Acute Hepatitis E Virus infection with coincident reactivation of Epstein-Barr virus infection in an immunosuppressed patient with rheumatoid arthritis: a case report.

BACKGROUND: Hepatitis E virus (HEV) is the most recently discovered of the hepatotropic viruses, and is considered an emerging pathogen in developed countries with the possibility of fulminant hepatitis in immunocompromised patients. Especially in the latter elevated transaminases should be taken as a clue to consider HEV infection, as it can be treated by discontinuation of immunosuppression and/or ribavirin therapy. To our best knowledge, this is a unique case of autochthonous HEV infection with coincident reactivation of Epstein-Barr virus (EBV) infection in an immunosuppressed patient with rheumatoid arthritis (RA). CASE PRESENTATION: A 68-year-old Swiss woman with RA developed hepatitis initially diagnosed as methotrexate-induced liver injury, but later diagnosed as autochthonous HEV infection accompanied by reactivation of her latent EBV infection. She showed confounding serological results pointing to three hepatotropic viruses (HEV, Hepatitis B virus (HBV) and EBV) that could be resolved by detection of HEV and EBV viraemia. The patient recovered by temporary discontinuation of immunosuppressive therapy. CONCLUSIONS: In immunosuppressed patients with RA and signs of liver injury, HEV infection should be considered, as infection can be treated by discontinuation of immunosuppression. Although anti-HEV-IgM antibody assays can be used as first line virological tools, nucleic acid amplification tests (NAAT) for detection of HEV RNA are recommended--as in our case--if confounding serological results from other hepatotropic viruses are obtained. After discontinuation of immunosuppressive therapy, our patient recovered from both HEV infection and reactivation of latent EBV infection without sequelae.

The SOCS3-independent expression of IDO2 supports the homeostatic generation of T regulatory cells by human dendritic cells.

Dendritic cells (DCs) are professional APCs that have a role in the initiation of adaptive immune responses and tolerance. Among the tolerogenic mechanisms, the expression of the enzyme IDO1 represents an effective tool to generate T regulatory cells. In humans, different DC subsets express IDO1, but less is known about the IDO1-related enzyme IDO2. In this study, we found a different pattern of expression and regulation between IDO1 and IDO2 in human circulating DCs. At the protein level, IDO1 is expressed only in circulating myeloid DCs (mDCs) and is modulated by PGE2, whereas IDO2 is expressed in both mDCs and plasmacytoid DCs and is not modulated by PGE2. In healthy subjects, IDO1 expression requires the presence of PGE2 and needs continuous transcription and translation, whereas IDO2 expression is constitutive, independent from suppressor of cytokine signaling 3 activity. Conversely, in patients suffering from inflammatory arthritis, circulating DCs express both IDO1 and IDO2. At the functional level, both mDCs and plasmacytoid DCs generate T regulatory cells through an IDO1/IDO2-dependent mechanism. We conclude that, in humans, whereas IDO1 provides an additional mechanism of tolerance induced by proinflammatory mediators, IDO2 is stably expressed in steady-state conditions and may contribute to the homeostatic tolerogenic capacity of DCs.

Toux sèche, douleurs thoraciques et dyspnée chez un patient atteint d'une polyarthrite rhumatoïde [Dry cough, chest pain and difficult breathing in a patient with rheumatoid arthritis]

Pulmonary involvement is the most frequent extra-articular manifestation of rheumatoid arthritis. The occurrence of a chronic hydro-pneumo-thorax associated with pulmonary nodules is rare. Cavitation of the most superficial nodules and their rupture into the pleural cavity are most likely involved in this complication. The presence of broncho-pleural fistulae may be responsible for the persistence of the phenomenon in our patient.

Identification of case complexity and increased health care utilization in patients with rheumatoid arthritis.

OBJECTIVES: To document biopsychosocial profiles of patients with rheumatoid arthritis (RA) by means of the INTERMED and to correlate the results with conventional methods of disease assessment and health care utilization. METHODS: Patients with RA (n = 75) were evaluated with the INTERMED, an instrument for assessing case complexity and care needs. Based on their INTERMED scores, patients were compared with regard to severity of illness, functional status, and health care utilization. RESULTS: In cluster analysis, a 2-cluster solution emerged, with about half of the patients characterized as complex. Complex patients scoring especially high in the psychosocial domain of the INTERMED were disabled significantly more often and took more psychotropic drugs. Although the 2 patient groups did not differ in severity of illness and functional status, complex patients rated their illness as more severe on subjective measures and on most items of the Medical Outcomes Study Short Form 36. Complex patients showed increased health care utilization despite a similar biologic profile. CONCLUSIONS: The INTERMED identified complex patients with increased health care utilization, provided meaningful and comprehensive patient information, and proved to be easy to implement and advantageous compared with conventional methods of disease assessment. Intervention studies will have to demonstrate whether management strategies based on INTERMED profiles can improve treatment response and outcome of complex patients.

Rhumatologie. Polyarthrite rhumatoide et spondylarthrite ankylosante [Rheumatoid arthritis and ankylosing spondylitis: rheumatologic highlights 2007]

L'utilisation des traitements biologiques est maintenant solidement ancrée dans la prise en charge des rhumatismes inflammatoires. Les anti-TNFa sont à juste titre devenus des agents de choix ces dix dernières années, et la littérature récente nous rappelle leurs places et indications dans la spondylarthrite ankylosante. Toutefois, tous les patients n'y répondent pas et la disponibilité de nouveaux traitements est certainement une addition bienvenue. L'abatacept est un nouveau traitement de la polyarthrite rhumatoïde avec un mode d’action innovateur, qui paraît efficace et adéquatement sûr et pour lequel quelques données et aspects pratiques d'utilisation sont présentés. Nous devons néanmoins encore apprendre à l'intégrer dans des stratégies thérapeutiques, comme nous sommes en train de le faire avec le rituximab. The use of biological therapy is now firmly established in the management of inflammatory rheumatism. The anti-TNFalpha have rightly become agents of choice over the last 10 years, and the recent literature reminds us of their places and indications in ankylosing spondylitis. However, not all patients respond, and the availability of new treatments is certainly a welcome addition. Abatacept is a new treatment for rheumatoid arthritis with an innovative mode of action. It appears effective and safe, and some data as well as practical aspects on its use are presented. Nevertheless, we must still learn to integrate it into our therapeutic strategies, as we are presently doing with rituximab

Use of abatacept in rheumatoid arthritis.

Abatacept (CTLA-Ig), a modulator of T-lymphocyte activation, has been approved by the Swiss health regulatory agency Swissmedic for the treatment of active rheumatoid arthritis (RA). This article summarises the key trial findings for this biologic agent in RA in different situations such as early erosive rheumatoid arthritis (RA), biologic-naïve RA, RA before and after the use of methotrexate or TNF-inhibitors and includes safety information from these trials. Based on these data, recommendations for clinical practice in Switzerland are made by a panel of experts.

Polyarthrite rhumatoïde et grossesse [Rheumatoid arthritis and pregnancy]

Rheumatoid arthritis occurs frequently in women in childbearing years. With the improvement of the treatments, more patients with rheumatoid arthritis consider a pregnancy. Close co-operation between the physician and the obstetrician caring for the mother and the foetus is necessary. The disease should be well controlled at the time of the conception, although an amelioration of rheumatoid arthritis occurs in about 75% of pregnancies, in the first trimester. Some medications can be used during pregnancy and lactation. There is no indication of any adverse effects of rheumatoid arthritis on pregnancy outcome. The mother needs to be followed up regularly after delivery because of the high risk of post-partum flare.

Evaluation clinique d'une polyarthrite rhumatoïde en pratique quotidienne [Clinical evaluation of rheumatoid arthritis in practice]

Clinical evaluation is an integral part of medical practice. However, recent data have demonstrated that a systematic and standardized evaluation modifies the prognosis of our rheumatoid arthritis patients. The systematic use of activity indexes allows us to better appreciate the needs of our patients and the necessity to optimize and intensifie treatment. Likewise, auto-evaluations tools bring useful information to patient management.

Rhumatologie [Rheumatoid arthritis and ankylosing spondylitis-rheumatologic highlights 2009]

In this year rheumatology highlights, we will especially note a new treatment, the tocilizumab, an interleukin-6 targeting therapy, effective and adequately safe for the treatment of rheumatoid arthritis. New classification criteria for axial spondylarthropathy have also been published, criteria that should facilitate earlier diagnosis, a diagnosis that should be pursue like a diagnosis of rheumatoid arthritis even in the absence of an inflammatory biological syndrome.

Swiss consensus statement: Recommendations for optimising re-treatment with MabThera (rituximab) in rheumatoid arthritis.

Rituximab is an effective treatment of rheumatoid arthritis (RA), which has been approved for the treatment of moderate to severe disease in patients with an inadequate response to anti-TNF therapies. Rituximab differs from other available biological agents for RA by way of its unique mode of action and unrivalled long dosing interval. The efficacy of rituximab subsides progressively over time and re-therapy is generally required to maintain long term disease control. The timing of re-treatment is currently not well established and varies widely in clinical practice. The present document is a concise recommendation regarding re-treatment with rituximab, based on validated outcomes such as the DAS28 and the EULAR response criteria. The recommendation was established through consensus between practitioners familiar with rituximab therapy in RA. Optimisation of the rituximab re-treatment schedule may improve patient outcomes and balance risks and benefits for the individual patient.

Rôle de l'imagerie dans le diagnostic et le suivi de la polyarthrite rhumatoïde [Role of imaging in the diagnosis and follow-up of rheumatoid arthritis].

Cross-sectional imaging techniques such as magnetic resonance imaging and ultrasound are becoming essential tools not only for making an early diagnosis of rheumatoid arthritis, but also to help clarify the prognosis of the disease and better assess the response to various therapies. This article summarises the recommendations established in 2013 by the European League Against Rheumatism on the role of imaging in the diagnosis and follow-up of rheumatoid arthritis, while adding comments and emphasising on our Swiss experience with the use of ultrasound.

CPPD crystal deposition disease in patients with rheumatoid arthritis.

The aim of this study was to assess the frequency and the outcome of patients suffering from rheumatoid arthritis in which calcium pyrophosphate dihydrate (CPPD) crystal deposits were found to coexist in synovial fluid analysis. Such association was more frequent than previously believed with CPPD crystals found in 25.8% of 93 patients with rheumatoid arthritis. As a group, a trend toward a worse outcome was suggested by more frequent prostheses of the lower limb.