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Daniela Opris
Sf. Maria Hospital, Carol Davila University of Medicine and Pharmacy, Research Centre on the Pathology and Treatment of the Systemic Rheumatic Diseases Bucharest, Romania
: malaise, fingers oedema -global swollen fingers and arthralgias, Raynauds Phenomenon: diagnosed with RA (treatment Tauredon)
-d SS was diagnosed
positive skin biopsy Hidroxicloroquin 400mg/day (6ys), Sulfasalasine 3 g/day (2007), low doses of steroids
-bilateral wrists, 2-5 MCF, 2-5 PIP Knees arthritis -3hs morning stiffness
CRP 77 mg/l (N<3mg/l) ESR 94 mm/h
mRodnans score: 8
1 1
0 0 0 2 0
0 0 0 0 2
Hands X-ray
-Acro-osteolysis of 2,3,4,5 distal phalanges -Flexion contractures -Periarticular osteoporosis -Bilateral carpitis
Laboratory evaluation:
SCL70-, U1 RNP (ELISA) ACA-, ANA + homogenous pattern (IIF on HEp2 cells) RF 5500 IU (N<10IU), antiCCP2 495 IU (N<20IU) DLCO 66%, Normal respiratory function tests PAP-ECHO 34 mmHg, normal ECG
Capillaroscopic pattern LATE Scleroderma pattern: few or absent capillaries and microbleeding, architectural derangement (angiogenesis), ramified/bushy capillaries
Joint involvement in SS
arthralgias
joint space narrowing 28%, flexion contractures 27%, erosions 21%, arthritis 18%
Radiological hand involvement in Systemic Sclerosis. J Avouac, H Guerini, J Wipff, A Kahn, Y Allanore. Ann Rheum Dis 2006:65
Particularities:
-RF = 5500 IU/ml
(x 550 H normal level)
Joint involvement
Acroosteolysis
Hands X-ray
Problems
Positive
diagnosis Worsening of joint involvement after TB High titers of anti CCP Positive ANA-homogenous pattern Treatment
Positive diagnosis:
OVERLAP Syndrome
Clinical features
+ or specific autoantibodies
Anti-cyclic citrullinated peptide antibody in systemic sclerosis. Morita Y, Clin Exp Rheumatol. 2008 Jul-Aug;26(4):542-7
OBJECTIVES: To determine if anti-cyclic citrullinated peptide (antiCCP) antibody titers can distinguish the overlap syndrome of systemic sclerosis and rheumatoid arthritis (SSc-RA) in patients with systemic sclerosis (SSc) and to investigate the clinical significance of anti-CCP antibodies in SSc
Elevated serum levels of anti-CCP antibodies were observed in 3 of 114 patients (2.6%) with SS, 9 of 14 patients (64%) with RA, 6 of 7 patients (86%) with SS/RA.
Anti-CCP antibody titers are a reliable marker of SSc-RA facilitating its distinction from SS alone.
Problems
Positive
diagnosis Worsening of joint involvement after TB High titers of anti CCP Positive ANA-homogenous pattern Treatment
arthritis- monoarticular Poncets disease aseptic polyarthritis (70%) that occurs during acute TB in which no mycobacterial involvement can be found.
-self limited -no chronic arthritis reported -no association reported with anti CCP -diagnosis of exclusion
Problems
Positive
diagnosis Worsening of joint involvement after TB High titers of anti CCP & RF Positive ANA-homogenous pattern Treatment
with RA
-when
S.
Relations
with SS
Relation with TB
Increased prevalence in patients with active TB (32-39%) 32% (2.6% control, p=0.002)-no correlation found between anti CCP+ and any rheumatologic symptoms No association between anti CCP and RF+
A significant proportion of patients with TB present high titer of anti CCP or Ig M RF. O Elkayan, R Segal, M Lidgi & D Caspi; Ann Rheum Dis doi:10.1136/ard.2005.045229
False positivity of anti CCP in TB patients ? Anti-CCP was inhibited by CCP peptide in sera from RA patients, but not in sera from TB patients. A slight increase in anti-CCP after initiating treatment for TB, thereafter the anti-CCP level decreased in 1-2 months
Patients with pulmonary tuberculosis are frequently positive for anti-cyclic citrullinated peptide antibodies, but their sera also react with unmodified argininecontaining peptide (p 1576-1581) P Kakumanu, H Yamagata, E S. Sobel, W H. Reeves, Edward K. L. C May 31 2008 Arthritis and Rheumatism
Problems
Positive
diagnosis Worsening of joint involvement after TB High titers of anti CCP Positive ANA-homogenous pattern Treatment
anti centromere Anti U1 RNP 2000 ANA-! Drug induced lupus (isoniaside)-Ab anti histone? (pattern homogenous)
Problems
Positive
diagnosis Worsening of joint involvement after TB High titers of anti CCP Positive ANA-homogenous pattern Treatment
Treatment
MTX10mg SSZ
QW sc
2g QD
Medrol
Aspirin
8 mg QD
ramid
Rheumatology 2002; 41: 262-26 (Fifty-five RA patients on methotrexate and 73 control patients with RA were enrolled for the study. Mean dose of methotrexate was 10.7 mg/week (S.D. 2.5 mg/week) and mean duration of treatment at entry into the study was 30 (20) months. Twenty per cent of patients with RA treated with methotrexate had pulmonary fibrosis (PF) on initial HRCT compared with 23% in the control group. When the patients with and without PF were compared, there was no statistical difference in the duration (mean difference -4.18 months, P=0.237) or dose (mean difference -0.8 mg/week P=0.52) of methotrexate therapy. Mean changes after 2 yr in forced expiratory volume, forced vital capacity, diffusion capacity for carbon monoxide and residual volumes were not different in the methotrexate group compared with the control group.)
Fatal pulmonary fibrosis complicating low dose methotrexate therapy of 2 aged rheumatoid arthritis patients . van der Veen MJ,J Rheumatol. 1995 Sep;22(9):1766-8
TREATMENT?
Absence
of large controlled trials Recommendations are based on conventional treatment for associated diseases
BIOLOGICS?
dcSSc received 5 infusions of infliximab (5mg/kg) Clinical assessment included skin sclerosis score, scleroderma-HAQ, self-reported functional score and physician global VAS. Collagen turnover, skin biopsy analysis and full safety evaluation was performed. In dcSSc infliximab did not show clear benefit at 26 weeks but was associated with clinical stabilisation and fall in two laboratory markers of collagen synthesis. The frequency of suspected infusion reactions may warrant additional immunosuppression in any future studies in SSc.
Problems:
blockers in patient with a history of active TB ANA positive ( high risk of infusion reactions ) and for that the necessity of combination therapy
A case of lung tuberculosis in a patient with rheumatoid arthritis treated with infliximab after antituberculosis chemoprophylaxis with isoniazid.
prednisolone, but the disease activity remained high. A tuberculin skin test was positive. After antituberculosis (TB) chemoprophylaxis with isoniazid for four weeks, infliximab was administered. Chemoprophylaxis was continued for nine months. Active lung TB was diagnosed at 17 months after the cessation of isoniazid, namely at 27 months after starting infliximab treatment.
treated
with
Anti-tuberculosis chemoprophylaxis was only of partial preventive success in the pacients receiving TNF agents.
Sichletidis L,
Int J Tuberc Lung Dis. 2006 Oct
Long-term folow up of patients with TB as a complication of TNF alfa antagonist therapy: safe re-initiation of TNF alfa blockers after appropriate anti TB treatment
21
TB cases complicating TNF alfa blocker therapy 29 % patients had recommenced TNF alfa antagonist treatment after appropriate anti TB therapy, without reactivation Conclusions: TNF alfa antagonist can be restarted in TB patients provided that adequate anti TB treatment has been completed
Other possibilities ?
In recent years, clinical trials with B cell
depleting agents, unveiled a role for B lymphocytes in the pathogenesis of several auto-immune diseases. Multiple elements point to a role for B cells in Ssc pathogenesis.
B cell depletion with rituximab in patients with diffuse cutaneous systemic sclerosis (15 pz)
The treatment with rituximab appeared to be safe and well tolerated among patients with dcSSc. Rituximab treatment resulted in both depletion of circulating B cells and depletion of dermal B cells but had little effect on the levels of SSc-associated autoantibodies. Rituximab treatment did not appear to result in a significant beneficial effect on skin disease. The potential efficacy of rituximab in other organs such as the lung could not be clearly evaluated in this small open-label trial. The modest B cell infiltrates that were present in most skin biopsy specimens at baseline were completely depleted at 6 months in most patients
Lafyatis R, Arthritis Rheum. 2009 Feb
Rituximab in diffuse cutaneous systemic sclerosis: an open-label clinical and histopathological study
Vanessa P Smith
Rituximab for the treatment of cutaneous involvement in Systemic sclerosis (10 pz)
Despite limitations of few patients, no control group and short follow up period, rituximab seems be a safe therapeutic option for skin fibrosis and to confirm the role of B cells and autoantibody mediated fibroblast activation in systemic sclerosis.
P. Fraticelli, Ann. Rheum Dis 2007
lcSSc, 23% dcSSc The diagnosis of RA followed that of SS -86.4% 82% erosive poliartritis (xRay) 77% pulmonary fibrosis & 55% oesophageal involv. Genetics: both SSc and RA- associated HLA-DR alleles ANA +: 100% Anti SCL70 +: 22.7% ACA +: 9.1% RF +: 72.7% Anti CCP +: 81.8%
Systemic sclerosis-rheumatoid arthritis overlap syndrome: a unique combination of features suggests s distinct genetic, serological and clinical entity. G. Szcs1,*,Z. Szekanecz1,*, E. Zilahi2, A. Kapitny2,3, S. Barth2, S. Szamosi1, A. Vgvri1,Z. Szab1, S. Sznt1, L. Czirjk4 and C. Gyrgy Kiss4 Rheumatology 2007;46:989-993
Problems
Positive
diagnosis Worsening of joint involvement after TB High titers of anti CCP Positive ANA-homogenous pattern Treatment Opinions & Suggestions