Infectious complications of treatment with biologic agents

Prevalence of tuberculosis infection among contacts of drug-resistant tuberculosis patients: A systematic review and meta-analysis

INTRODUCTION

Contact investigations with drug-susceptible tuberculosis (DS-TB) patients have demonstrated a high prevalence of tuberculosis infection (TBI). However, the prevalence of TBI among individuals in close contact with drug-resistant tuberculosis (DR-TB) patients is poorly understood. This systematic review and meta-analysis aimed to determine the prevalence of TBI among household and non-household contacts of DR-TB patients.

METHOD AND ANALYSIS

We searched five databases (Medline, Embase, Scopus, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) from inception to 2 June 2023. All studies that reported the prevalence of TBI among DR-TB contacts were included in the study. A random-effects meta-analysis was conducted to estimate the pooled prevalence of TBI with a 95% confidence interval (CI). Sub-group analyses were conducted using study characteristics as covariates.

RESULTS

Thirty studies involving 7659 study participants from 19 countries were included. The pooled prevalence of TBI among DR-TB contacts was 36.52% (95% CI: 30.27-42.77). The sub-group analysis showed considerable heterogeneity in the estimates, with the highest prevalence reported in Southeast Asia (80.74%; 95% CI: 74.09-87.39), household contacts (38.60%; 95% CI: 30.07-47.14), lower-middle-income countries (LMICs) (54.72; 95% CI: 35.90, 73.55), children (43.27%; 95% CI: 25.50, 61.04), and studies conducted between 2004 and 2012 (45.10; 95% CI: 32.44, 57.76).

CONCLUSION

The prevalence of TBI among DR-TB contacts was high, with substantial regional variations. Further research is needed to determine the drug susceptibility status of TBI in DR-TB contacts.

PROTOCOL REGISTRATION

The protocol is registered in PROSPERO (CRD42023390339).

Prevalence of Latent Tuberculosis Infection in the Middle East and North Africa: A Systematic Review

OBJECTIVE

Data on the prevalence of latent tuberculosis infection (LTBI) in Middle Eastern and North African countries are scarce. We aimed to review all relevant published data in countries belonging to this region to determine the overall prevalence of LTBI in the Middle East and North Africa (MENA) region.

METHODS

In this systematic review PubMed and Google Scholar databases were searched for observational, prospective, retrospective, cross-sectional, and cohort studies providing prevalence data of LTBI in any MENA country. Studies fulfilling the search criteria were incorporated in the review. Overall prevalence of LTBI with 95% confidence intervals (CI) was calculated using the random-effects model; heterogeneity was assessed using I 2 statistics. Gender and age group-based subgroup analyses were performed to evaluate the basis of heterogeneity.

RESULTS

The total number of overall LTBI studies identified was 956, of which 31 studies from ten countries within the MENA region were included that represented 12,439 subjects. The overall prevalence was 41.78% (95% CI 31.18% to 52.78%, I 2 = 99.31%). By gender-based subgroup analysis, the prevalence of LTBI was 33.12% (95% CI 18.97% to 49.04%, I 2 = 99.25%) and 32.65% (95% CI 19.79% to 47%, I 2 = 98.89%) in males and females, respectively, while in the age-based subgroup analysis, the prevalence of LTBI was 0.44% (95% CI -0.05% to 0.9%), 3.37% (95% CI 2.23% to 4.74%, I 2 = 0%), and 43.81% (95% CI 33.09% to 54.82%, I 2 = 99.18%) for children, adolescents, and adults, respectively.

CONCLUSION

This systematic review reveals a high prevalence of LTBI in the MENA region; enhanced LTBI surveillance and prompt infection prevention steps are urgently needed to prevent active tuberculosis, this would help achieve the World Health Organization End TB Strategy 2035, and the United Nations Sustainable Development Goals 2030 target in the MENA region.

Tuberculin skin test conversion in patients under treatment with anti-tumor necrotizing factor alpha agents

Background

Despite successful clinical outcomes of biologic medications in patients with chronic rheumatic diseases, some considerable adverse effects such as infections remain a major concern. Possibility of tuberculosis (TB) reactivation over treatment with anti-tumor necrotizing factor (TNF) alpha agents has necessitated a screening test before initiation of treatment. However, screening over the course of treatment is not recommended in those patients with negative baseline screening tests. This study aimed to evaluate the efficacy of tuberculin skin test (TST) before treatment in patients with chronic rheumatologic diseases who were indicated to receive anti-TNF-alpha therapy and the necessity of repeating this test over the course of treatment.

Methods

In this prospective study, patients with chronic rheumatologic diseases receiving anti-TNF-alpha agents were studied in a two-year period. TST was performed before treatment and those with positive results were excluded from the study. Thereafter, treatment with anti-TNF-alpha agents was initiated with the indicated dose. TST was repeated before administration of biologic treatment until TST became positive or 16 weeks after the initiation of treatment with anti-TNF-alpha.

Results

A total of 51 cases were studied, of whom one patient (1.9%) was excluded due to positive TST before treatment. All participants received infliximab and the TST test became positive in one patient (2%) 2 weeks after receiving the first dose. Also, the results of further tests at weeks 6, 10, and 14 were all negative for the remaining patients.

Conclusion

Due to the possibility of TST conversion after administration of anti-TNF-alpha therapy, it is important to consider TB monitoring in patients under treatment with these agents using available methods such as TST.

Managing Inflammatory Manifestations in Patients with Chronic Granulomatous Disease

Chronic granulomatous disease (CGD) is a primary immunodeficiency caused by lack of phagocyte nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, which results in inflammatory dysregulation and increased susceptibility to infections. Patients with CGD may develop severe obstructive disorders of the digestive tract as a result of their dysregulated inflammatory response. Despite a growing focus on inflammatory manifestations in CGD, the literature data on obstructive complications are far less extensive than those on infectious complications. Diagnosis and management of patients with concomitant predispositions to infections and hyperinflammation are particularly challenging. Although the inflammatory and granulomatous manifestations of CGD usually respond rapidly to steroid treatment, second-line therapies (immunosuppressants and biologics) may be required in refractory cases. Indeed, immunosuppressants (such as anti-tumor necrosis factor agents, thalidomide, and anakinra) have shown some efficacy, but the value of this approach is controversial, given the questionable risk-to-benefit ratio and the small numbers of patients treated to date. Significant progress in allogeneic hematopoietic stem cell transplantation (the only curative treatment for CGD) has been made through better supportive care and implementation of improved, reduced-intensity conditioning regimens. Gene therapy may eventually be an option for patients lacking a suitable donor; clinical trials with new, safer vectors are ongoing at a few centers.

Treatment of severe non-infectious uveitis in high-risk conditions (Part 2): systemic infections; management and safety issues

INTRODUCTION

Management of patients with severe immune-mediated uveitis requires the use of immunosuppressive (IS) drugs in selected cases. This may be particularly challenging in certain patients with associated conditions, which may increase the risk of side effects or modify guidelines for the use of such drugs. Chronic viral and mycobacterial infections in the setting of non-infectious uveitis create a number of diagnostic but also therapeutic dilemmas to clinicians because they can be exacerbated by IS therapies with detrimental effects.

AREAS COVERED

In this review, we will focus on very specific chronic infections that can be affected by IS therapies: human immunodeficiency virus infection, chronic hepatitis virus infection and tuberculosis. The main aim of this review is to provide an updated and comprehensive practical guide for practitioners regarding the therapeutic decision-making and management of patients with non-infectious uveitis affected by the aforementioned infectious conditions.

EXPERT OPINION

Clinicians should be aware of the risk of viral and mycobacterial reactivation of an underlying infection during IS therapy. However, most of these conditions do not represent an absolute contraindication if one were able to apply an appropriate prior screening and close monitoring of such therapy.

Systematic review: Whipple's disease (Tropheryma whipplei infection) and its unmasking by tumour necrosis factor inhibitors

BACKGROUND

The classical form of Whipple's disease (WD), clinically characterised by arthropathy, diarrhoea and weight loss, is rare. Recently, other more frequent forms of Tropheryma whipplei infection have been recognised. The clinical spectrum includes an acute, self-limiting disease in children, localised forms affecting cardiac valves or the central nervous system without intestinal symptoms, and asymptomatic carriage of T. whipplei which is found in around 4% of Europeans. Genomic analysis has shown that T. whipplei represents a host-dependent or opportunistic bacterium. It has been reported that the clinical course of T. whipplei infection may be influenced by medical immunosuppression.

AIM

To identify associations between immunomodulatory treatment and the clinical course of T. whipplei infection.

METHODS

A PubMed literature search was performed and 19 studies reporting on immunosuppression, particularly therapy with tumour necrosis factor inhibitors (TNFI) prior to the diagnosis in 41 patients with Whipple?s disease, were evaluated.

RESULTS

As arthritis may precede the diagnosis of WD by many years, a relevant percentage (up to 50% in some reports) of patients are treated with immunomodulatory drugs or with TNFI. Many publications report on a complicated Whipple?s disease course or T. whipplei endocarditis following medical immunosuppression, particularly after TNFI. Standard diagnostic tests such as periodic acid-Schiff stain used to diagnose Whipple?s disease often fail in patients who are pre-treated by TNFI.

CONCLUSIONS

In cases of doubt, Whipple?s disease should be excluded before therapy with TNFI. The fact that immunosuppressive therapy contributes to the progression of T. whipplei infection expands our pathogenetic view of this clinical entity.

Progressive disseminated histoplasmosis in the HIV population in Europe in the HAART era. Case report and literature review

INTRODUCTION

In highly endemic areas, up to 20 % of human immunodeficiency virus (HIV)-infected persons will develop progressive disseminated histoplasmosis (PDH). Europe is not endemic to histoplasmosis, and the disease is mainly found in immigrants often co-infected with HIV.

METHODS

We present a case of a patient with HIV and PDH highlighting the possible diagnostic difficulties that may arise in a non-endemic area and review the literature of histoplasmosis in the context of HIV infection with special focus on Europe.

DISCUSSION

When cellular immunity wanes (usually at CD4 T-lymphocyte counts <150 cells/μL) histoplasma infection, acquired earlier, can reactivate and disseminate. PDH is an acquired immune deficiency syndrome(AIDS)-defining disease and a life-threatening infection, with a clinical spectrum ranging from an acute, fatal course with lung infiltrates and respiratory failure, shock, coagulopathy and multi-organ failure, to a more subacute disease with focal organ involvement, pancytopenia and hepatosplenomegaly. Mortality rates remain high for untreated patients, but early diagnosis, proper antifungal treatment and early initiation of antiretroviral therapy have improved the prognosis.

CONCLUSION

European infectious diseases physicians, microbiologists and pathologists must be aware of histoplasmosis, particularly when facing HIV-infected immigrants from endemic areas. This is increasingly important due to migration and travel activities from these areas.

Severe cutaneous and arthritic psoriasis in patient with AIDS: a good outcome with therapy using etanercept

We report the case of a patient with cutaneous and arthropathic psoriasis for eight years, whose sudden increased severity of the clinical picture led to a diagnosis of AIDS, emphasizing the importance of the specialist in the diagnosis of systemic diseases. The appropriate therapeutic interventions, including antiretroviral therapy and the immunobiological agent etanercept, enabled rapid improvement of symptoms and quality of life of the patient, besides contributing to delay in immunodeficiency progression.

The affecting factors and comparison of tuberculin skin test in peritoneal dialysis and hemodialysis patients

Compared with the general population, patients with chronic renal failure have increased tuberculosis (TB) prevalence and mortality rates. In this study, we aimed to investigate tuberculin skin test (TST) positivity rates in hemodialysis (HD) and peritoneal dialysis (PD) patients and the factors influencing TST positivity. Ninety-two HD patients and 44 PD patients who had been on HD and PD treatment for at least 3 months were recruited into the study. TST was administered in all patients. Positivity was defined as an induration diameter >10 mm. At least 5 mm of induration following skin testing together with a chest radiography indicating previous infection was defined as latent TB infection. TST positivity rates, diameter of TST indurations, and serum albumin levels in HD patients were higher than the PD patients. TST induration size was not correlated with any other parameters in both HD and PD groups. TST-positive patients had higher albumin levels and lower leukocyte count than the TST-negative patients. In TST-positive patients, albumin level was correlated with the duration of dialysis but TST induration size was not correlated with the lymphocyte count and albumin level. In our study, TST positivity of patients was found in 30.4% of HD patients, 9% of PD patients, and 23.5% of total patients. It is still recommended to use TST for the screening test of TB. We found a significant relationship between TST and albumin level. It should be remembered that TST response may be lower in PD patients, especially in cases in which TB is suspected.

Incidence of tuberculosis among korean patients with ankylosing spondylitis who are taking tumor necrosis factor blockers

OBJECTIVE

To assess the incidence and relative risk of new tuberculosis (TB) infections in Korean patients with ankylosing spondylitis (AS) and patients with AS who are undergoing treatment with tumor necrosis factor (TNF) blockers.

METHODS

New cases of TB were identified by reviewing the medical records of 919 patients with AS not treated with TNF blockers and those of 354 patients with AS treated with adalimumab (n = 66), infliximab (n = 78), or etanercept (n = 210) between 2002 and 2009. Reference data were obtained from the Korean National Tuberculosis Association.

RESULTS

The mean incidence rate of TB was 69.8 per 100,000 person-years (PY) in the general population, 308 per 100,000 PY in the TNF blocker-naive AS cohort, and 561 per 100,000 PY in the TNF blocker-exposed AS cohort. The incidence rate of TB in the infliximab-treated AS cohort (540 per 100,000 PY) was higher than that in the adalimumab-treated AS cohort (490 per 100,000 PY). No cases of TB occurred in the etanercept-treated AS cohort. Comparing the relative risks of TB infections between the TNF blocker-exposed AS cohort and the TNF blocker-naive AS cohort, no statistically significant difference was identified (risk ratio 0.53; 95% CI 0.144-1.913).

CONCLUSION

The risk of TB was higher in the TNF blocker-naive AS cohort than it was in the general population. However, the risk of TB was not increased in the TNF blocker-exposed AS cohort compared with the TNF blocker-naive AS cohort. Among patients with AS, etanercept is associated with a lower risk of TB compared with monoclonal antibodies.

Infections in patients treated with tumor necrosis factor antagonists: incidence, etiology and mortality in the BIOBADASER registry

BACKGROUND AND OBJECTIVES

Whether the use of tumor necrosis factor antagonists increases the risk of infection remains a subject of open debate. Developing effective strategies of prevention and empirical treatment entails carefully establishing the etiology and prognosis of the infections.

PATIENTS AND METHODS

Analysis of the Spanish registry BIOBADASER (Feb-2000 to Jan-2006), a national drug safety registry of patients with rheumatic diseases.

RESULTS

907 episodes of infection occurring in 6,969 patients were analyzed. The infection incidence observed was 53.09 cases/1,000 patients-years (CI 95% 49.69-56.66). The most frequent infections were skin infection (12.18 cases/1,000 patients-yrs), pneumonia (5.97 cases/1,000 patients-yrs), cystitis (3.92 cases/1,000 patients-yrs), tuberculosis (3.51 cases/1,000 patients-yrs) and arthritis (3.76 cases/1,000 patients-yrs). Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, Pseudomonas aeruginosa and Salmonella spp. emerged as important pathogens. Varicella zoster virus and Herpes simplex virus caused most cases of viral infections. Mucocutaneous candidiasis accounted for most fungal infections. Mortality was increased in infected patients (log-rank test p<0.0001). Pneumonia, sepsis, tuberculosis, abdominal infection and endocarditis were associated with significant attributable mortality.

CONCLUSIONS

A significant number of bacterial, viral and fungal infections occurred in patients with rheumatic diseases treated with TNF antagonists. The information of this study can illuminate clinicians globally on how to address infection in this vulnerable group of patients.

Use of dipeptidyl peptidase-4 inhibitors and the reporting of infections: a disproportionality analysis in the World Health Organization VigiBase

OBJECTIVE

Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of antidiabetic drugs. They inactivate incretin hormones but also have many other effects throughout the body, among which are effects on the immune system. This might result in an increased infection risk. This study assessed the association between use of DPP-4 inhibitors and the reporting of infections.

RESEARCH DESIGN AND METHODS

A nested case-control was conducted using VigiBase, the World Health Organization-Adverse Drug Reactions (WHO-ADR) database. The base cohort consisted of ADRs for antidiabetic drugs (Anatomical Therapeutic Chemical code A10). Cases were defined as ADRs of infection according to the Medical Dictionary for Regulatory Activities (MedDRA) classification system. All other ADRs were considered controls. Reporting odds ratios (RORs) were calculated to estimate the strength of the association between different classes of antidiabetic drugs and the reporting of infections.

RESULTS

We identified 305,415 suspected ADRs involving antidiabetic drugs in 106,469 case reports, of which 8,083 involved DPP-4 inhibitors monotherapy. Overall, the reporting of infections was higher for patients using DPP-4 inhibitors compared with users of biguanides (ROR 2.3 [95% CI 1.9-2.7]). Reporting of upper respiratory tract infections (ROR 12.3 [95% CI 8.6-17.5]) was significantly associated with use of DPP-4 inhibitors.

CONCLUSIONS

This study indicates an increased reporting of infections, in particular upper respiratory tract infections, for users of DPP-4 inhibitors compared with users of other antidiabetic drugs. However, the limitations of spontaneous reporting systems (e.g., underreporting, the Weber-effect, reporting bias) should be taken into account. Therefore, further research is needed to evaluate this suspicion and the underlying mechanism.

Complications of tumor necrosis factor-α blockade in chronic granulomatous disease-related colitis

BACKGROUND

Chronic granulomatous disease (CGD) is a genetic disorder of the phagocyte NADPH oxidase, which predisposes patients to infections and inflammatory complications, including severe colitis. Management of CGD colitis is a challenge because standard immunosuppressive therapy increases the risk of infection in already immunocompromised hosts.

METHODS

We report the use of infliximab in 5 patients with CGD.

RESULTS

Infliximab administration predisposed patients to severe infections with typical CGD pathogens but not mycobacteria, as reported with infliximab in other conditions. In addition to infections, infliximab administration led to successful closure of fistulae, sometimes with other untoward consequences. Infliximab-associated complications were associated with 2 deaths.

CONCLUSIONS

Infliximab use in the treatment of CGD inflammatory bowel disease requires aggressive antimicrobial prophylaxis, assiduous surveillance for infection, and vigilance for untoward gastrointestinal complications. This experience suggests that infliximab therapy is effective but has untoward consequences in patients with CGD.

Mapping the safety profile of biologicals: a disproportionality analysis using the WHO adverse drug reaction database, VigiBase

BACKGROUND

Biologicals have specific characteristics, as compared with the small molecule drugs, and carry specific risks. Safety problems, for example infliximab and the risk for tuberculosis, have been identified via spontaneous reports of suspected adverse drug reactions (ADRs). However, in general there is limited data on the nature of spontaneously reported suspected ADRs for biologicals.

OBJECTIVE

To map the safety profile of biologicals as compared with all other drugs. In addition, mechanistic classes of biologicals will be compared.

METHODS

Data was obtained from the ADR database (VigiBase) maintained by the WHO Collaborating Centre for International Drug Monitoring. A disproportionality analysis was performed in which case reports for biologicals and all other drugs (the reference group), reported between January 1995 and December 2008, were selected. Vaccines were not included in the analysis. Suspected ADRs were classified according to Medical Dictionary for Regulatory Activities (MedDRA) version 12.0 at the System Organ Class (SOC) level. Biologicals were classified into mechanistic classes: antibodies, cytokines, enzymes, growth factors, hormones (reference group), interferons, receptors and others/various. The safety profile of the biologicals versus all other drugs in the database and of the various mechanistic classes of biologicals was compared using the proportional reporting ratio (PRR).

RESULTS

191,004 case reports containing 546,474 suspected ADRs were reported for 62 different biologicals, and 2,556,209 case reports containing 8,761,522 suspected ADRs were reported for all other drugs (the reference group). It was found that two-thirds of all suspected ADRs reported for biologicals were reported for five active substances: etanercept (20.3%), interferon-beta-1a (15.6%), infliximab (11.6%), teriparatide (10.7%) and adalimumab (9.0%). Comparison of the safety profile of biologicals and the reference group showed that suspected ADRs for biologicals were more frequently reported in the SOCs 'Infections and infestations' (PRR 4.5), 'Surgical and medical procedures' (PRR 2.4) and 'Neoplasms benign, malignant and unspecified' (PRR 2.1), and less frequently reported in the SOCs 'Psychiatric disorders' (PRR 0.4), 'Vascular disorders' (PRR 0.4) and 'Pregnancy, puerperium and perinatal conditions' (PRR 0.4). Regarding the differences in safety profile between various mechanistic classes of biologicals, compared with hormones (reference group), 'Infections and infestations' were more frequently reported for receptors and antibodies. 'Neoplasms benign, malignant and unspecified' were more frequently reported for antibodies, cytokines, interferons and receptors, and less frequently for enzymes as compared with the reference group.

CONCLUSIONS

In VigiBase, five biologicals comprise two-thirds of the suspected ADRs reported for biologicals, which might distort the relation found between a specific biological and a specific adverse event in case of quantitative signal detection. Therefore the choice of reference group to be used in case of quantitative signal detection should be considered very carefully. This study confirmed that biologicals have a different safety profile compared with all other drugs in the database and, within the group of biologicals, differences exist between mechanistic classes. Infections are, for example, frequently reported for receptors and antibodies, which often have an immune compromising effect. Such predictable safety issues should be specifically studied by preregistration clinical trials and/or targeted pharmacovigilance. In addition, since not all adverse reactions can be predicted or detected during development, spontaneous reporting remains an important tool for the early detection of signals.

Ustekinumab: an evidence-based review of its effectiveness in the treatment of psoriasis

Introduction:

Psoriasis is a chronic inflammatory skin disease affecting approximately 2% to 3% of the population worldwide. Discoveries over the past 3 to 5 years have significantly altered our view of psoriasis as primarily a T-cell mediated condition. The most recent research has demonstrated the essential role of specific cytokines in the development of this complex disease, including TNF-α, interleukin-23 (IL-23), and potentially, IL-22. These are all part of a newly defined autoimmune pathway directed by specialized T cells called Th17 helper T cells. Ustekinumab is a fully human monoclonal antibody that targets IL-12 and IL-23, thus targeting both Th1 and Th17 arms of immunity. It has a promising efficacy and safety profile that not only represents a valuable treatment alternative, but also a continuation in our constantly evolving understanding of this disorder.

Aims:

To review the emerging evidence supporting the use of ustekinumab in the management of moderate to severe plaque psoriasis.

Evidence review:

There is clear evidence that ustekinumab is effective in the treatment of moderate to severe psoriasis. Phase III trials (PHOENIX 1 and 2) demonstrated a statistically significant difference between Psoriasis Area and Severity Index (PASI) 75 responses achieved by patients receiving ustekinumab, given as a 45 mg or 90 mg subcutaneous injection every 12 weeks, than their placebo counterparts. Treatment with this novel agent resulted in a rapid onset of action, with over 60% of treated patients attaining Physician’s Global Assessment (PGA) scores of “cleared” or “minimal” by week 12. Quality of life assessments paralleled clinical improvements.

Clinical potential:

Ustekinumab is an effective and efficient therapeutic option for patients with moderate to severe psoriasis. Although further studies are required to establish ustekinumab’s place in the therapy of psoriasis, with its convenient dosing schedule and rapid onset of action, this drug could provide a great addition to the current therapeutic armamentarium available for psoriatic patients.

A case of tuberculous arthritis following the use of etanercept

Etanercept is a tumor necrosis factor (TNF) inhibitor that has been used for the treatment of chronic inflammatory diseases including rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. Because of its immunosuppressive activity, opportunistic infections have been noted in treated patients, most notably caused by Mycobacterium tuberculosis. Tuberculosis may present in an extrapulmonary or disseminated form. Since TNF-alpha inhibitors have been used in Korea, a few cases of TNF-alpha inhibitor associated tuberculosis have been described. However, tuberculous arthritis has not been previously reported. We describe a case of tuberculous arthritis in a 57-year-old woman with rheumatoid arthritis who was treated with etanercept.

Introduction: arthritis and myositis

In this chapter background medical information pertinent to the use of MRI and/or ultrasound in various musculoskeletal conditions is presented. Appreciation of the genetic, biochemical, histological, and immunological features of rheumatic diseases will be of benefit to the technician responsible for performing and interpreting these types of interrogations. For example, recognizing that cartilage disorder predates bone findings in osteoarthritis will help identify early versus late degenerative findings. Similarly, understanding the fibrovascular nature of rheumatoid pannus will help guide the use of more sophisticated ultrasound techniques such as power Doppler.

Administrative codes combined with medical records based criteria accurately identified bacterial infections among rheumatoid arthritis patients

OBJECTIVE

To evaluate diagnostic properties of International Classification of Diseases, Version 9 (ICD-9) diagnosis codes and infection criteria to identify bacterial infections among rheumatoid arthritis (RA) patients.

STUDY DESIGN AND SETTING

We performed a cross-sectional study of RA patients with and without ICD-9 codes for bacterial infections. Sixteen bacterial infection criteria were developed. Diagnostic properties of comprehensive and restrictive sets of ICD-9 codes and the infection criteria were tested against an adjudicated review of medical records.

RESULTS

Records on 162 RA patients with and 50 without purported bacterial infections were reviewed. Positive and negative predictive values of ICD-9 codes ranged from 54%-85% and 84%-100%, respectively. Positive predictive values of the medical records based criteria were 84% and 89% for "definite" and "definite or empirically treated" infections, respectively. Positive predictive value of infection criteria increased by 50% as disease prevalence increased using ICD-9 codes to enhance infection likelihood.

CONCLUSION

ICD-9 codes alone may misclassify bacterial infections in hospitalized RA patients. Misclassification varies with the specificity of the codes used and strength of evidence required to confirm infections. Combining ICD-9 codes with infection criteria identified infections with greatest accuracy. Novel infection criteria may limit the requirement to review medical records.

Fungal infections complicating tumor necrosis factor alpha blockade therapy

Tumor necrosis factor a (TNF-alpha) blockade has emerged as a useful therapy for collagen vascular diseases or graft-vs-host disease. Fungal infections complicating such therapy have been reported sporadically. MEDLINE and PubMed databases (from January 1, 1966, to June 1, 2007) were searched for reports of invasive fungal infections (IFIs) associated with the 3 available anti-TNF- alpha agents, ie, infliximab, etanercept, and adalimumab. Of the 281 cases of IFI associated with TNF-alpha inhibition, 226 (80%) were associated with infliximab, 44 (16%) with etanercept, and 11 (4%) with adalimumab. Fungal infections associated with infliximab occurred a median of 55 days (interquartile range [IQR], 15-140 days) after initiation of therapy and 3 infusions of the medication (IQR, 2-5), whereas those associated with etanercept occurred a median of 144 days (IQR, 46-240 days) after initiation of therapy. The median age of patients was 58 years (IQR, 44-68 years), and 62% were male. Use of at least 1 other immunosuppressant medication, typically a systemic corticosteroid, was reported during the course of the fungal infection in 102 (98%) of the 104 patients for whom data were available. The most prevalent IFIs were histoplasmosis (n=84 [30%]), candidiasis (n=64 [23%]), and aspergillosis (n equals 64 [23%]). Pneumonia was the most common pattern of infection. Of the 90 (32%) of 281 cases for which outcome information was available, 29 fatalities (32%) were recorded. Tumor necrosis factor a blockade is associated with IFI across a range of host groups. A high index of suspicion in patients treated with TNF-alpha antagonists is recommended because the course of such infections can be serious or fulminant, and rapid access to health care should be provided. Surveillance of IFIs complicating TNF-alpha blockade and other biologic therapies is warranted through well-organized prospective patient registries.

Infection of an urachal cyst during etanercept therapy in juvenile idiopathic arthritis

Etanercept, a tumor necrosis factor (TNF) receptor alpha antagonist is licensed for the treatment in patients affected by polyarticular juvenile idiopathic arthritis, who do not tolerate or had an inadequate response to methotrexate. Infections related to immunosuppression by etanercept are of major concern. We report on a 17-year-old boy with enthesitis-related arthritis who developed a major infection of an urachal cyst 18 months after initiation of etanercept therapy, which required surgery. The urachus had not been symptomatic before.

Strongyloides stercoralis hyperinfection in a patient with rheumatoid arthritis after anti-TNF-alpha therapy

Strongyloidiasis is epidemic in tropical and subtropical regions where the regional prevalence may exceed 25%. In the United States, highest infection rates are found in immigrants. Many infected individuals are asymptomatic, whereas others may have mild and nonspecific cutaneous, intestinal, and pulmonary symptoms. Strongyloides stercoralis may remain as a dormant infection, but replication and dissemination can be fatal in immunocompromised patients. We report on a 63-year-old native Filipino man with a history of rheumatoid arthritis who developed Escherichia coli sepsis, filariform larvae characteristic of S. stercoralis bronchoalveolar lavage, and adult respiratory distress syndrome 3 weeks after he presented with vague gastrointestinal symptoms. We believe that the addition of a tumor necrosis factor (TNF)-alpha inhibitor to his treatment with prednisone and methotrexate for rheumatoid arthritis further suppressed his cellular immunity leading to hyperinfection and life-threatening S. stercoralis infection. This is another, often latent, infection that should be considered in patients in or from endemic areas before institution of antitumor necrosis factor therapy.

Unusual manifestation of histoplasmosis in connective tissue diseases

This report describes the coexistence of three patients with rheumatic diseases (systemic lupus erythematosus, rheumatoid arthritis, and dermatomyositis) and infections because of Histoplasma capsulatum. Connective tissue diseases and histoplasmosis share several clinical findings. Therefore, histoplasmosis could be misdiagnosed as connective tissue disease or a flare of these diseases. Such cases highlight the importance of awareness of histoplasmosis in immunocompromised patients, particularly in those originating from endemic areas.

Disseminated mucormycosis and orbital ischaemia in combination immunosuppression with a tumour necrosis factor alpha inhibitor

Disseminated mucormycosis, with pulmonary and cerebral angioinvasive disease, developed in a 65-year-old woman with rheumatoid arthritis being treated with combination immunosuppression including adalimumab. Clinical presentation included progressive orbital ischaemia. To the best of the authors' knowledge, this is the first reported case of disseminated mucormycosis in a patient treated with a tumour necrosis factor inhibitor. Important pathophysiological factors are considered.

Off-label uses of biologics in dermatology: Rituximab, omalizumab, infliximab, etanercept, adalimumab, efalizumab, and alefacept (Part 2 of 2)

Recently, dermatologists have witnessed a revolution in our therapeutic armamentarium with the development of several novel biologic immunomodulators. Although psoriasis remains the only condition in dermatology for which the use of biologic immunomodulators has been approved by the Food and Drug Administration, these drugs have the potential to significantly impact the treatment of several inflammatory conditions in dermatology. This article includes a review of the mechanism of action, dosing, and side-effect profile, as well as a review of the current literature on off-label uses of the CD20-positive B-cell antagonist rituximab, the IgE antagonist omalizumab, the tumor necrosis factor-alpha antagonists infliximab, etanercept, and adalimumab, and the T-cell response modifiers efalizumab and alefacept.

Postoperative Infektion unter Adalimumab

Tumor necrosis factor (TNF) blocking agents, such as adalimumab, are well tolerated and provide improvement in the symptoms and signs of rheumatoid arthritis (RA). Due to its immunosuppressive effect, an increased risk of infection has been suggested, but so far no differences between adalimumab and placebo groups have been found in pivotal trials. Patients with RA succumb to postoperative complications because they have a systemic disease and use medication with immunosuppressive effects. We report on a patient with longstanding, active RA who had received adalimumab 40 mg every other week with prolonged infection, wound dehiscence and pseudoarthrosis following reconstructive forefoot surgery due to deformities secondary to RA. The postoperative infection occurred although adalimumab therapy had been stopped 8 days before surgery. The half-life of adalimumab is 10.0-13.6 days following a single intravenous dose. Whether patients under therapy with adalimumab are at an increased risk of developing postoperative complications is unclear, a retrospective analysis of the pivotal studies would be helpful in estimating the risk of perioperative (wound) infections in patients receiving anti-TNF. Moreover, it is not clear when therapy should be stopped prior to surgical intervention. Obviously prospective clinical trials would be more convincing.

Interleukin-23 drives innate and T cell-mediated intestinal inflammation

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract involving aberrant activation of innate and adaptive immune responses. We have used two complementary models of IBD to examine the roles of interleukin (IL)-12 family cytokines in bacterially induced intestinal inflammation. Our results clearly show that IL-23, but not IL-12, is essential for the induction of chronic intestinal inflammation mediated by innate or adaptive immune mechanisms. Depletion of IL-23 was associated with decreased proinflammatory responses in the intestine but had little impact on systemic T cell inflammatory responses. These results newly identify IL-23 as a driver of innate immune pathology in the intestine and suggest that selective targeting of IL-23 represents an attractive therapeutic approach in human IBD.

Use of etanercept in human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) patients

BACKGROUND

Etanercept (Enbrel, Amgen, Thousand Oaks, CA), a soluble p75 tumor necrosis factor receptor:FC (TNFR:FC) fusion protein for plasma cytokines, specifically tumor necrosis factor-alpha (TNF-alpha), is used in the treatment of immune-mediated rheumatic diseases. To our knowledge, the use of etanercept in patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) is relatively uncommon.

OBJECTIVE

The main purpose of this short review is to examine the safety of etanercept in patients with HIV/AIDS.

METHODS

A Medline search was conducted using the keywords etanercept and HIV and/or AIDS for any published articles between 1966 to the present (September 2004).

RESULTS

A case report, one case series, and one clinical trial pertained to the use of etanercept in HIV patients. No reports were found on the use of etanercept in AIDS. In addition, two case reports were found documenting the use of infliximab in HIV patients.

DISCUSSION

Preliminary reports indicate that the administration of etanercept does not appear to increase the morbidity or mortality rates in HIV. The inhibition of TNF-alpha may actually improve the symptoms of HIV/AIDS-associated aphthous ulcers, cachexia, dementia, fatigue, and fever, as well as help manage concomitant rheumatic diseases and psoriasis.

CONCLUSION

The use of etanercept shows promise for applications in disease management in patients with HIV/AIDS. Continued research efforts are necessary to establish the long-term safety and efficacy of etanercept and other biologic agents in this patient population.