Ji Seon Oh

Evaluation of disease activity using F-18 FDG PET-CT in patients with Takayasu arteritis.

Purpose of the Report: To evaluate the usefulness of F-18 fluoro-fluorodeoxygulose positron emission tomography computed tomography (F-18 FDG PET-CT) in detecting clinically defined active disease in patients with Takayasu arteritis. Methods: F-18 FDG PET-CT was performed in 32 patients with Takayasu arteritis. Disease activity was assessed clinically by the National Institutes of Health (NIH) criteria. In 10 of the 32 patients, F-18 FDG PET-CT was performed while the patients were taking immunosuppressive drugs. Two nuclear physicians visually assessed the degree of F-18 FDG uptake in the walls of the aorta, its major branches and the pulmonary artery using a 4-point scale from grade 0 to III. F-18 FDG uptake greater than grade I in the thoracic aorta or greater than grade 0 in other areas were interpreted as active vasculitic lesions. Results: Ten patients had active lesions on F-18 FDG PET-CT. According to the NIH criteria, 9 patients had active disease and 23 had inactive disease. Compared with disease activity assessed by the NIH criteria, F-18 FDG PET-CT had a sensitivity of 78% and a specificity of 87%. The erythrocyte sedimentation rate and CRP levels were significantly higher in F-18 FDG PET-CT-positive than in F-18 FDG PET-CT-negative patients. There was no significant difference in the proportion of positive PET scans according to the use of glucocorticoids. Conclusions: The sensitivity of F-18 FDG PET-CT for detecting active disease was higher in patients with higher erythrocyte sedimentation rate values. Although the specificity of F-18 FDG PET-CT was high, owing to the low sensitivity of the NIH criteria in detecting active disease, further studies are needed.

Clinical features and outcomes of microscopic polyangiitis in Korea.

Microscopic polyangiitis (MPA) is a systemic vasculitis affecting small vessels. To determine the clinical features and outcomes of MPA in Korean patients, we retrospectively reviewed the medical records of patients diagnosed with MPA at a single medical center in Korea between 1989 and 2006. The 18 patients who met the Chapel Hill criteria for MPA had a mean (±SD) age at the time of diagnosis of 62.4±12.7 yr. Renal manifestations and general symptoms were the most common features of MPA, with lung involvement also very common. Antineutrophil cytoplasmic antibodies (ANCA) were present in 17 of the 18 patients (94%). Of 17 patients treated with steroids and cyclophosphamide, 11 (65%) had stable or improved course. One patient treated with steroids without cyclophosphamide showed disease progression. Ten of the 18 patients (56%) died at a median follow-up of 8 months. MPA in Korean patients was distinguished by a higher rate of lung involvement, especially alveolar hemorrhage, which was the leading cause of death in our patients. Korean patients were also older at MPA onset and were more likely positive for ANCA. Other overall clinical manifestations did not differ significantly.

The effect of various disease-modifying anti-rheumatic drugs on the suppressive function of CD4+CD25+ regulatory T cells

Accumulating evidence suggests that defects in the function of CD4+CD25+ regulatory T cells (Tregs) are important in immune-mediated diseases such as rheumatoid arthritis. Here, we investigated the effects of various disease-modifying anti-rheumatic drugs (DMARDs) on Treg function. Tregs and CD4+CD25− effector T cells (Teffs) were isolated from peripheral blood mononuclear cells obtained from healthy adults. Isolated Tregs were cultured with the DMARDs methotrexate (MTX), sulfasalazine (SSZ), leflunomide (LEF), or infliximab (INF). We found that each DMARD had a different effect on Treg function. SSZ and LEF inhibited the anti-proliferative function of Tregs on cocultured Teffs and reduced Treg expression of Foxp3 mRNA, whereas MTX and INF did not.

Febuxostat in Hyperuricemic Patients With Advanced CKD

Age, y 58.7 6 13.9 59.6 6 14.0 54.4 6 12.5 Male sex, n (%) 227 (77.2) 186 (75.9) 41 (83.7) Follow-up, mo 14.5 6 11.1 14.8 6 11.3 12.7 6 10.2 Kidney disease cause Diabetic nephropathy 74 (25.1) 66 (26.9) 8 (16) IgA nephropathy 50 (16.9) 42 (17.1) 8 (16) Primary glomerulonephritis 30 (10.2) 24 (9.8) 6 (12) Polycystic kidney 14 (4.7) 9 (3.7) 5 (10) Urate nephropathy 4 (1.4) 4 (1.6) 0 (0) Lupus nephritis 2 (0.7) 1 (0.4) 1 (2) Others 120 (41.0) 99 (40.5) 21 (43)

A case of polymyositis associated with Hashimoto's thyroiditis

To the Editor, Autoimmune diseases encompass a wide spectrum of disorders from organ specific to multisystemic involvement. Sometimes, autoimmune diseases coexist with each other and the overlap syndrome is defined by the development of clinical features of two or more autoimmune diseases simultaneously. There are a number of mechanisms implicated in the pathogenesis of these overlaps. Genetic factors, such as shared susceptible alleles, cross-reactivity of autoantibody, autoreactive T cell and cytokine imbalance have been suggested [1]. Hashimotos thyroiditis is an organ specific autoimmune disorder. Its association with systemic autoimmune diseases has been described, including systemic lupus erythematosus, Sjogren syndrome, systemic sclerosis, and rheumatoid arthritis [2]. However, the occurrence of Hashimotos thyroiditis and polymyositis is very rare and not well documented. We describe a 20-year-old woman with polymyositis who was diagnosed as Hashimotos thyroiditis concomitantly. A 20-year-old woman was admitted to the hospital complaining of fever and pain with weakness in arms and thighs. Three months ago, she felt pain in the both extremities and had difficulty in standing, walking on stairs and rising arms over the head. At admission, blood pressure was 100/60 mmHg, heart rate was 110 beats per minute, and temperature was 39℃. Thyroid gland was diffusely enlarged with a smooth surface and soft consistency. Musculoskeletal examination revealed tenderness in all four extremities. Muscle strength of the extremities was 3 to 4/5 in arms and 3/5 in legs. On neurological examination, sensation, and deep tendon reflexes were normal or intact. Laboratory findings were as follows: white blood cell 23,180/mm3, hemoglobin 9.1 g/dL, platelet 511,000/mm3, erythrocyte sedimentation rate 58 mm/hr, C-reactive protein 10.4 mg/dL, serum total protein 8.5 g/dL, albumin 4.4 g/dL, aspartate transaminase (AST) 55 IU/L, creatinine 0.82 mg/dL, lactate dehydrogenase 1,296 IU/L (normal range, 218 to 472), creatine phosphokinase (CPK) 386 IU/L (normal range, 30 to 334), and aldolase 7.6 U/mL (normal range, 2 to 8). Thyroid stimulating hormone was 2.39 µU/mL (normal range, 0.35 to 5.50), free T4 1.03 ng/dL (normal range, 0.89 to 1.80), antithyroglobulin 732 IU/mL (normal range, 0 to 40), antimicrosomal antibody 245 IU/mL (normal range, 0 to 25), and thyroid stimulating immunoglobulin was 5% (normal range, 0 to 15). Immunological examination revealed the following: antinuclear antibody positive at 1 : 40 in speckled pattern, rheumatoid factor, anti-SSA, anti-SSB, anti-dsDNA antibody, anti-Scl-70 antibody, antiribonuclear protein and anti-Jo-1 antibody were all negative. Ultrasonogram of the thyroid gland demonstrated diffuse enlargement of the thyroid gland and 1 cm sized hypovascular echogenic nodule on right upper pole. An electromyography (EMG) finding was occasional small fasciculations and polyphasic motor unit potentials of low amplitude and short duration, suggestive of myopathy. Histological examination of the resected thyroid right lobe revealed follicular cell proliferative lesions in background of parenchymal extensive mononuclear inflammatory cell infiltration and oxyphilic changes of follicular epithelium, consistent with nodular hyperplasia in Hashimotos thyroiditis (Fig. 1). Muscle biopsy specimen from the quadriceps showed necrotic and regenerating various sized muscle fiber and phagocytosis with endomyseal inflammatory cell infiltration and the perivascular infiltration of mononuclear cells, consistent with polymyositis (Fig. 2). She was diagnosed as having polymyositis and Hashimotos thyroiditis and was treated with prednisolone (50 mg/day) and methotrexate (10 mg/wk). Her symptoms remarkably improved after treatment. Fever and myalgia disappeared quickly and muscle strength improved gradually. Figure 1 Microscopic finding of thyroid gland showing extensive mononuclear inflammatory cell infiltration of the parenchyma and oxyphilic changes of follicular epithelium with follicular cell proliferative lesions (H&E, × 100). Figure 2 Muscle biopsy specimen reveals interstitial mononuclear cell infiltration. Both regenerating and degenerating muscle fibers are scattered (H&E, × 200). This case showed some difficulties of interpreting laboratory data. Although, the levels of certain muscle enzyme (AST and CPK) were not so high at initial evaluation. The diagnosis of polymyositis was made by clinical, histological, and EMG findings. The conceivable explanation of these laboratory ambiguities lies in the use of corticosteroid for several weeks before the test. Although the pathogenesis and the nature of the relationship between thyroid autoimmunity and autoimmune diseases is not completely established, some hypotheses may be implicated: 1) immune modulatory effects of antithyroid antibodies; 2) molecular mimicry between thyroid and disease specific epitopes; and 3) genetic link between antithyroid autoimmunity and the susceptibility to autoimmune disease [2]. Cross-reactivity of antithyroid antibodies or autoreactive T cells with other organs and cytokine imbalance may also implicated [2,3]. About 2% of inflammatory myopathy patients exerted thyroid autoimmunity. Suppressor T cell dysfunction and lymphocyte mediated cytotoxicity have been described in patient with polymyositis and there are some evidences of suppressor T cell dysfunction in autoimmune thyroiditis [2,4]. It could be hypothesized that coexisting autoimmune thyroiditis and inflammatory myopathy develop from the common autoimmune pathogenic mechanism. In conclusion, systemic and thyroid autoimmune diseases may overlap with each other. It is important to be aware that polymyositis and autoimmune thyroiditis can coexist and a thorough evaluation of both conditions may be necessary in patients presenting with myalgia or muscle weakness.

In-stent Restenosis after Drug-eluting Stent Implantation in Rheumatoid Arthritis: Possible Protective Effect of Methotrexate

Patients with rheumatoid arthritis (RA) are at higher risk of cardiovascular events compared with the general population. Therefore, these patients with RA have a greater chance of undergoing percutaneous coronary intervention (PCI).