Anti-TNF Therapy and the Risk of Malignancies and Infections in Inflammatory Rheumatic Diseases - Our Experience.

BACKGROUND: Early diagnosis is the key to successful treatment of inflammatory rheumatic diseases and the use of conventional disease-modifying antirheumatic drugs (csDMARD) and biologic disease-modifying antirheumatic drugs (bDMARD) or biologics have substantially contributed to better disease control. Biological drugs have been approved for the treatment of rheumatoid arthritis (RA), juvenile arthritis (JIA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA). SUBJECTS AND METHODS: The study involved 79 adult patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS), psoriatic arthritis (PsA) or undifferentiated spondyloarthropathy (USpA) - the last three clinical entities belong to a common group called spondyloarthropathies (SpA); receiving anti-TNF therapy at the department of Rheumatology and Rehabilitation, Clinical Hospital Center Zagreb. The duration of therapy was a minimum of 1 month, with the mean duration of 32.0±24.0 months. The infections recorded were infections that appeared during treatment or soon after the treatment was stopped. RESULTS: During the course of therapy 17 patients (21.5%) experienced an infection, with the total number of 21 infections. This resulted in an overall incidence rate (IR) of 9.9/100 patient-years. Of the patients with RA 76.5% developed an infection, which was significantly higher than for patients with SpA (p<0.001). The IR/100 patient-years for all infections in RA patients was 23.7 compared to 2.8 in patients with SpA. Female gender was associated with a significantly higher infection rate (70.6%, p=0.005). There were 8 infections that were considered serious, yielding an IR of 3.8/100 patient-years. There was only one malignancy case in our study. CONCLUSION: Every fifth patient developed an infection during the course of anti-TNF therapy, and more than one third of all infections were serious. RA and female gender was associated with a significantly increased number of infections.

Klippel-Feil syndrome misdiagnosed as spondyloarthropathy: case-based review.

Spondyloarthropathy refers to any joint disease of the vertebral column, but the term is mainly used for a specific group of disorders called seronegative spondyloarthropathies (SpAs). The axial skeletal involvement, peripheral and extra-articular manifestations and an association with the major histocompatibility complex class I human leukocyte antigen-B27 (HLA B27) are commonly shared features of SpAs. Klippel-Feil syndrome (KFS) is a rare congenital disorder characterized by the fusion of one or more cervical vertebrae, accompanied by various skeletal and extra-skeletal anomalies. We report a case of an adult male patient with HLA B27 positivity presenting with chronic cervical spine pain accompanied by morning stiffness and periodic night pain, with radiologically confirmed ankylosis and fusion of several cervical segments. His medical history included urogenital abnormalities operated in childhood and mild mitral prolapse. Initially suspected diagnosis of an early axial form of SpA was rejected after thorough workup. Instead, the nature of vertebral defects along with the past medical history of urogenital and cardiac abnormalities pointed towards the diagnosis of KFS. HLA B27 presence can be a confounder in patients presenting with spinal pain and that is why the differential diagnosis of CSD-s and SpA can be challenging in some patients.

Prevalence and Correlation of Depressive Symptoms with Functional Scores, Therapy and Disease Activity among Croatian Patients with Rheumatoid Arthritis: A Preliminary Study.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic, autoimmune and disabling disease that significantly affects the quality of life. Additionally, significant number of patients with RA suffer from depressive disorders, which are commonly underrecognised and undertreated. We aimed to estimate the prevalence of depressive symptoms in Croatian RA patients and to assess the relationship between them and clinical correlates. SUBJECTS AND METHODS: Fifty-four RA patients treated at the Clinic for Rheumatic Diseases and Rehabilitation at the University Hospital Centre Zagreb were prospectively enrolled in the study and evaluated for functional status using the Disease Activity Score 28 (DAS-28), Health Assessment Questionnaire (HAQ), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and Visual Analogue Scale (VAS) for pain and health related quality of life (HRQL) measurement. The depressive symptoms were assessed using the Beck Depression Inventory-II (BDI-II) questionnaire. RESULTS: Thirty RA patients (55.6%) had some sort of mood disorder, with 10 (18.5%) patients accounting as depressed. Positive correlation was found between depressive symptoms, higher disease activity and disablity during daily activities (τb=0.385, p=0.001 and τb=0.282, p=0.024 respectively). We found no significant association between depression and disease activity in the whole sample of RA patients, but for postmenopausal patients, the disease activity correlated with postmenopausal patients accounting as depressed (BDI-II score moderate or severe; τb=0.363, p=0.021). The use of biologic therapy correlated negatively with the disease acitivity, pain intensity and worse health related quality of life score (τb=-0.360, p=0.06; τb=-0.310, p=0.07; τb=-0.380, p=0.01 respectively). CONCLUSION: Considering the high prevalence of depressive sympoms in RA patients and the effect on functional disability and quality of life, we wanted to emphasize the importance of recognizing and optimizing depression treatment through multidisciplinary approach in RA patients.