in the media, several patients receiving anti-TNF therapy were vaccinated without previously consulting their doctors. In Brazil, yellow fever vaccination is recommended every 10 years for those living in endemic areas. In view of this outbreak, there was a group of patients who had exceeded the 10-year revaccination period, and they demanded yellow fever vaccination in spite of receiving anti-TNF therapy. In this study we describe the clinical observations and laboratory findings of 17 rheumatoid arthritis patients receiving infliximab therapy while receiving the yellow fever vaccination and of paired controls.

Frequency of sexual dysfunction in women with rheumatic diseases.

OBJECTIVE To assess the prevalence of sexual dysfunction in women followed up at the Rheumatology Outpatient Clinic of the Hospital Universitário de Brasília and of the Hospital das Clínicas da Universidade de São Paulo with the following rheumatic diseases: systemic lupus erythematosus; rheumatoid arthritis; systemic sclerosis; antiphospholipid antibody syndrome; and fibromyalgia. METHODS The Female Sexual Function Index (FSfi), obtained by applying a 19-item questionnaire that assesses six domains (sexual desire, arousal, vaginal lubrication, orgasm, sexual satisfaction and pain), was used. RESULTS This study assessed 163 patients. The mean age was 40.4 years. The prevalence of sexual dysfunction was 18.4%, but 24.2% of the patients reported no sexual activity over the past 4 weeks. Patients with fibromyalgia and systemic sclerosis had the highest sexual dysfunction index (33%). Excluding patients with no sexual activity, the sexual dysfunction rate reaches 24.2%. CONCLUSION The prevalence of sexual dysfunction found in this study was lower than that reported in the literature. However, 24.2% of the patients interviewed reported no sexual activity over the past 4 weeks, which might have contributed to the low sexual dysfunction index found.

Psychiatric presentation of Hashimoto's encephalopathy.

Introduction: Hashimotos encephalopathy is an unusual condition that is associated with Hashimotos thyroiditis. Myoclonus, epileptic seizures, dementia, and disturbances of consciousness are the most common features. Case report: We present an atypical case of Hashimotos encephalopathy in a 33-year-old woman who presented with several brief and acute psychotic episodes. After treatment with steroids, there was an improvement in the patients psychiatric symptoms and electroencephalogram, and antithyroglobulin antibody titers returned to normal levels. Conclusions: It is our opinion that Hashimotos encephalopathy should be considered in the differential diagnosis of atypical psychosis, especially because this is a treatable syndrome. This is particularly important in patients with a previous history of thyroid disease, despite current normal thyroid function. CT = computed tomography; EEG = electroencephalogram.

Seroconversion in patients with rheumatic diseases treated with immunomodulators or immunosuppressants, who were inadvertently revaccinated against yellow fever.

Revaccination against yellow fever is contraindicated in patients receiving immunomodulators or immunosuppressants, and a mass campaign to vaccinate the population against yellow fever resulted in the inadvertent revaccination of patients with rheumatic diseases who attended the Hospital of the University of Brasilia (HUB) or a private rheumatology clinic in Brasilia, Brasil between December 2007 and May 2008. Vaccination is strongly recommended to all people living in Brasilia; thus, for the purposes of this study, we assumed that nearly 100% of the population was vaccinated. In 2007 and 2008, we collected relevant data (pertaining to rheumatic disease diagnoses, use of immunosuppressants, date of revaccination, and adverse events) within 30 days of the revaccination. Two years later, we evaluated the protective immune response in this group by analysis of neutralizing antibodies. Our study group comprised 31 patients (all women) (Table 1). A single serum analysis was conducted using a plaque reduction neutralization test. Patients with values of 794 mIU/ml were considered seropositive for protection against yellow fever. Twenty patients (64.5%) were recruited from HUB and 11 (35.5%) from the private clinic. The diagnoses among our patients were as follows: rheumatoid arthritis (RA) (n 23), systemic lupus erythematosus (SLE) (n 5), systemic sclerosis (SSc) (n 2), and ankylosing spondylitis (AS) (n 1). Seropositivity was observed in 27 individuals (87.1%). Among the 31 patients, the mean titer of neutralizing antibodies was 2,865.58 mIU/ml. (A large study by Camacho and colleagues [1] demonstrated that the geometric mean titer in revaccinated healthy individuals was equal to 14,000 mIU/ml.) Mean, geometric mean, and median titers of neutralizing antibodies were 2,535.4, 1,543.5, and 2,015.0 mIU/ ml, respectively, in the patients with RA (interquartile range [IQR] 923–3,353) and 1,934, 2,066.9, and 1,668 mIU/mL, respectively, in those with SLE (IQR 1,208.5–2,792.5). Among the RA patients, 16 were taking methotrexate (mean SD dosage 13.28 5.73 mg/week), 9 were taking leflunomide (20 mg/day), 3 were taking infliximab (3 mg/kg every 8 weeks), and 3 patients were taking rituximab (1,000 mg twice every 15 days). Four patients reported mild adverse events up to 30 days after vaccination, 24 reported no reactions, and 3 did not recall the occurrence of any adverse reaction. One patient with AS (who was taking 3.2 gm of mesalamine per day) and another patient with RA (who was taking 10 mg of prednisone per day) developed myalgia. One patient with SSc (who was receiving 1.2 gm of cyclophosphamide per month) had fever and rhinorrhea, and another patient with RA (who was taking 20 mg of methotrexate per week and 1.5 gm of sulfasalazine per day) had arthralgia. The mean SD titers of neutralizing antibodies in the patients who presented with adverse reactions and in the asymptomatic patients were 5,461 6,817 mIU/ml and 2,610.46 2,033.04 mIU/ml, respectively. No correlation was observed between the neutralizing antibodies and occurrence of adverse reactions ( 0.19) or age ( 0.246) at the time of revaccination in a sample of 28 of 31 patients. It is noteworthy that the patient with the lowest antibody titer was treated with 2 gm of rituximab 4 months before being revaccinated against yellow fever. The data presented herein are the only data currently available regarding protective immunity following yellow fever revaccination in patients with rheumatic disease. Our assessment was performed using the method that is considered to be the reference test. Although the titers of neutralizing antibodies were lower among the rheumatic disease patients than among healthy individuals, they were high enough to confer a protective response despite the use of immunosuppressive drugs. These results are compatible with the data already existing in the literature regarding revaccination in the general population (2,3). Dr. Oliveira’s work was supported by a scholarship from the National Council for Scientific and Technological Development. Dr. Mota has received speaking fees from Roche, Janssen, AbbVie, Bristol-Myers Squibb, and AstraZeneca Pharmaceuticals.

Frequência de disfunção sexual em mulheres com doenças reumáticas

OBJECTIVE: To assess the prevalence of sexual dysfunction in women followed up at the Rheumatology Outpatient Clinic of the Hospital Universitario de Brasilia and of the Hospital das Clinicas da Universidade de Sao Paulo with the following rheumatic diseases: systemic lupus erythematosus; rheumatoid arthritis; systemic sclerosis; antiphospholipid antibody syndrome; and fibromyalgia. METHODS: The Female Sexual Function Index (FSfi), obtained by applying a 19-item questionnaire that assesses six domains (sexual desire, arousal, vaginal lubrication, orgasm, sexual satisfaction and pain), was used. RESULTS: This study assessed 163 patients. The mean age was 40.4 years. The prevalence of sexual dysfunction was 18.4%, but 24.2% of the patients reported no sexual activity over the past 4 weeks. Patients with fibromyalgia and systemic sclerosis had the highest sexual dysfunction index (33%). Excluding patients with no sexual activity, the sexual dysfunction rate reaches 24.2%. CONCLUSION: The prevalence of sexual dysfunction found in this study was lower than that reported in the literature. However, 24.2% of the patients interviewed reported no sexual activity over the past 4 weeks, which might have contributed to the low sexual dysfunction index found.

What a rheumatologist needs to know about yellow fever vaccine

Patients with rheumatic diseases are more susceptible to infection, due to the underlying disease itself or to its treatment. The rheumatologist should prevent infections in those patients, vaccination being one preventive measure to be adopted. Yellow fever is one of such infectious diseases that can be avoided.The yellow fever vaccine is safe and effective for the general population, but, being an attenuated live virus vaccine, it should be avoided whenever possible in rheumatic patients on immunosuppressive drugs. Considering that yellow fever is endemic in a large area of Brazil, and that vaccination against that disease is indicated for those living in such area or travelling there, rheumatologists need to know that disease, as well as the indications for the yellow fever vaccine and contraindications to it. Our paper was aimed at highlighting the major aspects rheumatologists need to know about the yellow fever vaccine to decide about its indication or contraindication in specific situations.

Occurrence of Autoimmune Diseases Related to the Vaccine against Yellow Fever

Yellow fever is an infectious disease, endemic in South America and Africa. This is a potentially serious illness, with lethality between 5 and 40% of cases. The most effective preventive vaccine is constituted by the attenuated virus strain 17D, developed in 1937. It is considered safe and effective, conferring protection in more than 90% in 10 years. Adverse effects are known as mild reactions (allergies, transaminases transient elevation, fever, headache) and severe (visceral and neurotropic disease related to vaccine). However, little is known about its potential to induce autoimmune responses. This systematic review aims to identify the occurrence of autoinflammatory diseases related to 17D vaccine administration. Six studies were identified describing 13 possible cases. The diseases were Guillain-Barré syndrome, multiple sclerosis, multiple points evanescent syndrome, acute disseminated encephalomyelitis, autoimmune hepatitis, and Kawasaki disease. The data suggest that 17D vaccination may play a role in the mechanism of loss of self-tolerance.

O que o reumatologista deve saber sobre a vacina contra febre amarela

Patients with rheumatic diseases are more susceptible to infection, due to the underlying disease itself or to its treatment. The rheumatologist should prevent infections in those patients, vaccination being one preventive measure to be adopted. Yellow fever is one of such infectious diseases that can be avoided.The yellow fever vaccine is safe and effective for the general population, but, being an attenuated live virus vaccine, it should be avoided whenever possible in rheumatic patients on immunosuppressive drugs. Considering that yellow fever is endemic in a large area of Brazil, and that vaccination against that disease is indicated for those living in such area or travelling there, rheumatologists need to know that disease, as well as the indications for the yellow fever vaccine and contraindications to it. Our paper was aimed at highlighting the major aspects rheumatologists need to know about the yellow fever vaccine to decide about its indication or contraindication in specific situations.

Meta-iodobenzylguanidine iodine-123 and cardiac adrenergic activity in familial dilated cardiomyopathy.

Familial dilated cardiomyopathy (FDCM) is characterized by genetic heterogeneity, incomplete age-dependent penetrance, and a multifactorial pathogenesis ([1][1]). Diagnosis is still dependent on clinical criteria and familial investigation ([2][2]). On the other hand, several abnormalities have been