scholarly journals Successful use of Tofacitinib in Reactive Arthritis Refractory to Conventional Therapies – A Case Series

Author(s):  
Debashis Maikap ◽  
Prasanta Padhan

Abstract Reactive arthritis is an immune mediated aseptic arthritis resulting from either genitourinary or gastrointestinal tract in a genetically susceptible host. It commonly presents as oligoarthritis of the lower limbs with or without extra articular features such as urethritis and non-purulent conjunctivitis. Therapies include NSAIDs, conventional DMARDs and rarely biologics in severe cases. We report successful use of tofacitinib in four cases of reactive arthritis who failed to respond to conventional therapies.

Author(s):  
Prasanta Padhan ◽  
Debashis Maikap

ABSTRACT Reactive arthritis (ReA) is an immune-mediated aseptic synovitis resulting either from genitourinary or gastrointestinal tract, commonly presenting as oligoarthritis of the lower limbs and rarely urethritis and conjunctivitis. The treatment options include nonsteroidal anti-inflammatory drugs, conventional disease-modifying antirheumatic drugs, and biologics in severe cases. We report successful use of secukinumab in two cases of chronic severe ReA who initially failed to treatment with tumour necrosis factor inhibitor.


2019 ◽  
Vol 3 (Supplement_1) ◽  
Author(s):  
Siwalik Banerjee ◽  
Shirish Dubey

Abstract Introduction Statins are a commonly used group of drugs which lowers low density lipoprotein (LDL) levels by competitively inhibiting 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase. Though they are effective and safe, about 0.1% patients on statins can develop severe myonecrosis or immune mediated necrotising myopathy (IMNM). Here we present a case of IMNM secondary to atorvastatin exposure, resulting in severe muscle weakness and prolonged hospitalisation, and positive treatment response to intravenous immunoglobulin (IVIG). Case description A 59-year-old Caucasian lady with a history of hypothyroidism and hyperlipidaemia, presented with 5 weeks’ history of progressive weakness in both upper and lower limbs which was preceded by flu like symptoms. She was also having swallowing difficulty and had neck-flexor weakness. There was MRC grade 2 power around hips, knees and shoulders, with normal power distally. She had been started on atorvastatin 10 mg 6 months ago, which was stopped due to myalgia. She was admitted to the hospital, and soon developed respiratory muscle weakness. She had serial SVC assessment and required nasogastric feeding. Electromyography suggested myositis. MRI of the thighs showed extensive myositis, muscle biopsy confirmed necrotising myopathy. Autoantibodies were negative, but she had high titre HMGcoA reductase antibodies (anti-HMGCR). Creatine kinase levels on presentation was 24230 U/L, which increased to 31000 U/L. Initial SVC was 33% of predicted. CT scan of chest abdomen and pelvis did not reveal any malignancy. Cardiac MRI did not reveal myocarditis, though her troponin-T levels were raised 1096 ng/L. She was non responsive to 3 pulses of 1 gm methyl-prednisolone. She was treated with IVIG, cyclophosphamide infusions and oral prednisolone. She made steady progress and was discharged with SVC of 70%, CK of 664 U/I, proximal muscle strength of 3/5 and feeding orally. She received 9 cycles of 900 mg cyclophosphamide followed by mycophenolate mofetil 2gm/day. However, her CK levels plateaued to between 650 and 700; proximal lower limb power was fluctuating between 4 and 3. She received another course of IVIG- 6 months after the onset of myositis which significantly improved her power, which sustained for around 4 months. The plan is to manage her with serial IVIG infusions. Discussion Statins can cause adverse muscle related events, ranging from mild myalgia to severe myopathy and rhabdomyolysis. Rarely, patients can develop immune mediated necrotising myositis, as in our patient. IMNM can cause persisting myositis with predominantly proximal muscle weakness, and runs a protracted course. Statin-induced IMNM is associated with presence of anti HMGCR antibodies. There are no clinical trials to guide therapeutic decisions in IMNM, however some case series and observational studies have shown improvement with immunosuppression. IVIG have been shown to be effective in anti HMGCR associated IMNM, as in our case. Even after stopping statins, IMNM can progress and patients can have prolonged weakness requiring immunosuppression. Around 50% patients continue to have significant weakness even after 2 years of treatment, indicating an unfavourable prognosis. Our patient continues to have waxing waning weakness with persistently raised CK, and IVIG infusions seems to give a rapid clinical response , though sustaining for 3 to 4 months, indicating a need for repeated infusions. The other treatment option remains rituximab, which has shown to have some efficacy in anti-SRP positive IMNM. Our patient had hypothyroidism, which is known to potentiate statin induced myopathy, however, strong association with IMNM is not established. Around 80% patients with anti HMGCR associated myositis have prior statin exposure, however, a subgroup of patients, especially among Asians, can have anti-HMGCR antibody and myositis even without statin exposure. This indicates a possible a genetic susceptibility to statins. Also, exposure to oyster mushroom and red yeast rice have been reported to be associated with anti-HMGCR antibodies in this subgroup of patients. Key learning points Statins can cause muscle related adverse events. 2-11% patients can have mild myalgia and myopathy, however necrotising myopathy is extremely rare (0.1%). Anti-HMCGCR antibodies are associated with statin induced IMNM. IMNM has a protracted course and can continue for years after stopping statins. Long term Immunosuppression is required in IMNM. IVIG is effective in refractory cases. Anti-HMCGCR antibodies can be found in statin naïve patients. Hypothyroidism can potentiate statin induced myopathy. The risk of muscle injury is higher when taking a statin which is extensively metabolised by cytochrome P450 3A4 (CYP3A4) - like simvastatin and atorvastatin, with CYP3A4 inhibitors. Pravastatin, rosuvastatin are preferred in these cases. Conflict of interest The authors declare no conflicts of interest.


2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1357.1-1357
Author(s):  
S. M. Lao ◽  
J. Patel

Background:Reactive arthritis is a form of spondyloarthritis with aseptic joint involvement occurring after a gastrointestinal or urogenital infection. Most commonly associated with Chlamydia trachomatis, Salmonella, Shigella, Campylobacter, and Yersinia. Syphilis is an infection caused by the spirochete Treponema pallidum and is not usually associated with reactive arthritis. Syphilis is a great imitator of other diseases due to its broad presentation including painless chancre, constitutional symptoms, adenopathy, rash, synovitis, neurological and ocular findings.Objectives:To discuss a patient who presented with symptoms of rheumatoid arthritis (RA) but was later diagnosed with syphilis.Methods:31 year old male, former tobacco smoker, referred to Rheumatology for sudden onset joint pains, elevated anti-cyclic citrullinated peptide (anti-CCP), and elevated inflammatory markers. He reported pain in bilateral wrists, fingers, and right elbow for 6 weeks. Associated with 45 minutes of morning stiffness and new onset lower back pain without stiffness. He denied trauma, fever, chills, skin rash, dysuria, or diarrhea. Initiated trial naproxen 500mg twice a day only to have minimal relief. Patient is sexually active with men and was recently diagnosed with oropharyngeal gonorrhea treated with azithromycin 4 months prior. All other STI screening including syphilis, gonorrhea, HIV were negative at that time. Patient is on emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis. He denied family history of immune mediated conditions. Exam was significant for mild synovitis of both wrists and bilateral 2nd metacarpophalangeal joints. Initial labs revealed weakly positive anti-CCP 21 (normal <20), sedimentation rate 64 (normal ESR 0-15 mm/hr), C-reactive protein 24 (normal CRP 0-10 mg/L), and negative RF, ANA, HLA B27. During a short trial of prednisone taper, there was temporary improvement in symptoms, however synovitis recurred upon completion. Hydroxychloroquine (HCQ) 200mg twice a day was started for possible RA and he was referred to Ophthalmology for baseline retinopathy screening. Incidentally, he developed right sided blurry vision 2 weeks after initiation of HCQ. He was diagnosed with panuveitis of the right eye with inflammation of the optic nerve head and prednisone 40mg daily was initiated for presumed ocular manifestation of RA. However, further workup of panuveitis revealed reactive Treponema pallidum antibody and RPR quantity 1:32. Prednisone was immediately discontinued and he was referred to the emergency department for possible neurosyphilis.Results:Lumbar puncture showed cerebral spinal fluid with 260 red blood cells, 1 white blood cell, 27mg/dL protein, 60mg/dL glucose, non reactive VDRL, reactive pallidum IgG antibody, and negative cultures. Meningitis and encephalitis panels were negative. Patient completed a 14 day course of IV penicillin G with complete remission of joint pain, visual symptoms, and normalization of anti-CCP, ESR, and CRP.Conclusion:This case highlights how syphilis may mimic signs and symptoms of RA including symmetrical small joint pain, morning stiffness, elevated inflammatory markers, and positive anti-CCP. Anti-CCP is >96% specific for RA but was a false positive in this patient. There have only been few reported cases noting positive anti-CCP with reactive arthritis. This is a rare case of reactive arthritis secondary to syphilis with resolution of symptoms upon treating the syphilis.References:[1]Carter JD. Treating reactive arthritis: insights for the clinician. Ther Adv Musculoskelet Dis. 2010 Feb;2(1):45-54.[2]Cohen SE, Klausner JD, Engelman J, Philip S. Syphilis in the modern era: an update for physicians. Infect Dis Clin North Am. 2013 Dec;27(4):705-22.[3]Singh Sangha M, Wright ML, Ciurtin C. Strongly positive anti-CCP antibodies in patients with sacroiliitis or reactive arthritis post-E. coli infection: A mini case-series based review. Int J Rheum Dis. 2018 Jan;21(1):315-321.Disclosure of Interests:None declared.


2021 ◽  
Vol 10 (15) ◽  
pp. 3439
Author(s):  
Irene Motta ◽  
Juri Giannotta ◽  
Marta Ferraresi ◽  
Kordelia Barbullushi ◽  
Nicoletta Revelli ◽  
...  

Congenital anemias may be complicated by immune-mediated hemolytic crisis. Alloantibodies are usually seen in chronically transfused patients, and autoantibodies have also been described, although they are rarely associated with overt autoimmune hemolytic anemia (AIHA), a serious and potentially life-threatening complication. Given the lack of data on the AIHA diagnosis and management in congenital anemias, we retrospectively evaluated all clinically relevant AIHA cases occurring at a referral center for AIHA, hemoglobinopathies, and chronic hemolytic anemias, focusing on clinical management and outcome. In our cohort, AIHA had a prevalence of 1% (14/1410 patients). The majority were warm AIHA. Possible triggers were recent transfusion, infection, pregnancy, and surgery. All the patients received steroid therapy as the first line, and about 25% required further treatment, including rituximab, azathioprine, intravenous immunoglobulins, and cyclophosphamide. Transfusion support was required in 57% of the patients with non-transfusion-dependent anemia, and recombinant human erythropoietin was safely administered in one third of the patients. AIHA in congenital anemias may be challenging both from a diagnostic and a therapeutic point of view. A proper evaluation of hemolytic markers, bone marrow compensation, and assessment of the direct antiglobulin test is mandatory.


2020 ◽  
Vol 12 (04) ◽  
pp. 281-284
Author(s):  
Sawsan A. Mohammed ◽  
Azza A. Abdelsatir ◽  
Mohamed Abdellatif ◽  
Suliman Hussein Suliman ◽  
Omer Mohammed Ibrahim Elbasheer ◽  
...  

AbstractsBasidiobolomycosis is a fungal infection caused by Basidiobolus ranarum which affects the skin and subcutaneous tissue and rarely the gastrointestinal tract. We report seven cases of gastrointestinal basidiobolomycosis with interesting clinical, radiological, and histological presentations. To our knowledge, this is the first case series of abdominal basidiobolomycosis to be reported from Sudan.


2004 ◽  
Vol 17 (2) ◽  
pp. 348-369 ◽  
Author(s):  
Inés Colmegna ◽  
Raquel Cuchacovich ◽  
Luis R. Espinoza

SUMMARY Current evidence supports the concept that reactive arthritis (ReA) is an immune-mediated synovitis resulting from slow bacterial infections and showing intra-articular persistence of viable, nonculturable bacteria and/or immunogenetic bacterial antigens synthesized by metabolically active bacteria residing in the joint and/or elsewhere in the body. The mechanisms that lead to the development of ReA are complex and basically involve an interaction between an arthritogenic agent and a predisposed host. The way in which a host accommodates to invasive facultative intracellular bacteria is the key to the development of ReA. The details of the molecular pathways that explain the articular and extra-articular manifestations of the disease are still under investigation. Several studies have been done to gain a better understanding of the pathogenesis of ReA; these constitute the basis for a more rational therapeutic approach to this disease.


2021 ◽  
Vol 160 (6) ◽  
pp. S-17
Author(s):  
Arielle Elkrief ◽  
Jonathan U. Peled ◽  
Matthew D. Hellmann ◽  
Jamie E. Chaft ◽  
Juliana Eng ◽  
...  

2009 ◽  
Vol 67 (3b) ◽  
pp. 812-817 ◽  
Author(s):  
Leandro Alberto Calazans Nogueira ◽  
Felipe Resende Nóbrega ◽  
Kátia Nogueira Lopes ◽  
Luiz Claudio Santos Thuler ◽  
Regina Maria Papais Alvarenga

The purpose of this study was to determine the effect of functional limitations and fatigue on the quality of life (QoL) in people with multiple sclerosis (MS). A descriptive case series study at Lagoa Hospital - Rio de Janeiro, Brazil was carried. The main outcome measurements were demographic variables, QoL (SF-36 v.1), disability (EDSS), motor function of the upper limb (Box & Blocks test), Tone (Modified Ashworth Scale), gait (Hauser ambulatory index) and fatigue (Fatigue Severity Scale). Sixty one patients fulfilled the study criteria. The mean age of patients was 39 years and 74% of patients were female. The most of cases presented mild disability (EDSS<3.5). A decrease was found in all domains of QoL. It was found association between physical functioning and the variables of EDSS, fatigue, lower limb tone and gait. Gait, disability, hypertonia of the lower limbs and fatigue negatively affected QoL in people with MS.


2020 ◽  
Vol 383 (1) ◽  
pp. 85-88 ◽  
Author(s):  
Rebecca Haberman ◽  
Jordan Axelrad ◽  
Alan Chen ◽  
Rochelle Castillo ◽  
Di Yan ◽  
...  

2020 ◽  
Vol 14 (1) ◽  
pp. 1-13 ◽  
Author(s):  
Cassandra E.L. Fairhead ◽  
Alexander Hampson ◽  
Louis Dwyer-Hemmings ◽  
Nikhil Vasdev

Background: It is estimated that between 50 and 89% of non-gonococcal urethritis is not caused by Chlamydia trachomatis. Associations between non-chlamydial non-gonococcal urethritis (NCNGU) with balanoposthitis, epididymo-orchitis and reactive arthritis have been suggested, but evidence to support these often-theoretical relationships is sparse and further investigation is called for. Concerns over increasing antimicrobial resistance has rendered the need for clarity over this question ever more pressing in recent years. A review of the current evidence on the complications of NCNGU in men is therefore urgently warranted. Objective: This systematic review summarizes and evaluates the available evidence that NCNGU, whether symptomatic or asymptomatic, causes the significant complications that are already well-recognized to be associated with non-gonococcal urethritis. These significant complications are epididymo-orchitis, balanoposthitis, and sexually-acquired reactive arthritis (Reiter's syndrome) including arthritis or conjunctivitis. Summary: We conducted a systematic review and qualitative synthesis using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis framework. Five databases (PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and British Nursing Index) were searched. We included studies that measured clinical outcome after diagnosis of NCNGU in men. Bias was assessed using variations of the Newcastle-Ottawa scale. Data were extracted and entered into a pre-written data abstraction proforma. Seven peer-review studies were included. This included 2 retrospective cohort studies, 1 case series, 2 case reports and 2 cross-sectional studies. The studies described and analyzed 3 types of complication: balanitis, posthitis and/or meatitis; reactive arthritis and/or conjunctivitis; and epididymitis. All studies reported one or more complications. Key Messages: This review identifies an important avenue for future research: while the available evidence suggests that NCNGU has the potential to cause significant complications in men, with the strongest evidence existing for balanitis, posthitis and/or meatitis, the nature and significance of these relationships is far from clear. The findings of this review suggest that prospective, adequately powered research into whether there is a causal link between NCNGU and significant clinical complications in men would be highly worthwhile. The findings of this review raise important questions about the utility of the term NCNGU in research and clinical practice.


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