ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [II]: agents targeting interleukins, immunoglobulins and complement factors)

BACKGROUND

The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies.

AIMS

To review, from an Infectious Diseases perspective, the safety profile of agents targeting interleukins, immunoglobulins and complement factors and to suggest preventive recommendations.

SOURCES

Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family.

CONTENT

Patients receiving interleukin-1 (IL-1) -targeted (anakinra, canakinumab or rilonacept) or IL-5-targeted (mepolizumab) agents have a moderate risk of infection and no specific prevention strategies are recommended. The use of IL-6/IL-6 receptor-targeted agents (tocilizumab and siltuximab) is associated with a risk increase similar to that observed with anti-tumour necrosis factor-α agents. IL-12/23-targeted agents (ustekinumab) do not seem to pose a meaningful risk of infection, although screening for latent tuberculosis infection may be considered and antiviral prophylaxis should be given to hepatitis B surface antigen-positive patients. Therapy with IL-17-targeted agents (secukinumab, brodalumab and ixekizumab) may result in the development of mild-to-moderate mucocutaneous candidiasis. Pre-treatment screening for Strongyloides stercoralis and other geohelminths should be considered in patients who come from areas where these are endemic who are receiving IgE-targeted agents (omalizumab). C5-targeted agents (eculizumab) are associated with a markedly increased risk of infection due to encapsulated bacteria, particularly Neisseria spp. Meningococcal vaccination and chemoprophylaxis must be administered 2-4 weeks before initiating eculizumab. Patients with high-risk behaviours and their partners should also be screened for gonococcal infection.

IMPLICATIONS

Preventive strategies are particularly encouraged to minimize the occurrence of neisserial infection associated with eculizumab.

Rheumatic immune-related adverse events of checkpoint therapy for cancer: case series of a new nosological entity

Immunotherapy of cancer with checkpoint inhibitors has been associated with a spectrum of autoimmune and systemic inflammatory reactions known as immune-related adverse events (irAEs). Rheumatic irAEs are infrequently reported and extensively described. Here, we report our experience over an 18-month period with 15 patients evaluated in the rheumatology department for rheumatic irAEs. We identified 13 patients without pre-existing autoimmune disease (AID) who subsequently developed rheumatic irAEs, and two with established AID referred pre-emptively. irAEs encountered included: inflammatory arthritis, sicca syndrome, polymyalgia rheumatica-like symptoms and myositis. All cases required glucocorticoids, and three required a biological agent. Rheumatic irAEs led to temporary or permanent cessation of immunotherapy in all but five patients. One patient with pre-existing AID experienced a flare after starting immunotherapy. Our findings underscore that rheumatic irAEs are complex, at times require additional immunosuppressive therapy, and may influence ongoing immunotherapy regimens for the primary disease. Similar irAEs will be increasingly seen as checkpoint inhibitors adopted as standard of care in the community.

High-resolution MRI vessel wall imaging: spatial and temporal patterns of reversible cerebral vasoconstriction syndrome and central nervous system vasculitis

BACKGROUND AND PURPOSE

High-resolution MR imaging is an emerging tool for evaluating intracranial artery disease. It has an advantage of defining vessel wall characteristics of intracranial vascular diseases. We investigated high-resolution MR imaging arterial wall characteristics of CNS vasculitis and reversible cerebral vasoconstriction syndrome to determine wall pattern changes during a follow-up period.

MATERIALS AND METHODS

We retrospectively reviewed 3T-high-resolution MR imaging vessel wall studies performed on 26 patients with a confirmed diagnosis of CNS vasculitis and reversible cerebral vasoconstriction syndrome during a follow-up period. Vessel wall imaging protocol included black-blood contrast-enhanced T1-weighted sequences with fat suppression and a saturation band, and time-of-flight MRA of the circle of Willis. Vessel wall characteristics including enhancement, wall thickening, and lumen narrowing were collected.

RESULTS

Thirteen patients with CNS vasculitis and 13 patients with reversible cerebral vasoconstriction syndrome were included. In the CNS vasculitis group, 9 patients showed smooth, concentric wall enhancement and thickening; 3 patients had smooth, eccentric wall enhancement and thickening; and 1 patient was without wall enhancement and thickening. Six of 13 patients had follow-up imaging; 4 patients showed stable smooth, concentric enhancement and thickening; and 2 patients had resoluton of initial imaging findings. In the reversible cerebral vasoconstriction syndrome group, 10 patients showed diffuse, uniform wall thickening with negligible-to-mild enhancement. Nine patients had follow-up imaging, with 8 patients showing complete resolution of the initial findings.

CONCLUSIONS

Postgadolinium 3T-high-resolution MR imaging appears to be a feasible tool in differentiating vessel wall patterns of CNS vasculitis and reversible cerebral vasoconstriction syndrome changes during a follow-up period.

Progressive multifocal leucoencephalopathy in the rheumatic diseases: assessing the risks of biological immunosuppressive therapies

Progressive multifocal leucoencephalopathy (PML) is a rare and often fatal opportunistic infection that has been well reported in patients with rheumatic diseases. The contributions of predisposing factors such as underlying disease and immunosuppressive drug selection are incompletely understood but it would appear that patients with systemic lupus erythematosus may be at highest risk. Natalizumab, a biological agent approved for multiple sclerosis and Crohn's disease has the clearest pattern of small but definite risk. Although the risk due to rituximab is difficult to assess given the multiple confounders, continued vigilance is warranted. Rheumatologists need to become familiar with PML and feel able to help patients make shared and informed decisions about the risks when starting treatment with immunosuppressive therapies. In particular, rheumatologists need to be vigilant and pursue the diagnosis of PML in all patients with unexplained neurological signs or symptoms with clinical and MRI findings compatible with the diagnosis.

Arteriovenous malformation of the brain mimicking primary central nervous system vasculitis

In the diagnosis of primary central nervous system (CNS) vasculitis, it is crucial to rule out clinical, angiographic, and pathological mimics. We report a case of arteriovenous malformation (AVM) mimicking primary CNS vasculitis. A young male presented with intracerebral haemorrhage and no other clinical, laboratory, or angiographic features suggesting vasculitis. Cerebral biopsy showed perivascular inflammation and slight infiltration of the muscular layer of cerebral vessels by chronic inflammatory cells close to the haemorrhagic areas. These findings led to a diagnosis of CNS vasculitis. The patient was initially treated with corticosteroids, but 10 months after the discovery and surgical repair of the AVM, the patient is not receiving any immunosuppressant and has not developed any features of cerebral or systemic vasculitis.

Tumour-like mass lesion: an under-recognised presentation of primary angiitis of the central nervous system

OBJECTIVE

To describe the occurrence of mass lesions (ML) in primary angiitis of the central nervous system (PACNS) and assess the utility of diagnostic testing and treatment.

METHODS

We examined the case records of the Cleveland Clinic (CC), Massachusetts General Hospital (MGH), and the English language medical literature, for biopsy-proven PACNS cases presenting as a solitary ML. Relevant clinical variables were extracted and analysed with JMP software.

RESULTS

We identified a total of 38 ML: eight of 202 (4.0%) patients with CC/MGH and 30 of 535 (5.6%) patients with PACNS identified from the medical literature. A higher percentage (13 of 45; 29%) was seen in the amyloid-related angiitis subset. Poorer outcomes were reported in the amyloid group, with five deaths. Of the non-amyloid group, better outcomes were seen in the group treated with corticosteroids and cyclophosphamide as compared with the group treated with corticosteroids alone.

CONCLUSIONS

Although rare, PACNS should be considered in the differential diagnosis of ML; greater awareness of this manifestation may facilitate more prompt diagnosis and treatment. Biopsy evidence of angiitis is required for diagnosis; specimens should routinely be stained for amyloid. While excision of the lesion may be curative, aggressive immunosuppressive therapy is associated with favourable outcomes and may obviate the need for surgery.

Hepatitis C-associated mixed cryoglobulinaemia: a crossroad between autoimmunity and lymphoproliferation

Hepatitis C virus (HCV) infection is the second most cocmmon chronic viral infection in the world with a global prevalence of about 2%. Chronic HCV infection is commonly associated with a number of extrahepatic complications. Circulating mixed cryoglobulins (MCs) are detected in 40-60% of HCV-infected patients whereas overt cryoglobulinaemia vasculitis develops in only 5-10% of the cases. MC reflects the expansion of B cells producing a pathogenic IgM with rheumatoid factor (RF) activity. Because cryoglobulin-producing B cells in HCV are mostly monoclonal, HCV-associated MC can be viewed as a benign B cell lymphoproliferative condition. The disease expression of MC vasculitis is variable, ranging from mild clinical symptoms (purpura, arthralgia) to fulminant life-threatening complications (glomerulonephritis, widespread vasculitis). The overall risk of non-Hodgkin's lymphoma in patients with HCV-MC is estimated to be 35 times higher than that in the general population. This review will focus on recent advances in our understanding of the clinical course, complications, pathophysiology and treatment of those immune-mediated disorders.

Hepatitis B virus (HBV) reactivation with immunosuppressive therapy in rheumatic diseases: assessment and preventive strategies

Understanding of the natural history and basic biology of hepatitis B virus (HBV) has increased greatly in recent years. In view of this, the following are reviewed here: (a) recent advances in HBV biology pertinent to the rheumatic disease population; (b) the risks of HBV reactivation in patients with rheumatic disease undergoing immunosuppression; and (c) potential strategies to manage these risks.

Safety of antitumour necrosis factor (anti-TNF) therapy in patients with chronic viral infections: hepatitis C, hepatitis B, and HIV infection

Tumour necrosis factor alpha (TNFalpha) is a pivotal cytokine in host defences with broad ranging effects on the innate and adaptive immune systems. Clinically, TNFalpha inhibitors have demonstrated remarkable efficacy in a wide range of autoimmune and inflammatory disorders but clearly at the cost of heightened susceptibility to a variety of infections in those treated with these agents. Most reports to date have described increased susceptibility to intracellular pathogens in patients with underlying chronic viral infections, but little in the way of adverse event reporting in these patients has occurred. While the reported experience to date is rather limited, TNFalpha inhibitors have displayed a reasonable safety profile in the setting of some chronic viral infections and in certain circumstances have demonstrated adjunctive activity in the treatment of these infections. Given the high prevalence of chronic viral infections in patients who are candidates for anti-TNF therapy and the potential for these agents in the treatment of chronic viral illness, additional studies are urgently needed to assess the risks and benefits of such therapy in these populations.

Infection with the human immunodeficiency virus type 1 and vascular inflammatory disease

Since the beginning of the HIV epidemic a wide variety of vascular inflammatory diseases have been described in HIV infected patients. In terms of the primary forms of systemic necrotizing vasculitis, there are no convincing data suggesting HIV infection increases the risk of development of any form of these diseases, but it is possible--though yet unproven--that HIV may lessen the chance of developing other forms (i.e. ANCA-associated disease and HBV-associated PAN). Secondary vasculitis resulting from unusual pathologic expressions of opportunistic infections has been reported and has important clinical significance. Finally, there does appear to be growing clinical, epidemiologic and pathologic evidence that several distinctive forms of vascular inflammatory disease occur in certain settings. These include aneurysmal disease of the large arteries of the brain occurring in children and a large vessel aneurysmal disease primarily affecting the aorta and its branches in young HIV-infected patients from sub-Saharan Africa. Further study of these disorders is necessary to identify specific epidemiologic features and pathogenesis.

Branch retinal artery occlusions as the presenting feature of primary central nervous system vasculitis

A 39-year-old woman presented with multiple branch retinal artery occlusions almost three years before developing a mass lesion containing calcium in the left frontal lobe. Brain biopsy revealed a small vessel vasculitis and ischemic necrosis of brain with dystrophic calcification. We believe this to be the first case of primary CNS vasculitis with branch retinal artery occlusions and brain calcification.

Clinical management issues in vasculitis. Angiographically defined angiitis of the central nervous system: diagnostic and therapeutic dilemmas

A case of acute neurologic deficit accompanied by a cerebral angiogram consistent with CNS vasculitis is presented. The differential diagnosis and diagnostic decision process generated in this type of evaluation is illustrated.

Study of host and virological factors of patients with chronic HCV infection and associated laboratory or clinical autoimmune manifestations

OBJECTIVE

Chronic hepatitis C virus (HCV) infection is associated with an array of autoimmune laboratory and clinical manifestations. The goals of our study were to identify host and/or virological factors that are implicated in the pathogenesis of these manifestations.

METHODS

We performed a detailed prospective study of various demographic, virological, biochemical, immunological (including lymphocyte subsets, Fc gamma-receptor and HLA class-II genotyping), histological and host genetic parameters in 3 well defined subgroups of HCV patients (n = 40): patients with liver disease only (group I, n = 11) or with laboratory (group II, n = 20) and clinical (group III, n = 9) autoimmune manifestations.

RESULTS

Group III patients, mainly with features of mixed cryoglobulinemia, were older, with higher levels of rheumatoid factor and circulating cryoglobulins while they tended to have a longer estimated disease duration compared to the other two groups of patients. We did not identify any specific immunological features that could differentiate symptomatic versus asymptomatic patients, except from the elevated soluble interleukin-2 receptor levels. An increased frequency of the R/R131 FcR gamma IIIA and the NA1/NA1 Fc gamma RIIIB genotypes was observed in our total HCV population, regardless of autoimmune manifestations, compared to historical controls. No statistically significant differences in HLA class II allele frequencies was detected between patient subgroups or in comparison to healthy controls.

CONCLUSIONS

Chronically infected HCV patients with symptomatic mixed cryoglobulinemia display a number of unique characteristics that differentiate them from asymptomatic patients with chronic hepatitis C.

Molecular differences in anticytokine therapies

Biologic agents that inhibit proinflammatory cytokines have made a profound impact on the treatment of rheumatoid arthritis (RA). Of the agents that are currently approved by the US Food and Drug Administration (FDA) for this indication, etanercept and infliximab neutralize tumor necrosis factor (TNF), and anakinra inhibits interleukin-1 (IL-1). Adalimumab, which was just recently approved by the FDA, is also a TNF inhibitor. Despite their common ability to inhibit cytokine bioactivity, the molecular structures and mechanisms of action of these biologic agents are significantly different. The TNF-binding moiety of etanercept is derived from soluble TNF receptor subunits. Infliximab is a chimeric (mouse-human) monoclonal antibody to TNF, while adalimumab is a fully human anti-TNF monoclonal antibody. Anakinra has yet another mechanism of action: it is an IL-1 receptor antagonist. The molecular characteristics of these agents may be relevant to clinical efficacy and safety. These agents are still relatively new: to date, the longest reporting time is 5 years, for etanercept. Additional long-term data will be required to determine the relative benefits and drawbacks of different molecular characteristics in these anticytokine agents.

Vasculitis. A collection of pearls and myths

Important strides have been made in unraveling the pathophysiologic characteristics of some individual forms of vasculitis, but vasculitides continue to pose enormous challenges for clinicians. Over time, numerous myths and an occasional pearl have arisen from the care of patients with these disorders. In this collection of pearls and myths, we have attempted to pool our knowledge about the clinical care of vasculitis patients.

A disease-specific activity index for Wegener's granulomatosis: modification of the Birmingham Vasculitis Activity Score. International Network for the Study of the Systemic Vasculitides (INSSYS)

OBJECTIVE

To refine and validate the Birmingham Vasculitis Activity Score (BVAS) as a disease-specific activity index for Wegener's granulomatosis (WG).

METHODS

Sixteen members of the International Network for the Study of the Systemic Vasculitides (INSSYS) revised the BVAS, with 3 goals: to reduce the redundancy of some component items, to enhance its ability to capture important disease manifestations specific to WG, and to streamline the instrument for use in clinical research. We defined the items and weighted them empirically as either minor (e.g., nasal crusting = 1 point) or major (e.g., alveolar hemorrhage = 3 points). We then validated the new, disease-specific BVAS/WG in 2 simulation exercises and a clinical case series that involved 117 patients with WG.

RESULTS

We removed 38 items from the original BVAS, revised 9 items, and added 7 new items. Correlations between the scores on the BVAS/WG and the physician's global assessment (PGA) of disease activity were high, even when patients in remission were excluded. In the clinical case series, Spearman's rank correlation coefficient between the BVAS/WG and the PGA was r = 0.81 (95% confidence interval 0.73-0.87). The interobserver reliability using intraclass (within-case) correlation coefficients in the 2 simulation exercises was r = 0.93 for the BVAS/WG and r = 0.88 for the PGA in the first and r = 0.91 for the BVAS/WG and r = 0.88 for the PGA in the second. There was no significant observer effect in the scoring of the BVAS/WG or the PGA. The discriminant validity of the BVAS/WG was good: r = 0.73 (95% confidence interval 0.43-0.83).

CONCLUSION

The BVAS/WG is a valid, disease-specific activity index for WG. Tested in simulation exercises and in actual patients, the BVAS/WG correlates well with the PGA, is sensitive to change, and has good inter- and intraobserver reliability. The INSSYS will use the BVAS/WG to assess the primary outcome in a phase II/III trial of etanercept in WG.

Placebo-controlled trial of prednisone in advanced HIV-1 infection

OBJECTIVE

To examine the safety and the immunologic and virologic consequences of corticosteroid use in HIV-1 infection.

METHODS

A randomized, double-blinded, placebo-controlled trial of corticosteroid administration in 41 patients with advanced HIV-1 infection. Patients had a baseline median CD4 cell count of 131 x 10(6) cells/l at enrollment and 85% had a history of opportunistic infection. All but one of the patients had been taking stable antiretroviral regimen, including a protease inhibitor in 36, for a median duration of 158 days. Patients were randomized to 8 weeks of prednisone 0.5 mg/kg daily or placebo.

RESULTS

No AIDS-defining events occurred; two patients in each group developed oral candidiasis, and two patients on prednisone developed mild herpes simplex flares. None who developed oral candidiasis or herpes simplex was receiving prophylaxis and each responded promptly to therapy. In the prednisone group, two patients developed hyperglycemia and one diabetic increased insulin requirements. CD4 cell counts and plasma HIV-1 RNA levels did not change, but plasma tumor necrosis factor alpha levels and CD38+ CD8+ cells decreased significantly in those taking prednisone.

CONCLUSION

Short-term prednisone administration is well tolerated and reasonably safe in advanced HIV-1 disease and decreases immune activation without effects on HIV-1 RNA levels or CD4 cell counts. These results suggest that, in stable HIV-1 disease, these immune activation markers are more likely consequences of but not inducers of HIV-1 replication.

Changing patterns of morbidity and mortality in HIV disease

In patients with HIV infection, highly active antiretroviral therapy is improving survival, but at the price of a variety of metabolic side effects. Patterns of morbidity and mortality are changing: the leading cause of death is now kidney or liver failure instead of opportunistic infections.

Using viral load, CD4+ levels, and clinical response to guide antiviral therapy for HIV

The decision to start or modify antiviral therapy in patients with human immunodeficiency virus (HIV) infection is not based on any single factor. Although HIV RNA levels are the primary guide to therapy, the CD4+ count and clinical response are also important.

Progression of autoimmune thyroiditis in an HIV-infected woman on HAART

Changes in immunoregulation, among other factors, may initiate or exacerbate autoimmune thyroiditis. Strikingly high titers of antithyroid peroxidase antibodies have been found in HIV-infected patients, and, according to some studies, these increase further as HIV disease progresses. The pathogenesis of autoimmune thyroiditis is not totally understood, but activated CD4+ cells predominate in the infiltrate and are believed to be central to the process. Some investigators have postulated that endocrinologic autoimmunity might result from incomplete or unbalanced immune restoration with highly active antiretroviral therapy (HAART). The case presented here suggests progression from euthyroid Hashimoto's thyroiditis to hypothyroidism after initiation of HAART.

Rheumatoid arthritis and primary care: the case for early diagnosis and treatment

Rheumatoid arthritis is a chronic inflammatory disease that can cause severe pain and disability. Disease management historically was based on a "therapeutic pyramid" in which treatment escalated as symptoms worsened. However, the demonstration of early joint damage in patients with rheumatoid arthritis has emphasized the importance of early identification and treatment. Key features in establishing a diagnosis include joint examinations, assessments of extra-articular manifestations, laboratory tests, and radiologic examinations. Care must be taken to rule out other disorders with symptoms that overlap those of rheumatoid arthritis. Treatment of rheumatoid arthritis typically involves disease-modifying antirheumatic drugs, nonsteroidal anti-inflammatory drugs, and low-dose corticosteroids--often used in combination. A new class of therapeutic agents designed to neutralize inflammatory cytokines has added a new dimension to the therapeutic armamentarium against rheumatoid arthritis. Etanercept, a bioengineered soluble receptor fusion protein that blocks tumor necrosis factor activity, is the first compound in this class to be approved for treatment of patients with refractory rheumatoid arthritis. Therapeutic trials indicate that etanercept can reduce disease activity with relatively few drug-related adverse effects, thus helping persons with rheumatoid arthritis return to more normal, healthy lives.

A common-sense approach to chronic fatigue in primary care

Since chronic fatigue is so common, long-lasting, and fraught with functional and emotional consequences, early intervention can limit overuse of health care resources and forestall disability. To help patients, we must intervene before chronicity is established or iatrogenic harm has occurred. Care that integrates medical and psychologic concepts, together with symptom management, can prevent significant secondary impairment in most cases.

AIDS update 1999: viral reservoirs and immune-based therapies

The advent of highly active antiretroviral therapy (HAART) has brought about a dramatic decline in opportunistic infections, hospitalizations, and mortality in AIDS patients. However, the recent discovery that HIV can lay dormant in quiescent T cells and other tissues even in the face of HAART therapy has dampened optimism for a cure for AIDS, though it suggests new avenues of research.

Thalidomide's tightly controlled "comeback"

Thalidomide has anti-inflammatory properties and shows promise for treating a variety of infectious and autoimmune diseases, but it must be used with strict precautions.

T cell receptor peptide vaccination in rheumatoid arthritis: a placebo-controlled trial using a combination of Vbeta3, Vbeta14, and Vbeta17 peptides

OBJECTIVE

Restricted T cell receptor (TCR) gene usage has been demonstrated in animal models of autoimmune disease and has resulted in the successful use of TCR peptide therapy in animal studies. This clinical trial was undertaken to determine the safety and efficacy of a combination of Vbeta3, Vbeta14, and Vbeta17 TCR peptides in Freund's incomplete adjuvant (IFA) in patients with rheumatoid arthritis (RA).

METHODS

A double-blind, placebo-controlled, multicenter, phase II clinical trial was undertaken using IR501 therapeutic vaccine, which consists of a combination of 3 peptides derived from TCRs (Vbeta3, Vbeta14, and Vbeta17) in IFA. A total of 99 patients with active RA received either 90 microg (n = 31) or 300 microg (n = 35) of IR501 or IFA alone (n = 33) as a control. The study medication and placebo were administered as a single intramuscular injection (1 ml) at weeks 0, 4, 8, and 20.

RESULTS

Treatment with IR501 was safe and well tolerated. None of the patients discontinued the trial because of treatment-related adverse events. Efficacy was measured according to the American College of Rheumatology 20% improvement criteria. Using these criteria, patients in both IR501 dosage groups showed improvement in disease activity. In the most conservative analysis used to evaluate efficacy, an intent-to-treat analysis including all patients who enrolled, the 90-microg dosage group showed a statistically significant improvement compared with control patients at the 20-week time point after the third injection. Trends toward improvement were shown in both the 90-microg and the 300-microg dosage groups at week 24 after the fourth injection.

CONCLUSION

IR501 therapeutic vaccine therapy was safe and well tolerated, immunogenic, and demonstrated clinical improvement in RA patients. Additional clinical trials are planned to confirm and extend these observations.

Rheumatologic manifestations of HIV-1 and HTLV-1 infections

HIV infection is the new "great mimic." Although its more common signs and symptoms are well known, HIV infection sometimes presents with rheumatologic manifestations, as does human T-cell lymphotrophic virus type I (HTLV-I), the causative agent of adult T-cell leukemia. This review briefly describes these manifestations and presents a logical clinical approach to their diagnosis and treatment.

Dysphagia in patients with inclusion body myositis

OBJECTIVES

Inclusion body myositis (IBM) is an inflammatory myopathy with a 40% reported incidence of dysphagia. A protracted course, refractory to medical therapy, frequently leads to consultation with an otolaryngologist for dysphagia management. We studied the incidence, symptoms, and mechanisms of dysphagia in patients with IBM.

STUDY DESIGN

Retrospective study of medical records and self-reported follow-up survey; dysphagia is defined as difficulty in swallowing.

MATERIALS

Twenty-two patients with biopsy-proven IBM.

RESULTS

The rate of dysphagia was more than 80% (16 of 19), twice as high as previously reported. Progressive dysphagia was associated with a significantly worse functional class. Relevant management guidelines are established, including the timing for appropriate surgical intervention.

CONCLUSION

Progressive dysphagia may signify more aggressive IBM or an episodic worsening in status. Recognition of the disease manifestations will afford proper patient management. Informed otolaryngologists can have a favorable impact on the dysphagia associated with IBM.

The connection between chronic fatigue syndrome and neurally mediated hypotension

Research from several groups of investigators indicates that some patients with chronic fatigue syndrome have abnormal vasovagal or vasodepressor responses to upright posture. If confirmed, these findings may explain some of the symptoms of chronic fatigue syndrome. There is also speculation that neurally mediated hypotension may be present in fibromyalgia. This article discusses the original research in this area, the results of follow-up studies, and the current approach to treating patients with chronic fatigue syndrome in whom neurally mediated hypotension is suspected.

Infections and systemic vasculitis

Bacterial infections can clinically mimic a primary vasculitic syndrome and can directly cause a vasculitis that may respond to prompt recognition and treatment of the infection. Increasing direct and indirect evidence is establishing links between certain infections and vasculopathies, including aortitis, atherosclerosis, and Wegener's granulomatosis. The literature on the hepatitis viruses, particularly hepatitis C, and various vasculitic syndromes continues to grow. The spectrum of clinical syndromes, including "essential" cryoglobulinemia (elicited by the hepatitis viruses) and HIV, continues to broaden. Clinical trials have begun to demonstrate the therapeutic value of antiviral therapy in patients with these conditions.

Therapy of systemic vasculitis

The systemic vasculitides represent a highly heterogeneous and complex set of disorders primarily mediated via immunologic mechanisms. Standard therapy of these diseases includes the use of glucocorticoids without the use of additional cytotoxic agents. Recent long term follow-up investigations of patients treated with combined therapy has revealed an alarming incidence of treatment-related toxicity. Currently recommended therapeutic regimens are designed to minimize such toxicity while maintaining disease control. New therapeutic agents with greater disease specificity and lower toxicity are now being examined.

Granulomatous angiitis of the nervous system

Granulomatous angiitis of the nervous system (GANS) refers to distinctive clinicopathologic disorders with the essential feature of granulomatous inflammation of cerebral and spinal vessels, accompanied by multinucleate giant cells and epithelioid cells. This article reviews and examines the clinical, laboratory, and neuropathologic findings of patients with granulomatous angiitis.

Acute calcific tendinitis of the hip: case report with magnetic resonance imaging findings

The clinical presentation of acute calcific tendinitis can be quite dramatic. This report describes a patient with this entity who had calcification in an unusual area, accompanied by abnormalities seen on radiography and magnetic resonance imaging. Clinical aspects of acute calcific tendinitis are also reviewed. With recognition of this entity, treatment can be initiated promptly, with dramatic resolution.

Hearing and Sjögren's syndrome

Immune sensorineural hearing loss is manifested in several systemic immune diseases. Although hearing loss has been previously documented in patients with Sjögren's syndrome (SS), the effect of SS on hearing is unclear. This prospective study was designed to assess the presence of hearing loss in 14 patients with SS and, if sensorineural hearing loss was present, to determine if the hearing loss was immune-mediated. Patients were evaluated with basic audiologic tests as well as for cellular immune inner ear reactivity as measured by the lymphocyte transformation test (LTT). Three patients had evidence of sensorineural hearing loss. Two patients had a positive LTT without evidence of sensorineural hearing loss. This preliminary study suggests that SS may not directly cause sensorineural hearing loss, immuno-mediated or otherwise.

Microsporidial keratoconjunctivitis caused by Septata intestinalis in a patient with acquired immunodeficiency syndrome

PURPOSE

To examine and treat a patient with acquired immunodeficiency syndrome (AIDS) who had mildly hyperemic conjunctiva and epithelial keratopathy in both eyes.

METHODS

The patient underwent conjunctival biopsy. The specimen was examined by transmission electron microscopy.

RESULTS

Septata intestinalis was demonstrated to be the cause of keratoconjunctivitis in the patient. The keratoconjunctivitis resolved after three weeks of therapy with topical fumagillin. No organisms were seen on repeat conjunctival biopsy.

CONCLUSIONS

Microsporidial keratoconjunctivitis in patients with AIDS can be caused by S. intestinalis. This condition appears to respond to topical fumagillin.

Exercise, immunity, and infection

Although further research is needed with larger study groups and improved study designs, a review of the literature indicates that there are some scientific bases to suggest that heavy or exhaustive exercise may be predisposing to upper respiratory tract illness while moderate amounts may be protective. There exists no convincing evidence suggesting that moderate exercise poses a demonstrable negative influence on the frequency of common respiratory tract infections or adversely influences the course of certain chronic viral illnesses, including viral hepatitis and human immunodeficiency virus infection. Constitutional symptoms secondary to infectious diseases appear to compromise human performance. Exhaustive exercise appears to be a predisposing factor for the development of common respiratory tract infections and may potentially adversely affect the course of certain infectious diseases. Very limited data suggest an enhancement of resistance to respiratory tract infections from moderate exercise training. Although biologically plausible, data to support unequivocal exercise-induced enhancement or suppression of immunologic function are inconclusive at this time.

Intravenous immunoglobulin in rheumatic disease

With the advent of numerous commercial preparations of intravenous immunoglobulin preparations since 1981, it is now possible to administer these preparations in significant quantities to cause elevation of serum immunoglobulin levels both in patients with antibody-deficient states and in those with normal circulating immunoglobulin levels. This led to a report of dramatic improvement of thrombocytopenia in a child with agammaglobulinemia following the use of intravenous immunoglobulin preparations for recurrent infections, and further studies in both children and adults with associated symptoms suggested therapeutic efficacy of intravenous immunoglobulin preparations in controlling autoimmune symptoms.

Drug-induced vasculitis

Vasculitis resulting from drug use includes a wide variety of clinical and pathologic conditions that are, in general, empirically defined and poorly understood. Further complicating our grasp of these disorders are ambiguous terms such as hypersensitivity vasculitis, allergic vasculitis, leukocytoclastic vasculitis, serum sickness, and others, which are often used interchangeably without clear definition. The clinical picture varies widely from self-limiting to progressive and even fatal illness. These syndromes have now been reported in association with newer classes of therapeutic agents including biologic response modifiers. Vasculitis affecting the central nervous system may be related to a variety of drugs and remains one of the more important syndrome sets within the spectrum of drug-induced vasculitis. These disorders are clinically important, because removal of the offending drug often is associated with regression of the vasculitic condition.

Vasculitis of the central nervous system

Angiitis of the CNS remains a poorly understood form of vascular inflammatory disease. Primary angiitis of the CNS or PACNS, a disease once considered extremely rare, recently has been reported more frequently. Traditional views of PACNS held it to be a relentless and uniformly fatal disease if untreated, but it is now viewed as more heterogeneous, with some relatively benign subsets. Its pathophysiology is poorly understood. Secondary vasculitis of the CNS can occur with a variety of other conditions and diseases; each requires a different diagnostic and therapeutic approach. Regardless of whether primary or secondary CNS vasculitis is considered, an understanding of the limitations of currently available neurodiagnostic investigations is essential.