Antinuclear Antibodies and Lupus-like Manifestations in Rheumatoid Arthritis and Ankylosing Spondylitis Patients at 4 Months' Follow-up After Treatment with Infliximab and Etanercept.

BACKGROUND: Up to 44% of patients treated with infliximab and 7% of patients treated with etanercept reported to have anti-drug antibodies within the first 6 months of treatment. Recently, anti-TNF-α therapies have been reported to be employed in the induction of the druginduced lupus erythematous. OBJECTIVE: The aim of the present study was to investigate the relationship between anti-TNFα antibodies and various manifestations of lupus erythematous. METHODS: We enrolled a total of 56 cases divided into 28 known cases of rheumatoid arthritis and 28 cases of ankylosing spondylitis patients and 56 controls. The case group was divided into 4 groups according to the underlying disease (RA or AS) and treatment regimen (infliximab or etanercept). ANA and anti-dsDNA levels and lupus criteria were assessed at the beginning of the study and 4 months after the initiation of anti-TNFα. RESULTS: 36% and 21% of RA patients treated with infliximab, were ANA and anti-dsDNA positive after 4 months (P=0.003, P=0.025). 28% and 7% of RA patients treated with etanercept, were ANA and anti-dsDNA positive after 4 months (P=0.009, P=0.15). 21% and 7% of AS patients treated with infliximab, were ANA and anti-dsDNA positive, respectively (P=0.025, P=0.15). 14% and 7% of AS patients treated with etanercept, were ANA and anti-dsDNA positive, respectively (P=0.63, P=0.15). Three patients who were positive for auto-antibodies developed three criteria for SLE. CONCLUSION: Infliximab potentially may increase both ANA and anti-dsDNA levels in rheumatoid arthritis, but only ANA in ankylosing spondylitis patients. In general, clinicians should consider different clinical symptoms of ATIL, which may be present as a lupus-like syndrome similar to idiopathic SLE or classical DIL.

Neutrophil to lymphocyte count ratio as an early indicator of blood stream infection in the emergency department.

OBJECTIVES: Early identification of patients with blood stream infection (BSI), especially bacteraemia, is important as prompt treatment improves outcome. The initial stages of severe infection may be characterised by increased numbers of neutrophils in the peripheral blood and depression of the lymphocyte count (LC). The neutrophil to LC ratio (NLCR) has previously been compared with conventional tests, such as C-reactive protein (CRP) and white cell count (WCC), and has been proposed as a useful marker in the timely diagnosis of bacteraemia. METHODS: Data on consecutive adult patients presenting to the emergency department with pyrexial illness during the study period, November 2009 to October 2010, were analysed. The main outcome measure was positive blood cultures (bacteraemia). Sensitivity, specificity, positive and negative predictive values and likelihood ratios were determined for NLCR, CRP, WCC, neutrophil count and LC. RESULTS: 1954 patients met the inclusion criteria. Blood cultures were positive in 270 patients, hence the prevalence of bacteraemia was 13.8%. With the exception of WCC, there were significant differences in the mean value for each marker between bacteraemic and non-bacteraemic patients (p<0.001). The area under the receiver operating characteristic curve was highest for NLCR (0.72; 95% CI 0.69 to 0.75) and LC (0.71; 0.68 to 0.74) and lowest for WCC (0.54; 0.40 to 0.57). The sensitivity and specificity of NLCR for predicting bacteraemia were 70% (64% to 75%) and 57% (55% to 60%), respectively. Positive and negative predictive values for NLCR were 0.20 (0.18 to 0.23) and 0.92 (0.91 to 0.94), respectively. The positive likelihood ratio was 1.63 (1.48 to 1.79) and the negative likelihood ratio was 0.53 (0.44 to 0.64). CONCLUSIONS: Although NLCR outperforms conventional markers of infection, it is insufficient in itself to guide clinical management of patients with suspected BSI, and it offers no advantage over LC. However, it may offer some diagnostic utility when taken into account as part of the overall assessment.