Pronounced interferon-alpha production from plasmacytoid dendritic cells in patients with Behçet's disease following CpG D ODN stimulation

OBJECTIVE

Several lines of evidence point to a polarized T-helper-1 (Th1) immune response in Behçet's disease (BD). Interferon (IFN)-alpha which has an ability to promote strong Th1 type immune response has been shown to increase in patients with BD. In order to clarify if plasmacytoid dendritic cells (pDCs) abnormally respond to a stimulus in patients with BD, we investigated the levels of intracellular IFN-alpha and beta in pDCs with or without CpG D ODN stimulation.

METHODS

The study population consisted of 8 patients with clinically active BD, 8 ankylosing spondilitis (AS) patients having active disease and 11 healthy volunteers. pDC subsets in peripheral blood mononuclear cells (PBMCs) cultures were analysed by flow cytometry.

RESULTS

The percentage of IFN-alpha+ pDCs in unstimulated PBMCs cultures from patients BD was significantly higher (p=0.036) than in AS and HC. But this difference disappeared in stimulated PBMCs cultures (p=0.167). The mean fluorescence intensity (MFI) of IFN-alpha+ pDCs in stimulated PBMCs cultures of BD patients was significantly higher than those from patients with AS and HC. The percentage of IFN-beta+ pDCs in unstimulated PBMCs cultures from patients with BD and AS was significantly higher (p=0.004) than in HC. But this difference was not significant in stimulated PBMCs cultures (p=0.694). When compared to healthy subjects, the MFI of IFN-beta + pDCs in unstimulated and stimulated PBMCs cultures from patients with BD and AS was not different (p=0.287, p=0.152, respectively). In patients with BD, the percentage and MFI of IFN-alpha+ pDCs were higher (p=0.012 for all) in stimulated PBMCs cultures as compared to unstimulated ones.

CONCLUSION

We suggest that increased frequency of IFN-alpha+ pDC in BD patients and the higher sensitiveness of these cells to CpG D ODN stimulus contribute to high serum IFN-alpha levels found in these patients which eventually resulted in Th1 type immune response.

The role of HLA-DRB1 shared epitope alleles in predicting short-term response to leflunomide in rheumatoid arthritis

OBJECTIVES

To investigate the role of shared epitope (SE) alleles in the short-term clinical response to leflunomide for the treatment of active RA.

METHODS

In an open-label, multi-centre study of 16-weeks duration, 93 patients (82% female) fulfilling ARA 1987 RA criteria were treated with leflunomide (100 mg loading dose for 3 days, then 20 mg/day as the maintenance dose). The primary efficacy criterion was the response status according to the European League Against Rheumatism (EULAR) response criteria using Disease Activity Score-28 (DAS28) activity measure. SE determinations have been undertaken by polymerase chain reaction and sequence-specific oligonucleotide genotyping methods.

RESULTS

The mean (s.d.) Disease Activity Score-28 (DAS28) was 5.1 (1.3) before the treatment, which was significantly decreased after 16 weeks [3.0 (1.1), P < 0.001]. According to the EULAR response criteria, 55 patients (59.1%) were classified as good responders. SE was positive in 51 (54.8%) of the patients, with 13 (13.9%) having SE homozygosity or carrying any two SE alleles. Among SE-positive patients, 68.6% (35/51) were good responders, compared with 47.6% (20/42) in SE negatives (P = 0.04). No difference was present according to SE hetero- or homozygosity (68.4 vs 69.2%). RF was also present significantly more frequently in the SE-positive group compared with negatives (78.4 vs 57.1%, P = 0.03). However, no significant difference was observed in the prevalence of RF positivity in patients with a good clinical response (72.7 vs 63.2%, P = 0.32).

CONCLUSIONS

The results suggest that HLA-DRB1 SE presence may favourably affect the outcome of leflunomide monotherapy in an unselected group of RA patients with an active disease and naive to leflunomide.

Dendritic cell subsets and type I interferon system in Behçet's disease: does functional abnormality in plasmacytoid dendritic cells contribute to Th1 polarization?

OBJECTIVE

Several lines of evidence point to a polarized T-helper-1 (Th1) immune response in Behçet's disease (BD). However, it is not yet clear which factors are involved in the proposed Th1 mediated pathogenesis of BD. Dendritic cells (DCs) are antigen presenting cells which play a crucial role in the polarization of immune response. No previous study has examined the possible role of DCs in the pathogenesis of BD. We conducted both quantitative and functional analysis of the peripheral blood DC subsets in BD patients with different clinical presentations.

METHODS

Thirty-eight patients with BD, 12 healthy controls (HC), and 12 patients with undifferentiated spondylarthritis (uSpA) were enrolled in the study. Peripheral blood DC subsets were analysed by flow cytometry and were further characterized for maturation with CCR7. Serum levels of interferon (IFN)-alpha and IFN-b were measured by ELISA.

RESULTS

BD patients had a decreased percentage of plasmacytoid DCs (pDCs) compared to HC (p = 0.036). IFN-alpha levels were found to be increased in BD patients as compared to HC and uSPA (p < 0.001, p = 0.005, respectively). BD patients had decreased levels of IFN-Beta as compared to HC and uSpA (p = 0.013, p = 0.004, respectively). No difference was found between HC and patients with uSpA regarding IFN-Beta levels. Subgroup analysis of BD patients disclosed normalization of percentage of pDCs and the level of IFN-Beta in patients receiving IFN-alpha-2b.

CONCLUSION

We suggest abnormalities in pDCs and type I IFNs appear to be a master switch leading to the pathogenicity in BD by directing immune response towards Th1.

Serum MMP-2 and MMP-9 in patients with Behçet's disease: do their higher levels correlate to vasculo-Behçet's disease associated with aneurysm formation?

OBJECTIVES

Basic and clinical studies have revealed a strong correlation between matrix metalloproteinases (MMPs), particularly MMP-2 and MMP-9, and the formation of abdominal aortic aneurysms. In addition, previous studies have clearly shown that MMP-2 and MMP-9 play an important role in the pathogenesis of vasculitis characterized by aneurysm formation such as Kawasaki disease, temporal arteritis and Takayasu arteritis. Depending on those findings, we hypothesized that circulating MMP-2 and MMP-9 could be useful markers to demonstrate vascular aneurysmatic involvement in patients with Behçet's disease (BD).

METHODS

Fifty-eight patients with BD, and 20 healthy controls were enrolled in the study. We assessed the disease activity of patients according to the Leeds activity score system. We compared the Leeds activity scores of patients with their serum levels of MMP2 and MMP-9. Patients with BD were categorized as active (total activity score > or = 5) or inactive (total activity score < 5). Patients were further categorized with respect to their extent of involvement as muco-cutaneous or systemic. Patients with systemic involvement were subdivided into ocular or vascular involvement. Patients with vascular involvement were subgrouped as thrombotic or aneurysmatic involvement. The levels of MMP-2 and MMP-9 were measured by ELISA.

RESULTS

Serum MMP-9 but not MMP-2 levels were significantly higher both in patients with active and inactive disease as compared to healthy controls (p = 0.008 and 0.013 respectively). We found positive correlation between Leeds activity score and serum MMP-2 levels in patients with vascular involvement (p = 0.035 and r = 0.485), and serum MMP-9 levels in active BD patients (p = 0.003 and r = 0.599). The serum levels of MMP-2 and MMP-9 in patients with systemic involvement were higher than those of healthy controls but not patients with mucocutaneous involvement (p = 0.046 and 0.002 respectively). The serum levels of MMP-2 in patients with vascular involvement were found to be higher than those of healthy controls and patients with mucocutaneous involvement (p = 0.001 and 0.003, respectively) but not different in those with ocular involvement. The serum levels of MMP-9 in patients with vascular involvement were found to be higher than those of healthy controls and ocular disease (p = 0.001 and 0.033 respectively) but not different in those with mucocutaneous involvement. The serum levels of MMP-2 in patients with aneurysmatic involvement were found to be higher than those of healthy controls, mucocutaneous and ocular involvement (p = 0.004, 0.008 and 0.004 respectively). The serum levels of MMP-2 in patients with thrombotic involvement were found to be higher than those of healthy controls and mucocutaneous (p = 0.018 and 0.033 respectively) but not ocular involvement. The serum levels of MMP-9 in patients with aneurysmatic involvement were found to be higher than those of healthy controls, mucocutaneous and ocular involvement (p = 0.001, 0.048 and 0.007 respectively). The serum levels of MMP-9 in patients with thrombotic involvement were found to be higher than those of healthy controls but not mucocutaneous and ocular involvement (p = 0.046).

CONCLUSIONS

We concluded that serum MMP-2 and MMP-9 levels can be used as an activity indicator for vasculo-Behçet's or active Behçet's patients, respectively. But they can not be used as a marker reflecting the systemic involvement of patients with BD. The systemic expressions of MMP-2 and MMP-9 were strongly associated with vasculo-Behçet's disease, particularly aneurysmatic involvement, suggesting their pathogenetic roles in vasculo-Behçet's disease complicated with aneurysm formation.

Synovial lymphoid neogenetic factors in Behçet's synovitis: do they play a role in self-limiting and subacute course of arthritis?

OBJECTIVE

Lymphoid neogenesis seems to play an important role in the persistence of chronic inflammation and has been shown in various disorders characterized by chronic inflammation including rheumatoid arthritis. Arthritis of Behçet's disease is characterized by non-erosive arthritis in which the disease course is considered to be subacute and self limiting. However, molecular mechanisms underlying those features of Behçet's arthritis have not been defined yet. In order to determine the contribution of lymphoid neogenesis in the disease course of Behçet's arthritis, we investigated the synovial fluid (SF) levels of CXCL 12, CXCL 13, CCL 21 homeostatic chemokines and the percentage of SF naive lymphocytes expressing their receptors such as CXCR4+ and CCR7+. We further measured the SF TGF-Beta and INF-Beta levels which are known to contribute lymphoid neogenesis via leading persistent expression of CXCR4 on T cells and inhibiting T cell apoptosis, respectively.

METHODS

Fifty-one [15 BD, 17 RA, and 19 osteoarthritis (OA)] patients with at least one- sided knee arthritis were enrolled in the study. Patients with BD constituted the study group, and RA, OA patients were used as positive and negative control groups, respectively. The SF levels of CXCL 12, CXCL 13, CCL 21, TGF-Beta and INF-Beta were measured by ELISA. CXCR4, CCR7 chemokine receptors on SF lymphocytes were tested by Flow- cytometry. Kruskal-Wallis test and Mann-Whitney U test were used for statistical analysis where appropriate.

RESULTS

Synovial fluid CCL 21 levels were found to be increased in RA patients as compared to BD and OA patients (p = 0.003, and p = 0.013, respectively). No significant difference was detected between BD and OA patients with respect to CCL 21 levels. Both CXCL 12 and CXCL 13 SF levels were found to be higher in RA and BD patients as compared to OA patients (CXCL-12; p = 0.012, and p = 0.024), (CXCL 13; p < 0.001, and p = 0.007). However, no difference with regard to SF levels of both CXCL 12 and CXCL 13 were found between RA and BD patients. Percentages of both CD3+CXCR4+ lymphocytes and CD3+CCR7+ lymphocytes in the SF of RA patients were detected to be increased as compared to those of BD and OA patients (CD3+CXCR4+; p = 0.019, p = 0.048, respectively), (CD3+CCR7+; p = 0.023, p = 0.001, respectively). However, no differences with respect to the percentages of SF lymphocytes expressing CD3+CXCR4+ or CD3+CCR7+ were found between BD and OA patients. Both TGF-Beta and INF-Beta SF levels were found to be higher in RA patients as compared to BD and OA patients (TGF-Beta; p = 0.041, and p = 0.003), (INF-Beta; p = 0.012, and p = 0.016). However, no differences with regard to SF levels of both TGF-Beta and INF-Beta were found between BD and OA patients.

CONCLUSION

Considering the subacute, self limiting and non-erosive course of arthritis observed in BD, our finding of detection of lower levels of CCL21 and TGF-Beta1 and IFN-Beta in BD patients, seems to prevent the development of LN and chronic inflammation in Behçet's synovitis. In support of this view, percentages of SF naïve T lymphocytes were found to be lower in BD patients comparing with those of the RA. Absence of tertiary lymphoid structures in BD patients, may explain the spontaneous resolution of Behçet's arthritis in most of the cases.

Chimerical anti-TNF-alpha, infliximab, inhibits neutrophil chemotaxis and production of reactive oxygen species by blocking the priming effect of mononuclear cells on neutrophils

Clinical experience with anti-tumor necrosis factor alpha (anti-TNF-alpha) agents implies that these agents can cause a rapid onset amelioration of the symptoms and laboratory parameters in some inflammatory diseases. Precise explanation of this fast antiinflammatory action is not known. The aim of our study is to investigate the direct and indirect effects of anti-TNF agents on the chemotaxis and reactive oxygen species (ROS) production of neutrophils. For this purpose, isolated neutrophil cultures (INCs) and mixed leukocyte cultures were prepared from the venous blood of healthy subjects. Those cultures were separated to different groups according to the presence of anti-TNF or the stimulation of phytohemagglutinin (PHA). In this study, anti-TNF treatment did not change the migration ability of neutrophils in INCs. However, we established that chimerical anti-TNF-alpha, infliximab, inhibits neutrophil chemotaxis and production of ROS by blocking the priming effect of PHA-stimulated circulating mononuclear cells. These results may explain, at least partly, the rapid onset antiinflammatory actions of these agents observed in clinical practice.

Peripheral insulin resistance in patients with Behcet's disease

In this study, we examined peripheral insulin resistance in patients with Behçet's disease (BD) characterized by chronic inflammation and endothelial dysfunction. Fourteen patients with BD and 15 healthy controls were recruited to the study. Insulin resistance was investigated by the hyperinsulinaemic-euglycaemic glucose clamp technique. BD patients displayed an enhanced rate of insulin resistance compared to healthy controls (P = 0.014). The insulin sensitivity (M), measured as the glucose utilization rate under steady-state conditions of euglycaemia, was significantly decreased (P = 0.001) in BD patients compared to the controls (4.09 +/- 0.16 vs. 5.60 +/- 0.27 mg/kg/min). The C-reactive protein (CRP) level, but not the erythrocyte sedimentation rate (ESR), was significantly related to the presence of insulin resistance (CRP: r(s) = 0.589, P = 0.27; ESR: r(s) = 0444, P = 0112), whereas no relationship was found between the M-value and ESR or CRP. We conclude that patients with BD exhibit peripheral insulin resistance; this could be explained as the diverse consequences of inflammation and endothelial dysfunction in BD.

Serum interleukin-18 levels in patients with Behçet’s disease. Is its expression associated with disease activity or clinical presentations?

Interleukin (IL)-18 is a proinflammatory cytokine which plays a crucial role in T helper (Th)1 type immune response. The aim of this study is to investigate the relationship of serum levels of IL-18 with disease activity and clinical presentations in patients with Behcet's disease (BD). Sixty patients with BD and 20 healthy controls were included in the study. Patients were grouped as having active or inactive disease according to the Leeds activity score. They were also separated as a systemic involvement or mucocutaneous symptoms only. Patients with systemic involvement were further grouped according to the presence of ocular, articular and vascular involvement. IL-18 levels were significantly higher in all patient subgroups as compared to healthy controls and found to be correlated with the activity score in patients having active disease. In conclusion, this cytokine participates in the pathogenesis of BD and its levels are correlated with the disease activity. Detection of increased levels of IL-18 in patients with inactive disease implies that Th1 activation and subclinical inflammation persist during the inactive period of the disease.

Vascular endothelial growth factor and monocyte chemoattractant protein-1 in Behçet's patients with venous thrombosis

OBJECTIVE

Vascular lesions can involve both arterial and venous systems which are often the major causes complicating the disease course of Behçet's disease (BD). Vascular endothelial growth factor (VEGF) is a stimulant of angiogenesis secondary to ischemia while monocyte chemoattractant protein 1 (MCP-1) is induced by shear stresses leading to vascular collateral development. MCP-1 has been also shown to contribute to the recanalization of venous thrombi. Tumor necrosis factor-alpha (TNF-alpha) is known to play a major role in the pathogenesis of BD. Furthermore, up-regulation of secreted MCP-1 and VEGF was observed following stimulation with TNF-alpha. In view of the above functions of VEGF, MCP-1 and TNF-alpha, we hypothesized that these factors may be important in the pathogenesis of thrombosis seen in BD.

METHODS

A total of 36 patients with a diagnosis of BD were studied. BD patients were separated into 3 groups with respect to vascular involvement. Group BD-AT (n = 9) with acute thrombosis, BD-CT (n = 12) with chronic thrombosis and BD-MC (n = 15) with mucocutaneous involvement only. The control group (group H) was comprised of 20 healthy persons. In addition, patients with acute, DC-AT (n= 11) and patients with chronic DC-CT (n = 9) thrombosis without BD served as disease controls. Serum measurements of VEGF MCP-1 and TNF-alpha were performed by quantitative sandwich ELISA. The acute phase reactants, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were also measured.

RESULTS

The levels of VEGF were significantly higher in the patients in group BD-AT than either in group BD-CT or BD-MC (p = 0.03 and p < 0.001, respectively). However, no significant difference was found for VEGF levels of thrombotic patients regarding the cause (BD-AT vs. DC-AT, p = 0.063; BD-CT vs. DC-CT, p = 0.084) or the stage of thrombosis (DC-AT vs. DC-CT, p > 0.05). Both BD patients and disease controls with acute thrombosis had significantly higher levels of MCP-1 as compared to corresponding chronic thrombosis patients (BD-AT vs. DC-CT; p < 0.001; DC-AT vs. DC-CT, p < 0.001). Patients with BD and disease controls had significantly higher serum TNF-alpha level when compared with healthy subjects. No significant difference with respect to serum TNF-alpha level was noted when patient subgroups with BD and disease controls were compared with each other Serum levels of VEGF, MCP-1, and TNF-alpha were not found to be correlated with either ESR or CRP (p > 0.05).

CONCLUSIONS

Increased levels of VEGF and MCP-1 detected in BD thrombosis suggest the possible role of those angiogenic cytokines in the pathogenesis. Although not specific for BD, detection of VEGF or MCP-1 levels seems to serve as an assay for differentiation of BD patients with acute thrombosis from chronic.

The proportional Venn diagram of Behçet's disease-related manifestations among young adult men in Turkey

OBJECTIVES

To determine the frequency of the features associated with Behçet's disease (BD) in a young men population and generate a proportional Venn diagram of those features.

METHODS

Data was collected from 3714 otherwise healthy men recruited for military service at the entrance. Study was conducted in a two-step procedure. Firstly, all participants were questioned by a general practitioner via using visual Behçet's questionnaire. Those participants, in whom at least one BD-related manifestation of the disease (oral ulcer, genital ulcer, folliculitis, erythema nodosum, uveitis, venous involvement of the lower extremities) have been demonstrated, were further examined by a rheumatologist at the second-stage of the study.

RESULTS

The areas of intersection among the 6 individual BD-related manifestations produced 63 mutually exclusive symptom groups. Sixteen out 63 of these groups were functionally operative in our study population. Forty-seven (1.2%) of the all participants were considered to have at least 1 of the BD-related manifestation after examined by rheumatologist. The prevalence rates of the individual manifestations among the study population were as follows; oral ulcer 29 (0.78%), folliculitis 31 (0.83%), genital ulcer 9 (0.24%), venous involvement 13 (0.35%), erythema nodosum 4 (0.10%) and uveitis 3 (0.08%). The group consisting of oral ulcer with folliculitis was the largest proportion of participants followed by the group having oral ulcer only, accounting for 0.29% and 0.18%, respectively. Four (0.1%) of the participants were fulfilled the International Study Group for BD criteria following rheumatologic and ophthalmologic examinations. After excluding the group having oral ulcer with folliculitis, additional 12 cases had features suggesting BD though they didn't fulfill the International Study Group for BD criteria.

CONCLUSION

The Venn diagram of this study demonstrates that International Study Group for BD criteria can detect almost the quarter of 16 cases suspected as having BD. We suggest that the application of information regarding the frequencies of individual BD-related manifestations and their association with each other in a general population might serve as a helpful tool for physicians while making diagnosis.

Does immune activation continue during an attack-free period in familial Mediterranean fever?

Although some information is available regarding immune activation in familial Mediterranean fever (FMF), little is known about either peripheral blood T cell activation marker expression or the T cell proliferative response to phytohaemagglutinin (PHA). In the present study, we aimed to investigate the percentages of peripheral blood lymphocyte subsets, T cell expression of cellular activation markers (CD25, CD69, HLA-DR), the T cell response to PHA and serum levels of soluble interleukin-2 receptor (sIL-2R) and interleukin (IL)-10 in patients with FMF. Forty patients with FMF were enrolled into the study. Control groups were sex- and age-matched and consisted of 20 healthy blood donors and 15 patients with inactive Behcet's disease. The patients with FMF in an attack period had higher levels of sIL-2R than those in an attack-free period, and also in comparison with both control groups. The levels of sIL-2R were also found to be higher in patients with FMF in an attack-free period than those in both control groups. The mean levels of IL-10 were found to be lower in patients with FMF in an attack-free period than those in an attack period and were also lower than those in the healthy controls. In an acute attack period, the absolute counts of CD3+HLA-DR+, CD4+CD69+, CD8+CD25+ and CD8+CD69+ T cells in peripheral blood samples were also higher than those in both control groups. Both the percentages and absolute counts of CD4+CD69+ T cells in peripheral blood samples of patients with FMF in an attack-free period were slightly but significantly higher than those in the healthy controls. In conclusion, our study indicates that the T cell system is abnormally activated in patients with FMF in both the attack and attack-free period and that decreased IL-10 levels may create a tendency to perpetuate subclinical immune activation in the attack-free period.

Antiannexin V autoantibody in thrombophilic Beh�et?s disease

We propose that thrombosis in Behçet's syndrome may be due to disruption of the annexin V shield by antiphospholipid antibodies. Measurement of antiannexin V antibodies may be of value in confirming diagnosis and evaluating the risk of venous and arterial thrombosis in patients with Behçet's syndrome. To evaluate the efficiency of antiannexin V antibody in the formation of thrombosis, 53 male patients with Behçet's disease according to international study group criteria were involved in this study. The age range was 20-28 years (mean 23+/-3.4). All of these patients had been taking colchicum. Those taking medications that interfere with antiannexin V autoantibody levels were excluded, and serum samples were taken during the active period. Group I included 26 Behçet's patients with well-documented thrombosis, group II included 27 Behçet's patients without thrombosis, and group III was comprised of 27 healthy controls. There were no statistical differences between the mean concentrations of IgG and IgM antiannexin V autoantibodies in the three groups. The results indicate that these antibodies may not be associated with the pathogenesis of thrombotic events in patients with Behçet's syndrome.

Comparison of synovial MMP-1 and TIMP-1 levels in patients with various inflammatory arthritides: is there any difference between rheumatoid arthritis, Behçet's disease and familial Mediterranean fever?

The purpose of this study was to investigate synovial levels of matrix metalloproteinase-1 (MMP-1), known to break down collagen, and tissue inhibitor of metalloproteinase (TIMP-1), its natural antagonist, in patients with various inflammatory disorders. Eighty-five patients with different inflammatory arthritides (20 Behçet's disease, 20 familial Mediterranean fever, 26 rheumatoid arthritis and 19 osteoarthritis) were enrolled in the study. Synovial MMP-1 and TIMP-1 levels were measured by two-step sandwich ELISA. There were significant differences between study and control groups regarding erythrocyte sedimentation rate, C-reactive protein, MMP-1 and TIMP-1 values. The synovial MMP-1 levels of patients with Behçet's disease and familial Mediterranean fever were no different from those in patients with rheumatoid arthritis, but significantly higher than those of patients with osteoarthritis. The synovial TIMP-1 levels in patients with osteoarthritis were higher than those of patients with the other three diseases, among which the difference was not statistically significant, and the difference between osteoarthritis and the others was statistically significant. Because of the detection of similar levels of synovial MMP-1 in patients with familial Mediterranean fever, Behçet's disease and rheumatoid arthritis, we conclude that the absence of erosions in patients with familial Mediterranean fever and Behçet's disease may be explained by MMP-1 being a marker of cytokine-driven inflammation, or by the short-lived and transient nature of the arthritis observed in these patients.

A case of Churg-Strauss syndrome presenting with cortical blindness

A 46-year-old woman with a sudden sight loss due to infarction of the occipital lobes is reported. The association of pulmonary disease, digital ischaemia, polyneuropathy and peripheral eosinophilia led to a diagnosis of Churg-Strauss syndrome. Her vision partially improved by a treatment with steroids and monthly i.v. cyclophosphamide. To our knowledge, this is the first case of CSS with a sudden loss of vision due to bilateral occipital infarction.

Sulfasalazine-induced angioimmunoblastic lymphadenopathy developing in a patient with juvenile chronic arthritis

We describe a patient with juvenile chronic arthritis who developed reactive angioimmunoblastic lymphadenopathy, induced by sulfasalazine. Development of angioimmunoblastic lymphadenopathy although rare, is a very serious side effect of sulfasalazine treatment, and patients treated with this drug should be watched carefully.

Evaluation of vascular injury with proinflammatory cytokines, thrombomodulin and fibronectin in patients with primary fibromyalgia

OBJECTIVE

Cold intolerance, cold induced peripheral vasospasm, Raynaud's phenomenon, livedo reticularis and immunoglobulin deposition in the skin are often encountered clinical and laboratory findings in patients with primary fibromyalgia (FM). These findings are suggestive of vascular injury.

METHODS

Eighty patients (4 male, 76 female) with fulfilling primary FM criteria (FM (+) patient group), 60 patients (3 male, 57 female) with chronic musculoskeletal complaints but without FM (FM (-) patient control group) and 40 healthy volunteers (1 male, 39 female) without musculoskeletal complaints (healthy control group) were enrolled in this cross-sectional study. The study was carried out in two steps. In the first step, the clinical findings, routine laboratory tests, autoantibodies and radiological findings were investigated. The second step were consisted of the laboratory investigations of thrombomodulin and fibronectin as the mediators indicating vascular injury and proinflammatory cytokines in FM patients with Raynaud's phenomenon and/or livedo reticularis and in control groups.

RESULTS

There were no differences between study and control groups with regard to laboratory, radiological and immunological (ANA, AntidsDNA, ENA, anticardiolipin IgG and IgM) results. No statistically significant differences were found in the levels of proinflammatory cytokines between FM (+) patient group and control groups (p > 0.05). Thrombomodulin was also shown statistically insignificant difference between FM (+) patient group and control groups (p > 0.05). However, fibronectin, another mediator of vascular injury, was higher in FM (+) patient group and the differences between FM (+) patients and each control groups were statistically significant (p < 0.0001).

CONCLUSION

Our results were suggestive of the presence of a non-immunological vascular injury in FM patients with Raynaud's phenomenon and/or livedo reticularis.

Dermographism and atopy in patients with Behçet's disease

Dermographism is the appearance of whealing and erythema within minutes in a site where skin has been exposed to pressure or mechanical irritation. In our clinical observations, dermographism seems to be frequent in patients with Behçet's disease. Since the prevalence of allergic responses is reportedly increased in vasculitic syndromes, we aimed to assess dermographism and atopy in a group of Behçet's patients. The study group comprised 30 consecutive patients with Behçet's disease. The study was carried out in two parts: elicited dermographism and atopy tests. In the first part, dermographism was investigated in the study group (Behçet's patients) and 230 healthy controls. In the second part, the study group, 30 healthy controls and 17 patients with allergic bronchial asthma were evaluated for specific and nonspecific atopy. Dermographism was found to be increased in patients with Behçet's disease. Peripheral blood eosinophil count, serum total IgE and nasal eosinophil scores were similar in patients with Behçet's disease and healthy controls. Although blood eosinophil count and serum total IgE levels were higher in allergic bronchial asthma patients than in Behçet's patients, the difference was significant only in the former. Skin prick test was positive in three of the patients with Behçet's disease and in six healthy controls. The difference was statistically insignificant (p > 0.05). None of the Behçet's disease patients had pathergy or a pathergy-like reaction at the site of the skin prick test after 48 h. In conclusion, our results confirm the general impression that dermographism is common in patients suffering from Behçet's disease.

Combination therapy versus monotherapy for the treatment of patients with rheumatoid arthritis

OBJECTIVE

The response to single disease modifying antirheumatic drug (DMARD) is often suboptimal in patients with rheumatoid arthritis (RA). Thus, despite the limited data on the therapeutic efficacy of combination therapies, many patients are currently treated with a combination of DMARDs.

METHODS

We studied prospectively the efficacy of combination therapy with DMARDs. The study was designed as a randomized trial and a single DMARD or two or three DMARD combinations were administered to 180 consecutive, age- and sex-matched patients with active RA, each of whom was followed up for a period of 2 years under treatment. Patients were divided into 3 groups which did not differ with regard to demographic, clinical and laboratory parameters. Patients in group I were treated with a single DMARD [methotrexate (MTX) 7.5-15 mg/week or sulfasalazine (SSZ) 1-2 g/day or hydroxychloroquine (HCQ) 200 mg/day], group II with MTX + SSZ or MTX + HCQ, and group III with a combination of all three drugs. Patients were re-evaluated at regular intervals by means of clinical and biochemical tests designed to detect specific rheumatic activity. Radiological assessments were also performed and scored according to Larsen by the same radiologist who was blinded to the treatment groups.

RESULTS

At the end of the trial there were significant improvements in the clinical and laboratory parameters in all 3 groups. However, improvements were greater and much more significant in the patients who were given combination therapies. The combination of MTX + SSZ + HCQ was more effective than both monotherapy and the two-drug combinations.

CONCLUSION

In conclusion, we suggest that patients with RA should be treated with combinations of DMARDs.