RA and Unemployment, Lupus and Bruising, and Rheumatic Fever Pain


New in the non-rheumatology journals: Yet another reason to treat RA early, another quirk about lupus and skin color, and rheumatic fever presenting as joint pain. Also, why so many fungus-tainted injections in Michigan?

Last week's articles on rheumatology topics in the major non-rheumatology journals

Rheumatoid Arthritis

Biological vs Conventional Combination Treatment and Work Loss in Early Rheumatoid Arthritis: A Randomized TrialJAMA Intern Med, July 1, 2013. Full text  $30.

Not Better but Quite Good: Effects on Work Loss of Combination Treatment for Rheumatoid Arthritis With and Without Biological Agents.JAMA Intern Med, July 1, 2013. Full text $30.

Biological combination therapy was no better than conventional combination therapy in preventing work loss among patients with early rheumatoid arthritis (RA) after methotrexate alone failed, according to an analysis of the Swedish Swefot trial data. This is in contrast to the previously reported radiological results, which found biological combination treatment (adding the tumor necrosis factor inhibitor infliximab) superior to conventional combination therapy (adding sulfasalazine plus hydroxychloroquine). The new analysis used sick leave and disability pension days in the Swedish Social Insurance Office register. Compared to the general population, RA patients had three times greater sick leave and disability at randomization. After 21 months, the disability had been reduced to double that of the general population, for the 124 patients in both groups. Aggressive treatment will maintain employment; however, once patients stop working, they are unlikely to return, so aggressive treatment should be started early. The outcome of employment, which is the greatest single economic cost of RA, may be more refractory to medical treatment than are clinical and radiological outcomes.


A Patient with Migrating PolyarthralgiasN Engl J Med, July 4, 2013. Full text $15

Migrating Polyarthralgias
Now@NEJM, July 5, 2013. Free full text.

Rheumatic fever presented as migrating polyarthralgias in this case study that ponders links between bacterial infection and cardiovascular damage. A 28-year-old woman presented with migrating polyarthralgias, followed by progressive shortness of breath consistent with congestive heart failure. She was diagnosed with acute rheumatic fever, treated with penicillin, and later with mitral-valve replacement, leading to substantial improvement in exercise tolerance.The incidence of acute rheumatic fever is declining worldwide. In the United States, the prevalence of rheumatogenic strains of group A Streptococcus is declining while the prevalence of non-rheumatogenic strains is increasing.

Systemic Lupus Erythematosus

Hydroxychloroquine-Induced Pigmentation in Patients With Systemic Lupus Erythematosus: A Case-Control Study JAMA Dermatol, July 3, 2013.  Full text $30.

Twenty-four patients with systemic lupus erythematosus developed pigmentation after treatment with hydroxycloroquine for a median of 6.1 years. Most patients reported that the pigmented lesions were preceded by ecchymotic areas, which gave way to localized blue-gray or brown pigmentation. Most patients had at least one condition that predisposed to easy bruising. The pigmentation was independently associated with oral anticoagulants, antiplatelet agents, and blood hydroxychloroquine concentration. This supports the hypothesis that hydroxychloroquine-induced pigmentation is secondary to ecchymosis or bruising.

Contaminated Injections

News From the Centers for Disease Control and Prevention: Michigan Has Top Statistic in Contaminated Steroid InfectionsJAMA, July 3, 2013, $30

Spinal and Paraspinal Infections Associated with Contaminated Methylprednisolone Acetate Injections - Michigan, 2012–2013
MMWR, May 17, 2013, Free

A commentary in JAMA suggests that Michigan may have detected more cases of spinal or paraspinal infections without meningitis because the state took a proactive approach to detection. Alternately, Michigan may have received methylprednisolone acetate supplies that had higher levels of fungal contamination. Most patients in Michigan received their injections at Michigan Pain Specialists, which used 400 vials from one lot that was linked with a significantly higher risk for fungal infection.

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