Virginia Ruiz-Esquide

Lung sarcoidosis induced by TNF antagonists in rheumatoid arthritis: a case presentation and a literature review.

Abstract We report the case of a 72 year-old woman with established rheumatoid arthritis diagnosed with pulmonary granulomatosis compatible with sarcoidosis after 49 months of treatment with etanercept. The symptoms and radiology remitted after the suspension of treatment against tumor necrosis factor (TNF) and with a course of steroids. To date, 27 cases of histologically-proven pulmonary sarcoidosis have been reported in relation to anti-TNF therapy, with etanercept being more frequent in comparison with the anti-TNF monoclonal antibodies infliximab and adalimumab. Probable pathogenic mechanisms of the paradoxical effect of anti-TNF treatment are discussed. It is important for clinicians to be aware of this potential and uncommon complication of biological therapy with TNF antagonists.

Anti-citrullinated peptide antibodies in the serum of heavy smokers without rheumatoid arthritis. A differential effect of chronic obstructive pulmonary disease?

The objective of this study is to analyse the frequency and levels of anti-citrullinated peptide/protein antibodies (ACPA) in the serum of non-rheumatoid arthritis (RA) heavy smokers with and without chronic obstructive pulmonary disease (COPD) and compare them with healthy never smokers and patients with RA. Serum samples of 110 heavy smokers without RA, 209 healthy never smokers and 134 patients with RA were tested for ACPA using a commercial anti-cyclic citrullinated peptide antibodies (CCP2) test and a homemade chimeric fibrin/filaggrin citrullinated synthetic peptide (anti-CFFCP) ELISA test. The frequency of positive results and autoantibody levels were compared between groups. The prevalence of the two types of ACPA was slightly higher in heavy smokers than in never smokers, although the difference was not significant, and significantly lower than in RA patients. The highest prevalence of positive ACPA in heavy smokers was found in subjects with COPD (7.4% of positive anti-CFFCP in patients with COPD in comparison with 2.4% in never smokers: OR 3.26; 95% CI 0.85–12.6, p = 0.089). Mean serum levels of ACPA in heavy smokers were not significantly different from those of never smokers. Heavy smokers with COPD had significantly higher levels of anti-CFFCP than those without COPD, although almost all patients had serum levels below the cut-off values. The prevalence of ACPA in heavy smokers without RA is low, but seems to be higher in heavy smokers with COPD. Larger studies are necessary to confirm these findings and determine the relationship between ACPA and lung disease.

Effects of smoking on disease activity and radiographic progression in early rheumatoid arthritis.

Objective. To analyze the effects of cigarette smoking on disease activity and radiographic damage in patients with early rheumatoid arthritis (RA). Methods. Study subjects were 156 patients with early RA (< 2 yrs). Disease activity, therapeutic response, and radiographic progression were compared in smokers and nonsmokers at 24 months. Results. At baseline, ever-smokers had earlier disease onset and a closer association with the shared epitope (SE), but not more seropositive disease. No significant differences were observed in disease activity and European League Against Rheumatism therapeutic responses between smokers and nonsmokers. Multivariate analysis showed that baseline Larsen score, the HLA-DRB*04 genotype, being female, and current smoking were associated with radiographic progression. Conclusion. In patients with early RA, smoking was associated with earlier disease onset and the SE. Smoking was an independent factor of radiographic progression.

Sarcoidosis pulmonar inducida por antagonistas del factor de necrosis tumoral en la artritis reumatoide: presentación de un caso y revisión de la literatura médica

We report on a 72 year-old woman with long-standing rheumatoid arthritis diagnosed as granulomatosis due to pulmonary sarcoidosis after 49 months of treatment with etanercept. A clinical and radiological improvement was seen after tumor necrosis factor (TNF) antagonist withdrawal plus a course of steroids. Currently, 27 cases of histological proven sarcoidosis with pulmonary involvement have been reported in relation to anti-TNF therapy, with etanercept being more frequent in comparison with the anti-TNF monoclonal antibodies infliximab and adalimumab. Potential pathogenic mechanisms of the paradoxical effect of anti-TNF treatment is discussed. It is important for clinicians to be aware of this potential and uncommon complication of biological therapy with TNF antagonists.

Rheumatoid Arthritis: A Clinical Overview of New Diagnostic and Treatment Approaches

Rheumatoid arthritis (RA) is the most frequent form of chronic polyarthritis, affecting 0.5-1% of adults worldwide. In recent years there have been important advances in the pathogenesis of RA, together with new diagnostic and therapeutic insights. Early diagnosis is essential in order to prevent joint damage and improve the prognosis and quality of life of patients with RA. New classification diagnostic criteria have been proposed to achieve this objective. New therapeutic strategies have proved to be effective, including early and better use of synthetic disease-modifying anti-rheumatic drugs (DMARDS), mainly methotrexate, and a treat-to-target strategy focusing on achieving remission and with tight control of the disease. In the last decade, the introduction of various biological agents in the therapeutic armamentarium of RA has changed the disease prognosis, although no definite cure is currently possible. In this chapter, we present an overview of recent advances in the epidemiology, diagnosis, prognosis and treatment of this severe but treatable disease.

Tabaco y otros factores ambientales en la artritis reumatoide

Many environmental factors have been associated with an increased risk of developing Rheumatoid Arthritis (RA), but so far smoking is the only environmental risk factor that has been extensively studied and widely accepted. Smoking is associated with an increased risk of developing seropositive RA (RF and/or ACPA). Recent studies show that tobacco smoking can influence disease phenotype, with the development of more aggressive disease and greater joint damage; but other studies show contradictory results. Recent data suggests that response to antirheumatic therapy in RA is worse in smokers. In this article we review different environmental factors that have been associated with an increased risk of developing RA, with a special interest in tobacco smoking.

Reducción de dosis de terapias biológicas en enfermedades reumáticas: análisis descriptivo de 153 pacientes en condiciones de práctica clínica

OBJECTIVE To analyze the frequency and characteristics of dose reduction of biological agents in a cohort of patients with chronic arthritis, in clinical practice conditions in a tertiary level hospital. MATERIAL AND METHODS Descriptive, cross-sectional study, which included all patients, followed consecutively during 6 months (June 2011-November 2011), by one investigator, with patients who at least have received one dose of biological agents in 2011. RESULTS We included 153 patients: Rheumatoid arthritis (RA) (n=82), ankylosing spondylitis (n=29), psoriatic arthritis (n=20), and miscellaneous group (n=22). Mean disease duration was 14.9±7.7 years. At the time of analysis, 70 patients (45.7%) were receiving low doses of biological therapy (50% in miscellaneous group group, 50% in psoriatic arthritis, 48.2% in ankylosing spondylitis, and 42.6% in RA). Mean time of dosage reduction was 17.4±17.5 months. The most common biological agents used in low dose were: etanercept, adalimumab and tocilizumab; 57.6%, 54.9% and 40% respectively, in patients with a reduced dose of biological therapy. The patients at low dose of biological therapy compared with standard dose, had similar mean disease duration, but received significantly less DMARDs, glucocorticoids and NSAIDs, and similar biological agent duration. RA patients with reduced biological treatment, at the time of analysis, had higher remission rates versus patients receiving a standard dose (82.9% vs 34%, p<0.0001). The medical decision at the time of analysis was to maintain low-dosage biological treatment in almost all patients. CONCLUSION In our clinical practice, 45.7% of our chronic arthritis patients receive low dose of biological therapy, after achieving remission or low activity at standard doses, maintaining a good control of the disease.

Serum Calprotectin Versus Acute-Phase Reactants in the Discrimination of Inflammatory Disease Activity in Rheumatoid Arthritis Patients Receiving Tumor Necrosis Factor Inhibitors

To compare the accuracy of serum calprotectin and acute‐phase reactants (C‐reactive protein [CRP] and erythrocyte sedimentation rate [ESR]) in stratifying disease activity in rheumatoid arthritis (RA) patients receiving tumor necrosis factor inhibitors (TNFi), and to correlate calprotectin levels with TNFi trough serum levels.

Immunopathologic characterization of ultrasound-defined synovitis in rheumatoid arthritis patients in clinical remission

BackgroundPatients with rheumatoid arthritis (RA) in clinical remission may have ultrasound-defined synovitis according to the presence of power Doppler (PD) signal. The objective was to describe the immunopathologic characteristics of ultrasound-defined synovitis compared with synovitis in patients with clinically active RA.MethodsWe included between 6 and 8 ultrasound-guided synovial biopsies per patient from 20 patients with RA in clinical remission (DAS28-ESR <2.6) with PD signal, 22 synovial tissue samples (ST) from patients with clinically active RA (swollen joint with confirmed inflammatory synovial fluid) as inflammatory controls, and 10 ST from non-inflammatory controls. Immunostaining for CD3 (T lymphocytes), CD20 (B lymphocytes), CD68 (macrophages), CD117 (mast cells), hsp47 (fibroblasts), bFGF and CXCL12 (angiogenic factors) was made and quantified by digital image analysis. The number of CD31 vessels/mm2 was quantified.ResultsRA patients in remission with PD signal had significantly reduced synovial T-cell, B-cell, mast cell and fibroblast density, but similar macrophage infiltration compared with patients with clinically active RA. Vascularity, bFGF and CXCL12 were partially reduced in RA patients in remission with PD signal compared to those with active RA, but were significantly higher compared with ST from non-inflammatory controls. During the 12-month follow up, 8/20 RA patients (40 %) lost remission: all had synovial hypertrophy grade ≥2 and significantly more synovial B cells and mast cells than patients maintaining remission.ConclusionsAsymptomatic ultrasound-defined synovitis and clinically active arthritis differ in the degree of infiltrating lymphoid, mast cells and fibroblast density, but are similar with respect to macrophage infiltration. Persistently increased angiogenic factor expression and vascularity may explain the persistence of a PD signal.

Serum Calprotectin More Accurately Discriminates the Inflammatory Disease Activity of Rheumatoid Arthritis Patients Receiving TNF inhibitors than Acute Phase Reactants

To compare the accuracy of serum calprotectin and acute‐phase reactants (C‐reactive protein [CRP] and erythrocyte sedimentation rate [ESR]) in stratifying disease activity in rheumatoid arthritis (RA) patients receiving tumor necrosis factor inhibitors (TNFi), and to correlate calprotectin levels with TNFi trough serum levels.