The Incidence of Uveitis in Ankylosing Spondylitis Patients Undergoing Tumor Necrosis Factor Inhibiting Therapy in Korea

OBJECTIVE: The purpose of this study is to evaluate the outcome of uveitis in ankylosing spondylitis (AS) during tumor necrosis factor (TNF)-inhibiting therapy and to compare the incidence rate of uveitis in infliximab, adalimumab, and etanercept. METHODS: A retrospective evaluation was performed in AS patients who had started TNF-inhibiting therapy from June 2003 to June 2011. The clinical characteristics of patients with documented uveitis were evaluated. RESULTS: Among 316 patients treated with TNF inhibitor, 26 patients (8%) had experienced uveitis during TNF-inhibiting therapy. Among them, 15 patients were treated with etanercept, eight with adalimumab, and three with infliximab. The overall incidence rate of uveitis flare during therapy with TNF inhibitor was 46 per 1,000 person-years (pys) (95% confidence interval [CI], 32 to 64). The incidence rate did not differ between TNF inhibitors, with 54/1,000 pys (95% CI, 34 to 81) for etanercept, 46/1,000 pys (95% CI, 21 to 87) for adalimumab, and 22/1,000 pys (95% CI, 5 to 64) for infliximab. Fourteen patients experienced a first episode of uveitis. The overall incidence rate of new onset-uveitis after therapy with TNF inhibitor was 19 per 1,000 pys (95% CI, 10 to 31). The incidence rate for etanercept was 24/1,000 pys (95% CI, 12 to 45); adalimumab, 15/1,000 pys (95% CI, 3 to 45); and infliximab, 7/1,000 pys (95% CI, 0 to 40). There was no statistical difference in the incidence of uveitis flare or the cumulative uveitis-free rate among the three TNF inhibitors. CONCLUSION: The relative rate of uveitis, including the first episode, was determined using the TNF inhibitor. However, there was no difference in the incidence rate of uveitis among the three TNF inhibitors.

Mortality in patients with rheumatoid arthritis-associated interstitial lung disease treated with an anti-tumor necrosis factor agent

BACKGROUND/AIMS: To evaluate the impact on mortality of anti-tumor necrosis factor (anti-TNF) treatment of rheumatoid arthritis-associated interstitial lung disease (RA-ILD). METHODS: We retrospectively reviewed the medical records of 100 RA-ILD patients who visited our tertiary care medical center between 2004 and 2011, identified those treated with an anti-TNF agent, divided patients into non-survivor and survivor groups and evaluated their clinical characteristics and causes of death. RESULTS: A total of 24 RA-ILD patients received anti-TNF therapy, of whom six died (25%). Mean age at initiation of anti-TNF therapy was significantly higher in the nonsurvivor versus survivor group (76 years [range, 66 to 85] vs. 64 years [range, 50 to 81], respectively; p = 0.043). The mean duration of anti-TNF treatment in the non-survivor group was shorter (7 months [range, 2 to 14] vs. 23 months [range, 2 to 58], respectively; p = 0.030). The duration of anti-TNF therapy in all nonsurviving patients was < 12 months. Pulmonary function test results at ILD diagnosis, and cumulative doses of disease-modifying drugs and steroids, did not differ between groups. Five of the six deaths (83%) were related to lung disease, including two diffuse alveolar hemorrhages, two cases of acute exacerbation of ILD, and one of pneumonia. The sixth patient died of septic shock following septic arthritis of the knee. CONCLUSIONS: Lung complications can occur within months of initial anti-TNF treatment in older RA-ILD patients; therefore, anti-TNF therapy should be used with caution in these patients.

Clinical Characteristics of Patients with Rheumatoid Arthritis Who have Sustained High Erythrocyte Sedimentation Rates after Clinical Remission

OBJECTIVE: The aim of this study is to determine the clinical characteristics of patients with rheumatoid arthritis (RA) sustaining high erythrocyte sedimentation rate (ESR) despite clinical remission. METHODS: This cross-sectional study involved 91 patients, who visited a tertiary medical center. Patients underwent laboratory tests and a physical examination by a rheumatologist. The disease activity score (DAS) was calculated and patients who were in remission (defined as DAS28-CRP or =40 and <40 mm/hr, respectively). RESULTS: DAS 28-CRP scores revealed that 61 of the 91 patients were in remission. Of these 61 patients, 15 and 46 were allocated to the high and low ESR groups, respectively. Compared to the low ESR group, the high ESR group had a longer disease duration (99.2+/-60.2 vs. 59.1+/-48.9 months), significantly higher white blood cell counts, and CRP levels, total modified Sharp radiographic joint scores, and erosion scores, as well as significantly lower hemoglobin, albumin and alanine aminotransferase levels. CONCLUSION: Patients who have high ESRs despite their remission status may show progressive radiographic change. In such patients, additional treatments that decreases the inflammation and prevents radiological progression should be considered.

A Case of Adult-Onset Still's Disease Presenting with Periorbital Edema

Adult-onset Still's disease (AOSD) is a systemic inflammatory disorder of unknown etiology that is characterized by high-spiking fever, arthralgia, sore throat, and skin rash. The typical rash of AOSD is an evanescent, salmon-colored erythema, which is considered to be the major diagnostic criterion. Recently, other cutaneous manifestations of AOSD, such as persistent plaque and urticaria, have been reported. Here, we report a rare case of AOSD presenting with periorbital swelling and erythema. A 47-year-old woman was presented with periorbital swelling, erythema, high fever, arthritis, and a sore throat. One year prior to admission, she was diagnosed with AOSD based on the diagnostic criteria of Yamaguchi. The patient's periorbital swelling and erythema may not have been associated with periorbital cellulitis because they did not respond to antibiotics but did improve after treatment with steroids. Considering all of her signs and symptoms with a history of AOSD, periorbital lesion was suspected as atypical cutaneous manifestation of AOSD.

A Case Report of Patient with Takayasu's Arteritis Complicated by Reversible Cerebral Vasoconstriction Syndrome

Takayasu's arteritis (TA) is a chronic inflammatory vascular disease that mainly affects large vessels. Central nervous system involvement occurs in about 20% of cases with rare involvement of intracranial vessel, and its typical manifestation is cerebral ischemia or stroke. Reversible cerebral vasoconstriction syndrome (RCVS) is a group of disorders with prolonged, but reversible vasoconstriction of the cerebral arteries with acute-onset, severe, recurrent headaches with or without neurologic signs or symptoms. We report a case of TA in a 17-year old girl who presented with secondary RCVS. She complained of thunderclap headache, seizure and acute stroke. 3-dimensional computed tomography scan and magnetic resonance angiography of head revealed irregular thickening of aortic wall and its main branches with multifocal narrowing of intracranial basilar artery, which improved after oral nimodipine intake. This case highlights RCVS as an unusual manifestation of TA and demonstrates the diagnosis, treatment and response to therapy of RCVS in TA, which resolved after treatment with calcium channel blocker.

A Case of Tuberculous Optochiasmatic Arachnoiditis / 대한내과학회지

Tuberculous optochiasmatic arachnoiditis (OCA) is a rare complication of tuberculous meningitis. We describe a 47-year-old female with tuberculous OCA confused with ethambutol-associated optic neuropathy. She was on anti-tuberculous treatment (i.e., isoniazid, rifampin, ethambutol, and pyrazinamide) for two months due to tuberculous meningitis. Visual impairment occurred during treatment, and ethambutol was changed to levofloxacin because of concern for ethambutol-associated optic neuropathy. Her visual impairment did not improve three months after anti-tuberculous treatment that excluded ethambutol, and she was referred to our hospital. Brain MRI showed enhancement of the optic chiasm and bilateral optic tract, and fundoscopy revealed bilateral optic nerve atrophy, suggesting tuberculous OCA. Her visual acuity was partially improved after anti-tuberculous treatment. Tuberculous OCA should be considered in addition to ethambutol-associated optic neuropathy for a patient with tuberculous meningitis who presents with visual impairment.

Acute Pancreatitis as a Complication of Adult Henoch-Schonlein Purpura

Pancreatitis is a rare manifestation of adult Henoch-Schonlein purpura (HSP). We describe here a 53-year-old man who presented with acute pancreatitis as a complication of adult HSP. Pancreatic involvement in HSP is self-limiting and benign. Prompt resolution can be achieved by treatment with steroids. Elevated serum amylase and lipase concentrations may be early diagnostic indicators of HSP pancreatitis. Patients with HSP who have abdominal pain should be evaluated for pancreatitis by measuring serum amylase and lipase concentrations and by abdominal computed tomography scan, to plan specific treatment and avoid unnecessary surgery.

A Case of Tuberculous Optochiasmatic Arachnoiditis / 대한내과학회지

Tuberculous optochiasmatic arachnoiditis (OCA) is a rare complication of tuberculous meningitis. We describe a 47-year-old female with tuberculous OCA confused with ethambutol-associated optic neuropathy. She was on anti-tuberculous treatment (i.e., isoniazid, rifampin, ethambutol, and pyrazinamide) for two months due to tuberculous meningitis. Visual impairment occurred during treatment, and ethambutol was changed to levofloxacin because of concern for ethambutol-associated optic neuropathy. Her visual impairment did not improve three months after anti-tuberculous treatment that excluded ethambutol, and she was referred to our hospital. Brain MRI showed enhancement of the optic chiasm and bilateral optic tract, and fundoscopy revealed bilateral optic nerve atrophy, suggesting tuberculous OCA. Her visual acuity was partially improved after anti-tuberculous treatment. Tuberculous OCA should be considered in addition to ethambutol-associated optic neuropathy for a patient with tuberculous meningitis who presents with visual impairment.

A Case of Severe Community-acquired Acinetobacter baumannii Pneumonia with Bacteremia / 감염과화학요법

Acinetobacter baumannii is a significant pathogen in nosocomial infections, especially in intensive care units. However, community-acquired A. baumannii (CAAB) pneumonia is an uncommon disease. Most of the CAAB pneumonia in the literature is characterized by an abrupt onset and rapid progression to respiratory failure and hemodynamic instability. In our case, a 51-year-old man without underlying diseases developed severe pneumonia. Respiratory distress rapidly worsened and mechanical ventilation was applied. Extra-corporeal membrane oxygenation was applied due to refractory septic shock. Fully sensitive A. baumannii pneumonia was confirmed by the sputum culture and blood culture. The patient was effectively treated by the meropenem. However, the patient died of uncontrolled ventilator-associated pneumonia, developed on the 10th hospital day, and refractory septic shock. We report the case of severe CAAB pneumonia with bacteremia in a patient without underlying diseases in Korea.

A Case of Acute Eosinophilic Pneumonia after Hematopoietic Stem Cell Transplantation / 결핵및호흡기질환

Pulmonary complications occur in 40~60% of patients who receive hematopoietic stem cell transplantation (HSCT) and are a source of substantial morbidity and mortality. Acute eosinophilic pneumonia (AEP) is an uncommon, non-infectious pulmonary complication occurring in HSCT recipients. We now report the case of a 52-year-old man with AEP who was treated with allogenic HSCT due to acute myeloid leukemia. He complained of fever, cough and dyspnea 390 days after allogenic HSCT. He also had skin and hepatic graft versus host disease (GVHD). Hypoxemia, diffuse pulmonary infiltrates on a chest x-ray and eosinophilia in bronchoalveolar lavage fluid were also noted in several tests. His symptoms, pulmonary infiltrates, hepatic dysfunction and skin lesions rapidly improved after treatment with corticosteroid therapy. Our case supports the idea that AEP is a late phase non-infectious pulmonary complication and one of the manifestations of chronic GVHD.

A Case of Adult-onset Still's Disease in a Patient with Ankylosing Spondylitis Complicated with Crohn's Disease

Adult-onset Still's disease (AOSD) is an inflammatory disorder of unknown aetiology characterized by a variety of clinical symptoms. AOSD can precede or occur concomitantly with AS and only a few cases of AOSD with AS have been reported. A 21-year-old man presented with spiking fever, sore throat, arthralgia, maculopapular rash, lymphadenopathy, and chronic inflammatory back pain. His laboratory findings showed marked elevations of liver enzyme, C-reactive protein, erythrocyte sedimentatioin rate, ferritin, and sacroiliitis (grade 2), which were the main characteristics of AOSD and AS. Most symptoms except chronic low back pain were improved after treatment with corticosteroid and disease modifying anti-rheumatic drugs. He was then treated with anti-tumor necrosis factor-alpha (anti-TNF-alpha) agents to control the disease activity of AS and subsequently showed clinical and serological improvement. This is a first case report of AOSD combined with AS in Korea.