Publications (3)6.61 Total impact
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Article: Anti-neutrophil antibody associated vasculitis in systemic sclerosis.
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ABSTRACT: To report 3 cases ANCA-associated vasculitis (AAV) that developed in patients suffering from systemic sclerosis (SSc) and to review previously reported cases. We describe 3 patients diagnosed with SSc who developed severe AAV that presented as crescentic glomerulonephritis (GN) and/or alveolar hemorrhage. A retrospective review of the literature was performed using the PubMed database. The first patient presented with rapidly progressive renal failure and then with 2 episodes of massive alveolar hemorrhage. She was partially refractory to treatment with corticosteroids and cyclophosphamide but responded promptly to treatment with rituximab. The second patient suffered from 2 episodes of fulminant alveolar hemorrhage; the first responded to intravenous corticosteroids, but the second was fatal despite aggressive immune suppression with corticosteroids and cyclophosphamide. The third patient presented with a clinical picture compatible with scleroderma renal crisis (SRC) but was later diagnosed with crescentic GN and subsequently died from probable alveolar hemorrhage. Thirty-seven cases of AAV in SSc patients have been described in the English literature. Clinical manifestations include rapidly progressive GN, alveolar hemorrhage, limb ischemia, and vasculitic skin rash. In contrast to SRC that usually develops early in the course of SSc, ANCA-associated GN in SSc patients occurred later, after several years of illness. Hypertension, microangiopathic hemolytic anemia, and thrombocytopenia that are the hallmark of SRC were observed only in a minority of AAV cases. Almost all cases of AAV in SSc were positive for MPO-ANCA. AAV in the setting of SSc is a diagnostic challenge. Differential diagnosis from SRC is crucial as treatment approach for these conditions completely differs. High doses of corticosteroids and immune suppression are advocated in severe AAV. In resistant cases, treatment with rituximab may be considered.Seminars in arthritis and rheumatism 01/2011; 41(2):223-9. · 4.72 Impact Factor -
Article: The effect of infliximab on antiviral antibody profiles in patients with rheumatoid arthritis.
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ABSTRACT: The duration of humoral immunity in patients treated with immunosuppressive drugs is poorly defined. The objective of the study was to investigate the effect of infliximab on the levels of antiviral antibodies against poliomyelitis, rubella and measles in rheumatoid arthritis (RA) patients. Fifty-two consecutive RA patients being treated with 3 mg/kg infliximab were prospectively studied. The antiviral antibody profiles for measles, rubella and three serotypes of poliomyelitis were tested on the day of the first infusion of infliximab and 6 months later. The study group comprised 36 women and 16 men (mean age 54 years, range 33-81) with a mean disease duration of 15 +/- 9 years. Forty-two (81%) patients were being treated with methotrexate and 22 (42%) were receiving prednisone. All patients had baseline protective levels of antibodies against measles and the three strains of polio, while 48 (92%) patients had protective antibodies against rubella. No significant change in the levels of antiviral antibodies was observed after 6 months of treatment with infliximab: from 3.67 at baseline to 3.87 IU/ml for measles, 169.50-197.0 IU/ml for rubella. No change was noticed for the geometric mean concentrations of antibodies against strains of poliomyelitis: 366-478 IU/ml for the Mahoney polio strain, 906-845 IU/ml for the MEF strain and 175-196 IU/ml for the Sauket strain. Patients with longstanding RA conserve long-term immunity to common viruses despite the use of immunosuppressive drugs. Levels of antiviral antibodies against measles, rubella and polio remain stable under treatment with infliximab.Rheumatology International 06/2009; 30(3):325-9. · 1.88 Impact Factor -
Article: [Guidelines of the Israeli association of rheumatology for the prevention of tuberculosis in patients treated with TNF-alpha blockers].
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ABSTRACT: The use of TNFalpha blockers is associated with reactivation of tuberculosis. The Israeli Association of Rheumatology nominated a committee to determine guidelines for the prevention of tuberculosis in patients taking TNFalpha blockers. The risk of reactivation of tuberculosis is higher with monoclonal antibodies to TNFalpha (infliximab, adalimumab) in comparison with the soluble receptor of TNFalpha (etanercept). All patients who are candidates to receive TNFalpha blockers should be screened for active or latent tuberculosis. The screening includes: Tuberculin Skin Test (TST), chest X-ray and a questionnaire about possible exposure to tuberculosis. Two-step screening should be used as recommended by the Ministry of Health. The reaction elicited in the second test (if applied) should be used. In the general population latent tuberculosis is diagnosed when the TST response is 15 mm. or above; a reaction of 10 mm. or above is positive in populations with a history of definite or probable exposure to TB and 5 mm. is the threshold for populations who are immunosuppressed or if chest radiography reveals old tuberculosis without clear documentation of previous treatment. Patients with a TST less than 5 mm. should be questioned about prior exposure to tuberculosis. Latent tuberculosis should be treated with a 9 month course of isoniazid (300mg/d) or a 4 month course of rifampicin (600mg/d) or for 3 months with a combination of 300 mg. isoniazid and 600 mg. rifampicin daily. The committee recommends postponing treatment with TNFalpha blockers until completion of anti-tuberculosis therapy. If the clinical condition requires the urgent use of TNFalpha blockers, these may be initiated one month after starting treatment for latent tuberculosis.Harefuah 04/2007; 146(3):235-7, 244.
