Update upon the infection risk in patients receiving TNF alpha inhibitors

The (neuro)inflammatory system in anxiety disorders and PTSD: Potential treatment targets

Targeting the immune system has recently garnered attention in the treatment of stress- associated psychiatric disorders resistant to existing pharmacotherapeutics. While such approaches have been studied in considerable detail in depression, the role of (neuro)inflammation in anxiety-related disorders, or in anxiety as an important transdiagnostic symptom, is much less clear. In this review we first critically review clinical and in part preclinical evidence of central and peripheral immune dysregulation in anxiety disorders and post-traumatic stress disorder (PTSD) and briefly discuss proposed mechanisms of how inflammation can affect anxiety-related symptoms. We then give an overview of existing and potential future targets in inflammation-associated signal transduction pathways and discuss effects of different immune-modulatory drugs in anxiety-related disorders. Finally, we discuss key gaps in current clinical trials such as the lack of prospective studies involving anxiety patient stratification strategies based on inflammatory biomarkers. Overall, although evidence is rather limited so far, there is data to indicate that increased (neuro)inflammation is present in subgroups of anxiety disorder patients. Although exact identification of such immune subtypes of anxiety disorders and PTSD is still challenging, these patients will likely particularly benefit from therapeutic targeting of aspects of the inflammatory system. Different anti-inflammatory treatment approaches (microglia-directed treatments, pro-inflammatory cytokine inhibitors, COX-inhibitors, phytochemicals and a number of novel anti-inflammatory agents) have indeed shown some efficacy even in non-stratified anxiety patient groups and appear promising as novel alternative or complimentary therapeutic options in specific ("inflammatory") subtypes of anxiety disorder and PTSD patients.

Drug-induced herpes zoster: a pharmacovigilance analysis of FDA adverse event reports from 2004 to 2024

Background

Herpes zoster severely impacts patients' quality of life and therapeutic results. This research utilized data from the FDA Adverse Event Reporting System (FAERS) to examine the prevalence and attributes of drug-induced herpes zoster.

Methods

We analyzed FAERS reports about zoster from Q1 2004 to Q3 2024 and developed a list of possible pathogenic agents. Ranked the 30 medicines with the greatest incidence of reported herpes zoster cases. Statistical disproportionality analysis was employed to identify an elevated reporting frequency of herpes zoster linked to a particular medication.

Results

Herpes zoster was referenced in 50,164 FAERS reports from 2004 to 2024. The majority of the implicated drugs were immunosuppressants. Anifrolumab exhibited the greatest ROR and PRR ratings among the drugs evaluated. Furthermore, rozanolixizumab, tozinameran, elapegademase, and other medications not indicated for inducing herpes zoster were recognized, underscoring the necessity for increased clinical vigilance and awareness. Nonetheless, these correlations should be regarded with caution, as they do not establish a direct causative relationship.

Conclusion

This study underscores the need of pharmacovigilance in recognizing and comprehending drug-induced herpes zoster. Additional research is required to validate these findings and to design strategies for risk management and reduction to enhance treatment outcomes in patients.

Decoy peptides that inhibit TNF signaling by disrupting the TNF homotrimeric oligomer

Tumor necrosis factor (TNF) is a pro-inflammatory cytokine and its functional homotrimeric form interacts with the TNF receptor (TNFR) to activate downstream apoptotic, necroptotic, and inflammatory signaling pathways. Excessive activation of these pathways leads to various inflammatory diseases, which makes TNF a promising therapeutic target. Here, 12-mer peptides were selected from the interface of TNF-TNFR based upon their relative binding energies and were named 'TNF-inhibiting decoys' (TIDs). These decoy peptides inhibited TNF-mediated secretion of cytokines and cell death, as well as activation of downstream signaling effectors. Effective TIDs inhibited TNF signaling by disrupting the formation of TNF's functional homotrimeric form. Among derivatives of TIDs, TID3c showed slightly better efficacy in cell-based assays by disrupting TNF trimer formation. Moreover, TID3c oligomerized TNF to a high molecular weight configuration. In silico modeling and simulations revealed that TID3c and its parent peptide, TID3, form a stable complex with TNF through hydrogen bonds and electrostatic interactions, which makes them the promising lead to develop peptide-based anti-TNF therapeutics.

Dietary omega-3 fatty acids modulate the production of platelet-derived microvesicles in an in vivo inflammatory arthritis model

PURPOSE

The aim of this study was to investigate the effects of different ω-3 polyunsaturated fatty acid (PUFA) enriched diets, including a novel renewable plant source of ω-3 fatty acids (Buglossoides arvensis), on the development and progression of rheumatoid arthritis (RA).

METHODS

RA was induced in mice consuming experimental diets using the K/BxN model. The experimental diets consisted of either a western control diet (control), diets containing B. arvensis oil or fish oil. The effects of the diets on platelets, platelet microvesicles (PMVs), and inflammatory markers such as clinical index, ankle thickness and cytokine/chemokine release were measured.

RESULTS

While ω-3 PUFA-enriched diets did not prevent the development of arthritis in the K/BxN model, a significant decrease in ankle swelling was observed compared to the control group. Platelets isolated from mice consuming either low content of B. arvensis oil or fish oil diets exhibited significantly decreased PMVs production compared to mice consuming the control diet.

CONCLUSION

Our study provides insight into the contribution of ω-3 PUFA supplementation in modulating the pro-inflammatory phenotype of platelets in RA pathology. Furthermore, our study suggests that low concentrations of dietary B. arvensis oil may have similar anti-inflammatory potential seen with dietary fish oil supplementation.

RATE OF INFECTION (TUBERCULOSIS) IN BRAZILIANS IBD PRIVATE PATIENTS: FOLLOW-UP 15 YEARS

BACKGROUND

Latent tuberculosis (LTB) is a condition where the patient is infected with Mycobacterium tuberculosis but does not develop active TB. There's a possibility of tuberculosis (TB) activation following the introduction of anti-TNFs.

OBJECTIVE

To assess the risk of biological therapy inducing LTB during inflammatory bowel diseases (IBD) treatment over 15 years in a high-risk area in Brazil.

METHODS

A retrospective study of an IBD patients' database was carried out in a private reference clinic in Brazil. All patients underwent TST testing and chest X-ray prior to treatment, and once a year after starting it. Patients were classified according to the Montreal stratification and risk factors were considered for developing TB.

RESULTS

Among the analyzed factors, age and gender were risk factors for LTB. DC (B2 and P) and UC (E2) patients showed a higher number of LTB cases with statistical significance, what was also observed for adalimumab and infliximab users, compared to other medications, and time of exposure to them favored it significantly. Other factors such as enclosed working environment have been reported as risk.

CONCLUSION

The risk of biological therapy causing LTB is real, so patients with IBD should be continually monitored. This study reveals that the longer the exposure to anti-TNFs, the greater the risk.

BACKGROUND

•Rate of infection (tuberculosis) in Brazilians IBD private patients: follow-up 15 years.

BACKGROUND

•Patients treated with immunosuppressants and/or anti-TNFs have a higher risk of developing opportunistic infections, among them the most common is latent tuberculosis or even active tuberculosis.

BACKGROUND

•Similar risks may be noted in patients with inflammatory bowel diseases (IBDs).

BACKGROUND

•This study reveals that the longer the exposure to anti-TNFs, the greater the risk for de IBD patients.

BACKGROUND

•The study demonstrated the importance of monitoring these patients permanently and continuously.

Size Matters! Anti-HBs Titer and HBV Reactivation During Anti-TNF Therapy

BACKGROUND AND AIMS

We and others have previously described that hepatitis B surface antibody (anti-HBs) seems to protect against clinically significant HBV reactivation in cohort studies of patients undergoing anti-tumor necrosis factor (TNF) therapy. However, there were too few cases of HBV reactivation within cohort studies to assess the role of anti-HBs titer on reactivation. The purpose of this study was to systematically review the correlation between anti-HBs titer and the degree of clinically relevant HBV reactivation in patients undergoing anti-TNF therapy.

METHODS AND RESULTS

We systemically reviewed all studies discussing anti-TNF therapy in patients with resolved HBV infection, defined as hepatitis surface antigen (HBsAg) negative and hepatitis B core antibody (anti-HBc) positive. We identified a total of 48 cases of reactivation from 5 cohort studies and 10 case reports or case series; 21 were anti-HBs negative, 7 were only reported as anti-HBs positive, 16 were anti-HBs positive with titer below 100, and 4 were anti-HBs positive with titer above 100. HBsAg sero-reversion was dominantly seen in patients with negative, low and/or declining anti-HBs titers. There was a significant trend toward less clinically relevant form of reactivation with increase in baseline anti-HBs titer (p = 0.022).

CONCLUSION

Anti-HBs titers greater than 100 iU/L protect against clinically relevant HBV reactivation, while patients with low anti-HBs titers or negative anti-HBs had more clinically relevant HBV reactivation and higher rates of HBsAg sero-reversion. This suggests the importance of baseline quantitative anti-HBs prior to starting anti-TNF therapy and consideration vaccination for boosting anti-HBs titers prior to and/or during therapy.

What predicts the recurrence in ıdiopathic granulomatous mastitis?

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is a rarely seen chronic and benign disease of the breast. IGM usually emerges in women between 30 and 45 years of age and within the first 5 years after lactation. There is no consensus on the treatment of the disease. Steroids, immunosuppressive agents such as methotrexate and azathioprine, antibiotics, and surgical and conservative treatments can be preferred. In the present study, it was aimed to demonstrate the treatment options and follow-up data of the patients with IGM and to investigate the effective factors on recurrence if developed in the follow-up period.

MATERIALS AND METHOD

The data of 120 patients diagnosed with idiopathic granulomatous mastitis were evaluated for this cross-sectional retrospective study. The demographic, clinical, treatment, and follow-up features of the patients were obtained from the file records.

RESULTS

The median age value of the 120 female patients included in the study was 35 (24-67) years. Of the patients, 45%, 79.2%, 49.2%, and 15% had a past history of surgical intervention, steroid use, methotrexate use, and azathioprine use, respectively. Recurrent lesion developed after the treatment in 57 (47.5%) patients. The recurrence rate was 66.1% in the patients who underwent surgical intervention in the initial treatment. There was a statistically significant difference between the patients with and without recurrence regarding the presence of abscess, the presence of recurrent abscess, and having surgical intervention as the initial treatment in the past history. The rate of having surgery was statistically significantly higher compared with the administration of steroid therapy alone and the combination of steroid and immunosuppressive therapy in the initial treatment of the patients who developed recurrence. The rate of having surgery together with the administration of steroid and immunosuppressive therapy was statistically significantly higher than the administration of steroid and immunosuppressive therapies.

DISCUSSION

Our study showed that surgical intervention and the presence of abscess increased recurrence in the treatment of IGM. Key Points • This study has shown that surgical intervention and the presence of abscess increase recurrence. • A multidisciplinary approach to the treatment of IGM and management of the disease by the rheumatologists may be critical.

Vaccination therapy for inflammatory bowel disease

Recently, several novel medications, such as Ustekinumab, Infliximab, and Vedolizumab, have emerged as potential options for inflammatory bowel disease(IBD) management. Despite achieving some effects in clinical applications, these therapies are still plagued by inadequate response rates and adverse side effects. With rapid progress in immunological research, therapeutic vaccines are gaining traction as an alternative. These vaccines aim to activate the body's immune system to generate specific antibodies, thereby offering a potential avenue for treating IBD. The efficacy and safety of vaccines, coupled with their potential to mitigate the financial and healthcare burden associated with disease treatment, render therapeutic vaccines a more favorable approach for managing patients with IBD. In this review, we critically examine the existing literature pertaining to therapeutic vaccines for IBD, aiming to offer researchers a comprehensive understanding of their applications and prospects and stimulate novel vaccine development by presenting innovative ideas in this field.

FAM3C/ILEI protein is elevated in psoriatic lesions and triggers psoriasiform hyperproliferation in mice

FAM3C/ILEI is an important cytokine for tumor progression and metastasis. However, its involvement in inflammation remains elusive. Here, we show that ILEI protein is highly expressed in psoriatic lesions. Inducible keratinocyte-specific ILEI overexpression in mice (K5-ILEIind ) recapitulates many aspects of psoriasis following TPA challenge, primarily manifested by impaired epidermal differentiation and increased neutrophil recruitment. Mechanistically, ILEI triggers Erk and Akt signaling, which then activates STAT3 via Ser727 phosphorylation. Keratinocyte-specific ILEI deletion ameliorates TPA-induced skin inflammation. A transcriptomic ILEI signature obtained from the K5-ILEIind model shows enrichment in several signaling pathways also found in psoriasis and identifies urokinase as a targetable enzyme to counteract ILEI activity. Pharmacological inhibition of urokinase in TPA-induced K5-ILEIind mice results in significant improvement of psoriasiform symptoms by reducing ILEI secretion. The ILEI signature distinguishes psoriasis from healthy skin with uPA ranking among the top "separator" genes. Our study identifies ILEI as a key driver in psoriasis, indicates the relevance of ILEI-regulated genes for disease manifestation, and shows the clinical impact of ILEI and urokinase as novel potential therapeutic targets in psoriasis.

Juvenile idiopathic arthritis and its associated uveitis

INTRODUCTION

Juvenile idiopathic arthritis is the most common chronic rheumatologic disease in children. Uveitis is the most common extra-articular manifestation of JIA, and it can be a sight-threatening condition.

AREAS COVERED

In this review article, we discussed epidemiology, risk factors, clinical presentation, supportive laboratory tests, treatment options, and complications of Juvenile idiopathic arthritis and Juvenile idiopathic arthritis associated uveitis. We covered conventional immunomodulatory therapy and biologic response modifiers agents for different types of Juvenile idiopathic arthritis and their associated uveitis. Finally, we discussed the course of disease, functional outcome, and the quality of life of Juvenile idiopathic arthritis and Juvenile idiopathic arthritis-associated uveitis.

EXPERT OPINION

Although clinical outcomes of Juvenile idiopathic arthritis and its associated uveitis have been improved over the past three decades by biologic response modifier agents, a significant proportion of patients require active treatment into adult life therefore screening and monitoring of these patients is required during the patient's entire life. The limited number of food and drug administration approved biologic response modifier agents for the treatment of Juvenile idiopathic arthritis associated uveitis justify more randomized clinical trials with new medications in this field.

Clinically Evaluated COVID-19 Drugs with Therapeutic Potential for Biological Warfare Agents

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak resulted in hundreds of millions of coronavirus cases, as well as millions of deaths worldwide. Coronavirus Disease 2019 (COVID-19), the disease resulting from exposure to this pathogen, is characterized, among other features, by a pulmonary pathology, which can progress to "cytokine storm", acute respiratory distress syndrome (ARDS), respiratory failure and death. Vaccines are the unsurpassed strategy for prevention and protection against the SARS-CoV-2 infection. However, there is still an extremely high number of severely ill people from at-risk populations. This may be attributed to waning immune response, variant-induced breakthrough infections, unvaccinated population, etc. It is therefore of high importance to utilize pharmacological-based treatments, despite the progression of the global vaccination campaign. Until the approval of Paxlovid, an efficient and highly selective anti-SARS-CoV-2 drug, and the broad-spectrum antiviral agent Lagevrio, many pharmacological-based countermeasures were, and still are, being evaluated in clinical trials. Some of these are host-directed therapies (HDTs), which modulate the endogenic response against the virus, and therefore may confer efficient protection against a wide array of pathogens. These could potentially include Biological Warfare Agents (BWAs), exposure to which may lead to mass casualties due to disease severity and a possible lack of efficient treatment. In this review, we assessed the recent literature on drugs under advanced clinical evaluation for COVID-19 with broad spectrum activity, including antiviral agents and HDTs, which may be relevant for future coping with BWAs, as well as with other agents, in particular respiratory infections.

Drug Survival of Tumor Necrosis Factor-Alpha Inhibitors and Switched Subsequent Biologic Agents in Patients with Psoriasis: A Retrospective Study

INTRODUCTION

This study aimed to retrospectively examine the drug survival of tumor necrosis factor (TNF)-alpha inhibitors and switched subsequent biologic agents after discontinuation of TNF inhibitors.

METHODS

This real-world setting study was conducted at a single academic center. We included patients who were treated with adalimumab (n = 111), certolizumab pegol (n = 12), and infliximab (n = 74) at Jichi Medical University Hospital from 1 January 2010 to 31 July 2021.

RESULTS

No significant differences were noted in drug survival between the three TNF inhibitors. The 10-year drug survival rate for adalimumab and infliximab was 14% and 18%, respectively. Of the patients who discontinued TNF inhibitors for any reason (n = 137), 105 chose biologics as their subsequent treatment. The subsequent biologics included 31 cases of TNF inhibitors (adalimumab in 20, certolizumab pegol in 1, and infliximab in 10), 19 of interleukin-12/23 inhibitor (ustekinumab), 42 of interleukin-17 inhibitors (secukinumab in 19, brodalumab in 9, and ixekizumab in 14) and 13 of interleukin-23 inhibitors (guselkumab in 11, risankizumab in 1, and tildrakizumab in 1). Cox proportional hazards analysis for the subsequent drugs in cases of discontinuation due to inadequate efficacy revealed that female sex was a predictor of drug discontinuation (hazard ratio 2.58, 95% confidence interval 1.17-5.70) and that taking interleukin-17 inhibitors rather than TNF inhibitors was a predictor of drug persistence (hazard ratio 0.37, 95% confidence interval 0.15-0.93).

CONCLUSIONS

Interleukin-17 inhibitors may be a favorable option for patients who need to switch from TNF inhibitors due to inadequate efficacy. However, this study is limited by the small number of cases and its retrospective design.

Safety of current systemic therapies for nail psoriasis

INTRODUCTION

A discussion of safety of systemic treatments for nail psoriasis is lacking, particularly in reference to approval of new therapies assessed for nail outcomes. A review of safety profiles for agents commonly utilized for treatment of nail psoriasis is warranted to help inform treatment choices. The PubMed database was searched on 5 April 20235 April 2023, with articles discussing safety of nail psoriasis systemic therapies identified and reviewed.

AREAS COVERED

Systemic treatments for nail psoriasis include biologic therapies (tumor necrosis factor-alpha inhibitors, interleukin-17 inhibitors, interleukin-23 inhibitors, interleukin-12/23 inhibitors), small molecule inhibitors (apremilast, tofacitinib), and oral systemic immunomodulators (methotrexate, cyclosporine, acitretin), each with unique safety profiles and considerations. Herein, we discuss adverse events, contraindications, drug-drug interactions, screening/monitoring guidelines, as well as utilization for special populations, including pregnant, older, and pediatric patients.

EXPERT OPINION

The advent of targeted therapies, including biologic treatments and small molecule inhibitors, has revolutionized outcomes for nail psoriasis patients, but warrant review and monitoring for potential adverse events. Oral systemic immunomodulators have demonstrated moderate efficacy for nail psoriasis treatment, but are notable for frequent contraindications and drug-drug interactions. Further study of these agents and their use in special populations is needed to elucidate safety profiles for long-term use.

Advancing Biologic Therapy for Refractory Autoimmune Hepatitis

Biologic agents may satisfy an unmet clinical need for treatment of refractory autoimmune hepatitis. The goals of this review are to present the types and results of biologic therapy for refractory autoimmune hepatitis, indicate opportunities to improve and expand biologic treatment, and encourage comparative clinical trials. English abstracts were identified in PubMed by multiple search terms. Full-length articles were selected for review, and secondary and tertiary bibliographies were developed. Rituximab (monoclonal antibodies against CD20 on B cells), infliximab (monoclonal antibodies against tumor necrosis factor-alpha), low-dose recombinant interleukin 2 (regulatory T cell promoter), and belimumab (monoclonal antibodies against B cell activating factor) have induced laboratory improvement in small cohorts with refractory autoimmune hepatitis. Ianalumab (monoclonal antibodies against the receptor for B cell activating factor) is in clinical trial. These agents target critical pathogenic pathways, but they may also have serious side effects. Blockade of the B cell activating factor or its receptors may disrupt pivotal B and T cell responses, and recombinant interleukin 2 complexed with certain interleukin 2 antibodies may selectively expand the regulatory T cell population. A proliferation-inducing ligand that enhances T cell proliferation and survival is an unevaluated, potentially pivotal, therapeutic target. Fully human antibodies, expanded target options, improved targeting precision, more effective delivery systems, and biosimilar agents promise to improve efficacy, safety, and accessibility. In conclusion, biologic agents target key pathogenic pathways in autoimmune hepatitis, and early experiences in refractory disease encourage clarification of the preferred target, rigorous clinical trial, and comparative evaluations.

Increased susceptibility to pneumonia due to tumour necrosis factor inhibition and prospective immune system rescue via immunotherapy

Immunomodulators such as tumour necrosis factor (TNF) inhibitors are used to treat autoimmune conditions by reducing the magnitude of the innate immune response. Dampened innate responses pose an increased risk of new infections by opportunistic pathogens and reactivation of pre-existing latent infections. The alteration in immune response predisposes to increased severity of infections. TNF inhibitors are used to treat autoimmune conditions such as rheumatoid arthritis, juvenile arthritis, psoriatic arthritis, transplant recipients, and inflammatory bowel disease. The efficacies of immunomodulators are shown to be varied, even among those that target the same pathways. Monoclonal antibody-based TNF inhibitors have been shown to induce stronger immunosuppression when compared to their receptor-based counterparts. The variability in activity also translates to differences in risk for infection, moreover, parallel, or sequential use of immunosuppressive drugs and corticosteroids makes it difficult to accurately attribute the risk of infection to a single immunomodulatory drug. Among recipients of TNF inhibitors, Mycobacterium tuberculosis has been shown to be responsible for 12.5-59% of all infections; Pneumocystis jirovecii has been responsible for 20% of all non-viral infections; and Legionella pneumophila infections occur at 13-21 times the rate of the general population. This review will outline the mechanism of immune modulation caused by TNF inhibitors and how they predispose to infection with a focus on Mycobacterium tuberculosis, Legionella pneumophila, and Pneumocystis jirovecii. This review will then explore and evaluate how other immunomodulators and host-directed treatments influence these infections and the severity of the resulting infection to mitigate or treat TNF inhibitor-associated infections alongside antibiotics.

Interferon-Inducible Protein-10 as a Marker to Detect Latent Tuberculosis Infection in Patients with Inflammatory Rheumatic Diseases

It is important to identify cases of latent tuberculosis infection (LTBI) who are at risk for tuberculosis (TB) reactivation. We aimed to evaluate the performance of interferon (IFN)-gamma-inducible protein 10 (IP-10) as a marker to detect LTBI in patients with inflammatory rheumatic diseases (IRD). This study comprised 76 consecutive subjects with IRD. Patients with a history of TB or having active TB were excluded. In all patients, IP-10 level was measured and tuberculin skin test (TST) and QuantiFERON-TB Gold In-Tube test (QFT-GIT) were performed. Seventy patients with complete test results were analyzed. Twenty-one (30%) QFT-GIT-positive patients were defined as having LTBI. IP-10 yielded 2197 pg/mL cut-off point. At this cut-off point, IP-10 showed 89% specificity with a sensitivity of 91% (AUC: 0.950, 95% CI 0.906–0.994). TST, QFT-GIT, and IP-10 were positive in 77.1%, 30%, and 44.3% of the patients, respectively. Concordance among the results of TST, QFT-GIT, and IP-10 tests was evaluated. Agreement was poor between IP-10 and TST (58.6%, κ = 0.19), whereas it was good between QFT-GIT and IP-10 (84.3%, κ = 0.65). The results of the present study demonstrated that sensitivity and specificity of released IP-10 were as high as those of QFT-GIT in indicating LTBI in IRD patient group.

Management of Non-response and Loss of Response to Anti-tumor Necrosis Factor Therapy in Inflammatory Bowel Disease

Anti-tumor necrosis factor (anti-TNF) therapy has been successfully used as first-line biologic treatment for moderate-to-severe inflammatory bowel disease (IBD), in both "step-up" and "top-down" approaches, and has become a cornerstone of IBD management. However, in a proportion of patients the effectiveness of anti-TNF therapy is sub-optimal. Either patients do not achieve adequate initial response (primary non-response) or they lose response after initial success (loss of response). Therapeutic drug monitoring determines drug serum concentrations and the presence of anti-drug antibodies (ADAbs) and can help guide treatment optimization to improve patient outcomes. For patients with low drug concentrations who are ADAb-negative or display low levels of ADAbs, dose escalation is recommended. Should response remain unchanged following dose optimization the question whether to switch within class (anti-TNF) or out of class (different mechanism of action) arises. If ADAb levels are high and the patient has previously benefited from anti-TNF therapy, then switching within class is a viable option as ADAbs are molecule specific. Addition of an immunomodulator may lead to a decrease in ADAbs and a regaining of response in a proportion of patients. If a patient does not achieve a robust therapeutic response with an initial anti-TNF despite adequate drug levels, then switching out of class is appropriate. In conjunction with the guidance above, other factors including patient preference, age, comorbidities, disease phenotype, extra-intestinal manifestations, and treatment costs need to be factored into the treatment decision. In this review we discuss current evidence in this field and provide guidance on therapeutic decision-making in clinical situations.

Angiotensin Converting Enzyme Activity in Anti-TNF-Treated Rheumatoid Arthritis and Ankylosing Spondylitis Patients

Introduction

Angiotensin-converting enzyme (ACE) and ACE2 have been implicated in the regulation of vascular physiology. Elevated synovial and decreased or normal ACE or ACE2 levels have been found in rheumatoid arthritis (RA). Very little is known about the effects of tumor necrosis factor α (TNF-α) inhibition on ACE or ACE2 homeostasis. In this study, we assessed the effects of one-year anti-TNF therapy on ACE and ACE2 production in RA and ankylosing spondylitis (AS) in association with other biomarkers.

Patients and Methods

Forty patients including 24 RA patients treated with either etanercept (ETN) or certolizumab pegol (CZP) and 16 AS patients treated with ETN were included in a 12-month follow-up study. Serum ACE levels were determined by commercial ELISA, while serum ACE2 activity was assessed using a specific quenched fluorescent substrate. Ultrasonography was performed to determine flow-mediated vasodilation (FMD), common carotid intima-media thickness (ccIMT) and arterial pulse-wave velocity (PWV) in all patients. In addition, CRP, rheumatoid factor (RF) and ACPA were also measured. All assessments were performed at baseline and 6 and 12 months after treatment initiation.

Results

Anti-TNF therapy increased ACE levels in the full cohort, as well as in the RA and AS subsets. ACE2 activity increased in the full cohort, while the ACE/ACE2 ratio increased in the full cohort and in the RA subset (p < 0.05). Uni- and multivariable regression analyses determined associations between ACE or ACE/ACE2 ratios at different time points and disease duration, CRP, RF, FMD and IMT (p < 0.05). ACE2 activity correlated with CRP. The changes of ACE or ACE2 over 12 months were determined by treatment together with either RF or FMD (p < 0.05).

Conclusions

Anti-TNF treatment may increase ACE and ACE2 in the sera of RA and AS patients. ACE and ACE2 may be associated with disease duration, markers of inflammation and vascular pathophysiology. The effects of TNF inhibition on ACE and ACE2 may reflect, in part, the effects of these biologics on the cardiovascular system.

Effectiveness and safety of low-dose interferon alpha-2a treatment in Behçet’s Syndrome with refractory vascular or neurological involvement: a case series

Objective:

The aim of this study was to evaluate the effectiveness and safety of low-dose interferon alpha-2a (IFNα2a) in Behçet’s syndrome (BS) patients with refractory vascular/cardiac or neurological involvement.

Methods:

In this retrospective cohort study, we consecutively included 25 BS patients with refractory vascular/cardiac ( n = 16) or neurological involvement ( n = 9) who received IFNα2a treatment in our center between June 2018 and September 2021. The low-dose IFNα2a (3 million IU, every other day) was used as an add-on treatment with the continuation of glucocorticoids (GCs) and immunosuppressants.

Results:

In total, 25 patients (20 males, 5 females) with a mean age of 31.92 ± 9.25 years were included. IFNα2a was administered for BS patients with refractory vascular/cardiac involvement ( n = 16) and neurological involvement ( n = 9). Before the initiation of IFNα2a, patients had insufficient response or intolerance to conventional therapies. After a median follow-up of 23 [interquartile range (IQR), 11–30] months, all patients achieved clinical improvement. The Behçet’s disease Current Activity Form (BDCAF) score improved significantly (5 versus 0, median, p < 0.0001). BS Overall Damage Index (BODI) and vasculitis damage index (VDI) remain stable ( p > 0.05). Decrease in erythrocyte sedimentation rate [ESR; 24 (IQR, 12–43.5) versus 5 (IQR, 2.75–10.5) mm/h, p = 0.0001] and C-reactive protein [CRP; 6.64 (IQR, 3.67–19.82) versus 1.24 (IQR, 0.24–3.12) mg/liter, p < 0.005] was achieved effectively. The median GCs dosage tapered from 26.25 (IQR, 11.88–41.25) to 10.00 (IQR, 7.50–10.63) mg/d, p < 0.0001. Immunosuppressants were also reduced in number ( p < 0.005). No serious adverse events were observed during follow-up.

Conclusion:

Our study suggests that low-dose IFNα2a, combined with GCs and immunosuppressants, is well-tolerated and effective for BS patients with refractory vascular/cardiac or neurological involvement and has a steroid- and immunosuppressant-sparing effect.

Systemic lupus erythematosus complicated by Crohn's disease with rectovaginal fistula

BACKGROUND

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease, and few cases combine with Crohn's disease. We present the first SLE patient concurrent with Crohn's disease and rectovaginal fistula. She was successfully treated with vedolizumab and surgical intervention. Besides, she also had a rare opportunistic infection, cryptococcal pneumonia, in previous adalimumab treatment course.

CASE

A 57 year-old female had SLE in disease remission for 27 years. She suffered from progressive rectal ulcers with anal pain and bloody stool, and Crohn's disease was diagnosed. She received adalimumab, but the lesion still progressed to a rectovaginal fistula. Besides, she suffered from an episode of cryptococcal pneumonia under adalimumab treatment course. Therefore, we changed the biologics to vedolizumab, and arrange a transverse colostomy for stool diversion. She had clinical remission without active inflammation, but the fistula still persisted. Then, she received a restorative proctectomy with colo-anal anastomosis and vaginal repair. Follow-up endoscopy showed no more rectal ulcers or fistula tracts, and contrast enema also noted no residual rectovaginal fistula.

CONCLUSION

When a SLE patient had unusual rectal ulcers, Crohn's disease should be considered. Biologics combined with surgical intervention is an optimal solution for Crohn's disease with rectovaginal fistula. Although cryptococcal pneumonia is a rare opportunistic infection in the biological treatment, we should always keep it in mind.

Risk factors for losing hepatitis B virus surface antibody in patients with HBV surface antigen negative/surface antibody positive serostatus receiving biologic disease-modifying anti-rheumatic drugs: a nested case-control study

BACKGROUND

Hepatitis B virus (HBV) reactivation consequent to immunosuppressive therapy is an increasingly prevalent problem with serious clinical implications. Treatment with biologic agents conduces to the loss of protective antibody to HBV surface antigen (anti-HBs), which significantly increases the risk of HBV reactivation. Hence, we investigated the risk factors for losing anti-HBs in patients with rheumatic diseases and HBV surface antigen negative/anti-HBs positive (HBsAg-/anti-HBs+) serostatus during treatment with biologic disease-modifying anti-rheumatic drugs (DMARDs).

METHODS

Using a nested case-control design, we prospectively enrolled patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis/psoriasis, or juvenile idiopathic arthritis, who were treated with biologic DMARDs at Changhua Christian Hospital, Taiwan, from January 2013 to June 2019 and had HBsAg-/anti-HBs+ serostatus; the analytic sample excluded all patients with HBsAg+ or anti-HBs- serostatus. Anti-HBs titers were monitored 6-monthly and cases were defined as anti-HBs < 10 mIU/ml during follow-up. Cases were matched one-to-all with controls with anti-HBs ≥ 10 mIU/ml on the same ascertainment date and equivalent durations of biologic DMARDs treatment (control patients could be resampled and could also become cases during follow-up). Between-group characteristics were compared and risk factors for anti-HBs loss were investigated by conditional logistic regression analyses.

RESULTS

Among 294 eligible patients, 23 cases were matched with 311 controls. The incidence of anti-HBs loss was ~ 2.7%/person-year during biologic DMARDs treatment. Besides lower baseline anti-HBs titer (risk ratio 0.93, 95% CI 0.89-0.97), cases were significantly more likely than controls to have diabetes mellitus (risk ratio 4.76, 95% CI 1.48-15.30) and chronic kidney disease (risk ratio 14.00, 95% CI 2.22-88.23) in univariate analysis. Risk factors remaining significantly associated with anti-HBs loss in multivariate analysis were lower baseline anti-HBs titer (adjusted risk ratio 0.93, 95% CI 0.88-0.97) and chronic kidney disease (adjusted risk ratio 45.68, 95% CI 2.39-871.5).

CONCLUSIONS

Besides lower baseline anti-HBs titer, chronic kidney disease also strongly predicts future anti-HBs negativity in patients with HBsAg-/anti-HBs+ serostatus who receive biologic DMARDs to treat rheumatic diseases. Patients with low anti-HBs titer (≤ 100 mIU/ml) and/or chronic kidney disease should be monitored during biologic DMARDs therapy, to enable timely prophylaxis to preempt potential HBV reactivation.

Evaluating safety and compatibility of anti-tumor necrosis factor therapy in patients with connective tissue disorders

Inhibition of the proinflammatory cytokine tumor necrosis factor alpha (TNFα) has been utilized as a treatment strategy for a variety of immune-mediated inflammatory disorders (IMID), including rheumatoid arthritis, Crohn’s disease and psoriasis. A wide array of biologic therapies targeting the TNFα molecule, including etanercept, infliximab, certolizumab, golimumab and adalimumab, are routinely used in the care of patients with these conditions. In addition to their therapeutic potential, anti-TNFα agents commonly induce the formation of autoantibodies such as anti-nuclear antibodies and anti-double stranded DNA antibodies; however, the vast majority of these are of IgM isotype and of unclear clinical significance, uncommonly leading to drug-induced autoimmune disease. For these reasons, TNFα inhibition has been a controversial strategy in the treatment of primary connective tissue disorders (CTDs). However, as new therapeutics continue to be developed for the management of CTDs, the potential utility for anti-TNFα agents has become of great interest, demonstrated in several recent case series and small open-label trials. We review the safety and compatibility of anti-TNFα therapy in the management of systemic lupus erythematosus (SLE) and cutaneous lupus erythematosus (CLE), two well-studied example CTDs, as well as summarize the risks of autoantibody generation, infection, malignancy, and iatrogenic lupus flares as side effects of blocking TNFα in patients with these conditions.

Anti-PD-1 and Anti-PD-L1 Monoclonal Antibodies in People Living with HIV and Cancer

PURPOSE OF REVIEW

Immune checkpoint inhibitors targeting the programmed cell death-1 (PD-1) pathway are a class of anti-cancer immunotherapy agents changing treatment paradigms of many cancers that occur at higher rates in people living with HIV (PLWH) than in the general population. However, PLWH have been excluded from most of the initial clinical trials with these agents.

RECENT FINDINGS

Two recent prospective studies of anti-PD-1 agents, along with observational studies and a meta-analysis, have demonstrated acceptable safety in PLWH. Preliminary evidence indicates activity in a range of tumors and across CD4⁺ T cell counts. Safety and preliminary activity data suggest monoclonal antibodies targeting PD-1 or its ligand, PD-L1, are generally appropriate for PLWH and cancers for which there are FDA-approved indications. Ongoing and future trials of anti-PD-1 and anti-PD-L1 therapy alone or in combination for HIV-associated cancers may further improve outcomes for this underserved population.

Harnessing Tumor Necrosis Factor Alpha to Achieve Effective Cancer Immunotherapy

Tumor necrosis factor alpha (TNFα) is a pleiotropic cytokine known to have contradictory roles in oncoimmunology. Indeed, TNFα has a central role in the onset of the immune response, inducing both activation and the effector function of macrophages, dendritic cells, natural killer (NK) cells, and B and T lymphocytes. Within the tumor microenvironment, however, TNFα is one of the main mediators of cancer-related inflammation. It is involved in the recruitment and differentiation of immune suppressor cells, leading to evasion of tumor immune surveillance. These characteristics turn TNFα into an attractive target to overcome therapy resistance and tackle cancer. This review focuses on the diverse molecular mechanisms that place TNFα as a source of resistance to immunotherapy such as monoclonal antibodies against cancer cells or immune checkpoints and adoptive cell therapy. We also expose the benefits of TNFα blocking strategies in combination with immunotherapy to improve the antitumor effect and prevent or treat adverse immune-related effects.

The Key Comorbidities in Patients with Rheumatoid Arthritis: A Narrative Review

Comorbidities in patients with rheumatoid arthritis (RA) are often associated with poor health outcomes and increased mortality. Treatment decisions should take into account these comorbidities due to known or suspected associations with certain drug classes. In clinical practice, it is critical to balance potential treatment benefit against the possible risks for comorbidities as well as the articular manifestations of RA. This review summarises the current literature relating to prevalence and risk factors for the important comorbidities of cardiovascular disease, infections, lymphomas and nonmelanoma skin cancers in patients with RA. The impact on patient outcomes and the interplay between these comorbidities and the therapeutic options currently available, including tumour necrosis factor inhibitors and newer biological therapies, are also explored. As newer RA therapies are developed, and patients gain wider and earlier access to advanced therapies, in part due to the emergence of biosimilars, it is important to consider the prevention or treatment of comorbidities as part of the overall management of RA.

Increased mRNA expression of key cytokines among suspected cases of Pneumocystis jirovecii infection

Background

Pneumocystis pneumonia (PCP) is a fatal infectious disease caused by Pneumocystis jirovecii (PJP). The major factor relevant to morbidity and mortality seems to be the host inflammatory reaction. The objective of this study was to evaluate the role of IL-2, IL-4, IL-10, and IL-13 cytokine mRNA expression among suspected P. jirovecii infection.

Methods

This was a cross-sectional analytical study undertaken in Aseer region, Saudi Arabia. One hundred suspected PCP cases and 100 healthy controls were included in the study. Basic clinical manifestations, radiological findings, microbiological and immunological findings were extracted from the hospital records from January 2019 to August 2019, Pneumocystis detection was done by immune-fluorescent staining (IFAT, Gomorimethanamine silver staining (GMSS), Giemsa staining, Toluidine blue O (TBO), and Pneumocystis RT-PCR.

Results

Increased more than 5 fold, 3 fold, 4 fold, and 7 fold of IL-2, IL-4, IL-10, and IL-13 mRNA expression were observed in PCP cases compared to controls. Higher expression of IL-2 mRNA was connected with crept, wheezing and chest X-ray findings like central perihilar infiltrate, patchy infiltrate, consolidation, hilar lymphadenopathy, pneumothorax, pleural effusion which showed higher expression compared to counterpart (p< 0.0001). Higher expression of IL-4 mRNA was found to be significantly associated with weight loss (p=0.002), dyspnea (p=0.003), crept (p=0.01), and chest X-ray findings (p< 0.0001). Significantly increased expression of IL-10 mRNA was observed to be associated with weight loss, dyspnea, night sweats, wheezing, and different findings of chest X-ray compared to their counterparts, whereas, IL-13 mRNA was observed in cases with fever. Suspected cases of PCP confirmed positive by IFTA with higher IL-2, IL-4, and IL-10 mRNA expression compared to negative cases. RT-PCR confirmed PCP cases had significantly higher expression of IL-2, IL-4, and IL-10 as well as IL-13 mRNA compared to negative cases. Positive detected cases by GMSS showed higher IL-2, IL-10 mRNA expression, while Giemsa showed only higher IL-4 mRNA expression compared to negative cases.

Conclusion

Confirmed cases of P. jirovecii showed higher IL-2, IL-4, IL-10, and IL-13 mRNA expression comparatively to negative cases. Increased expression of cytokines may be indicative of infection severity and could help in patients’ management.

Risk of hepatitis B reactivation in patients receiving anti-tumor necrosis factor-α therapy

OBJECTIVE

The purpose of this study was to determine hepatitis B virus (HBV) screening rates in patients receiving anti-tumor necrosis factor (TNF)-α therapy and the frequency of HBV reactivation in patients with resolved hepatitis B virus infection (hepatitis B surface antigen [HBsAg] negative, hepatitis B core antibody [Anti-HBc] positive).

PATIENTS AND METHODS

Data from 1834 patients who underwent anti-TNF-α therapy in the Rheumatology, Gastroenterology and Dermatology Departments of our hospital between 2010 and 2020 were retrospectively analyzed. Within 6 months before the initial anti-TNF-α therapy, performing a HBsAg and/or anti-HBc test is defined as HBV screening. HBV reactivation is defined as the presence of detectable serum HBV DNA or HBsAg seroconversion from negative to positive.

RESULTS

The overall HBV screening rate was 82.3% before starting anti-TNF-α therapy. There was an increasing trend in HBV screening rates during the years analyzed (64% in 2010, 87.4% in 2019) (P < .001). Before anti-TNF-α therapy was initiated, 272 patients were HBsAg negative and anti-HBc positive. Among these patients, HBV reactivation did not occur in 31 patients who received antiviral prophylaxis, whereas HBV reactivation occurred in only 1 (0.4%) of the 241 patients who did not receive antiviral prophylaxis.

CONCLUSION

Hepatitis B virus screening rates prior to starting anti-TNF-α therapy were relatively high, and its trend was increased by year. HBV reactivation because of anti-TNF-α use rarely occurred in patients with resolved HBV infection. Further studies are needed on whether routine anti-HBc screening and/or HBV DNA follow-up are necessary in these patients aside from HBsAg.

Use of biologic agents and risk of tuberculosis in Brazil, a tuberculosis high-burden country

Background

Brazil is a country with a high burden of tuberculosis (TB). The immunomodulatory effect of biological therapies is associated with an increased risk of infection. This study evaluated the frequency of TB infection in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), juvenile idiopathic arthritis (JIA), and psoriatic arthritis (PsA) after the use of biologic agents in a single center of rheumatology.

Methods

In this observational study, 161 consecutive adult patients with RA, JIA, AS, and PsA using biological therapy were followed up during 55 months to evaluate the occurrence of TB infection throughout treatment. All patients were screened for latent TB infection (LTBI), and TB disease was excluded before introduction of biological therapy. Patients with LTBI received prophylaxis with isoniazid before the start of biological treatment.

Results

Of 161 patients on biologics, 31 (19.25%) had positive tuberculin skin test (TST) and received LTBI treatment. Eleven (6.8%) cases of TB were detected in patients on biologics, six (54.5%) had AS, one had PsA (9.09%), two had RA (18.18%), and two had JIA (18.18%). Regarding the use of different biologics, six (54.5%) patients received adalimumab, three (27.2%) infliximab, one (9.09%) etanercept, and one (9.09%) tocilizumab.

Conclusion

In this study, the frequency of TB infection among 161 patients on biologics, during 55 months of follow-up, was 6.8%. Compared with the national registry of patients receiving biologics (BiobadaBrasil — January 01, 2009 to May 31, 2013), a higher incidence of TB (6.8 versus 0.44%) was found in this sample of patients receiving biological therapy. This study highlights that in a country with high TB burden, the possibility of TB infection in a patient receiving biological therapy should always be considered, even after prophylaxis with isoniazid.

Safety update of etanercept treatment for moderate to severe plaque psoriasis

Introduction: Conventional topical therapies and disease-modifying anti-rheumatic drugs (DMARDs) for patients with psoriasis are often linked to inadequate outcomes and risk of multiple adverse effects. Biologic agents such as etanercept (ETN) have revolutionized the therapeutic management of psoriasis, allowing the treatment of most difficult cases, and fragile patients.Areas covered: The authors searched PubMed using the term 'psoriasis,' 'etanercept,' and 'safety.' Articles considered by the authors to be most relevant, such as randomized controlled studies, cohort studies, and review articles placing emphasis on studies of efficacy and safety were selected. Case reports and letters relating to safety were also included. The main sources of data referenced by these articles were also included in the review. Besides, to get the relevant studies, the reference lists were examined to identify the potentially available studies. The aim of this review is to describe the safety profile of ETN, used for psoriasis treatment, focusing on related clinical implications.Expert opinion: ETN has a favorable safety profile, and its use should be largely considered in psoriatic patients. Caution should be recommended in case of chronic heart failure, autoimmune disease, previous malignancies, familial history of demyelinating diseases, latent TBC infection, chronic HBV and HCV infection or HIV.

Infliximab ameliorates tumor necrosis factor-alpha exacerbated renal insulin resistance induced in rats by regulating insulin signaling pathway

Infliximab (IFX), a monoclonal antibody for tumor necrosis factor-alpha (TNF-α), is known to restore blood glucose homeostasis. However, its effects on improving renal insulin resistance (IR) are not yet studied. So we investigate the impact of infliximab on renal insulin signaling pathway in IR rat model regarding to metformin (MET). The induced IR was confirmed by a high oral glucose tolerance test, an elevation of lipid profile and the homeostatic model assessment of insulin resistance 2 (HOMA-IR 2) values. Subsequently, IR rats were concurrently treated with either MET (100 mg/kg/day) or IFX (one dose 5 mg/kg) besides IR and normal control (NC) groups. Four weeks later, IR control rats displayed hyperglycemia, hyperinsulinemia and elevation in HOMA-IR 2, renal function markers and renal tissue TNF-α, interleukins-1β and 6 (Il-1β, IL-6) and suppressor of cytokines signaling 3 (SOCS3) contents as well as glomerulosclerosis when compared to NC group. Additionally, the phosphorylation of renal insulin receptor substrate 1 (IRS1), phosphatidylinositol 3-kinase (PI3K) and protein kinase B (Akt) were markedly impaired. Treatment with either MET or IFX significantly improved IR and kidney functions. The effects of the drugs were achieved by the downregulation of renal inflammatory cytokines and SOCS3 levels and the amelioration of the renal IRS1/PI3K/Akt pathway. In conclusion, MET and IFX ameliorated the TNF-α worsening effect on IR in rat renal tissues by regulating insulin signaling. Interestingly, infliximab was superior to metformin in regulating insulin signaling pathway. Therefore, infliximab could be used as an adjuvant therapy in improving renal IR.

TNF-alpha inhibitors for the six treatment targets of psoriatic arthritis

Introduction: Psoriatic Arthritis (PsA) is a chronic inflammatory disease characterized by psoriasis, synovitis, enthesitis, spondylitis, and association with extra-articular manifestations and comorbidities. Treatment of PsA dramatically changed since the introduction of anti-TNF drugs which have shown to reduce the symptoms and signs of the disease and slow the radiographic progression. Despite the introduction of new molecules with different mechanisms of action, the role of anti-TNF in the treatment of all disease manifestations of this intriguing disease is still central.Areas covered: The aim of this paper is to review the role of anti-TNF drugs in the treatment of different disease domains in PsA (peripheral and axial joints, skin, enthesis, patient's reported outcomes, extra-articular manifestations), reporting data from randomized clinical trials and observational studies. An extensive literature search was performed on PubMed, with no limits or filters. The following search terms were used: 'anti-TNF', 'Psoriatic Arthritis'.Expert opinion: Despite the emergence of different new treatments, anti-TNF therapy remains central in the management of all disease domains in PsA patients.

Successful treatment in a child with enthesitis-related arthritis involving the sternoclavicular joint: a case report

Background

Although the sternoclavicular joint (SCJ) may be involved in ankylosing spondylitis, rheumatic arthritis, and Behçet’s disease and participates in the systemic inflammatory process of arthritis, it is often neglected during routine rheumatologic clinical examinations. To the best of our knowledge, this is the first study to report etanercept treatment in juvenile idiopathic arthritis (JIA) with SCJ involvement.

Case presentation

In this study, we describe an unusual case of a child with juvenile idiopathic arthritis with an initial presentation of sternoclavicular mass. The patient (age, 14 years 10 months) presented with an insidious onset atraumatic swelling of the left SCJ and complained of right hip and bilateral ankle tenderness without an apparent cause. Initial ultrasonography indicated a heterogeneous mass in the left SCJ, while computed tomography identified mild swelling of the left SCJ with a thickened synovial lining, mild bone erosion, and some turbid fluid. The patient ultimately underwent left SCJ arthrotomy, during which tapping of the SCJ revealed 2 cc of yellowish fluid, inflammation and necrosis of tissues within the SCJ. A clear yellow joint fluid was aspirated, and testing revealed a negative culture result. The patient was diagnosed with JIA. The joint tenderness improved and erythrocyte sedimentation rate decreased after administering anti-tumor necrosis factor etanercept. An additional ultrasonography demonstrated that the initial imaging findings have been resolved. At the end of a 2-year follow-up period, the patient was completely symptom-free.

Conclusions

JIA with SCJ involvement is an uncommon presentation in adolescents. Etanercept may be a beneficial treatment for SCJ involvement in patients with JIA. The upper limbs showed no signs of limited range of motion during the follow-up period. Further studies are warranted to elucidate the efficacy of etanercept in JIA with sternoclavicular joint involvement.

Etanercept for the Treatment of Chronic Arthritis Related to Chronic Granulomatous Disease: A Case

Introduction: Chronic granulomatous disease (CGD) is a rare primary immunodeficiency, in which infections are the main presenting symptoms. Moreover, patients may also experience inflammatory and autoimmune manifestations. With proper management of infections, patients now survive to adulthood, and inflammatory manifestations have become more prominent problems. Treatment of the inflammatory manifestations in CGD is challenging and requires a multidisciplinary approach. Since tumor necrosis factor (TNF)-α has been cited as having a possible role on inflammatory conditions in CGD, etanercept, an anti-TNF agent, may represent a major advance in the management of inflammatory manifestations. Case Presentation: In this report, we described a 15-year-old boy, suffering concurrently both from human leukocyte antigen (HLA)-B27-positive chronic arthritis and CGD, whose arthritis did not respond to treatment with methotrexate and ibuprofen. Remission was achieved 6 months after etanercept initiation and during the next 18 months on medication, we did not encounter any signs of severe infections. Conclusion: Treatment of inflammatory conditions in CGD patients is still challenging in view of the lack of evidence-based therapeutic options. In this study, we report the first pediatric CGD case, in which chronic arthritis was successfully treated with etanercept.

New onset or exacerbation of uveitis with infliximab: paradoxical effects?

Objective

To report four cases of new onset or exacerbation of uveitis following administration of infliximab.

Methods

This retrospective observational case series includes four patients who developed new onset or exacerbation of uveitis paradoxically during infliximab treatment.

Results

Four patients were assessed, including three women, with a mean age of 33 (14–84) years. Infliximab was introduced for the treatment of scleritis associated with rheumatoid arthritis (two cases), chronic anterior uveitis associated with juvenile idiopathic arthritis (JIA) (one case) and Crohn’s disease (one case). Anterior scleritis associated with rheumatoid arthritis successfully improved following infliximab administration; however, macular oedema or dense vitritis paradoxically developed in two cases. In one case, infliximab was switched to tocilizumab. In another case, infliximab was discontinued, and additional corticosteroids and immunosuppressive medications were added. In one patient with JIA, new-onset macular oedema and exacerbation of anterior uveitis were observed during infliximab treatment, so the patient was switched to adalimumab. In the patient with Crohn’s disease treated with infliximab, severe vasculitis and macular oedema occurred, requiring intravitreal triamcinolone injection. The patient was switched to adalimumab. Given that these reactions were paradoxical effects of infliximab, infliximab treatment was discontinued in all cases, and additional corticosteroids or immunosuppressive medications were added. All cases remained free of ocular inflammation at the last visit.

Conclusion

Uveitis rarely occurs de novo or is exacerbated during infliximab treatment. Cessation of infliximab led to resolution of this paradoxical adverse effect.