Determining the cause of isolated midline destructive lesions: comment on the clinical images presented by Kasifoglu et al

Palate perforation differentiates cocaine-induced midline destructive lesions from granulomatosis with polyangiitis

Cocaine abuse occasionally causes extensive destruction of the osteocartilaginous structures of the nose, sinuses and palate, which mimics the clinical picture of other diseases associated with necrotising midfacial lesions. The differentiation of cocaine-induced midline destructive lesions (CIMDL) and limited granulomatosis with polyangiitis (GPA) may be difficult, particularly if patients do not readily admit substance abuse. We studied 10 patients with CIMDL and palate perforation referred to our Unit between 2002 and 2015. All cases underwent nasal endoscopy, sinus CT or MRI and ANCA test. In 8 patients, a nasal biopsy was performed. The PubMed database was searched to review all cases of palate perforation described in patients affected by CIMDL or GPA. All 10 cases presented with septal perforation and inferior turbinate destruction. We found hard palate perforation in 7 patients, soft palate perforation in 2 patients, and perforation of both in one patient. ANCA testing was negative in 8 patients and positive in 2, with C-ANCA and P-ANCA specificity, respectively. A review of the English literature identified palate perforation in 5 patients with GPA and in 73 patients with CIMDL. The presence of palate perforation in patients with MDL may represent a clinical marker that strongly favors CIMDL over GPA.

The efficacy of biologic agents in patients with rheumatoid arthritis and an inadequate response to tumour necrosis factor inhibitors: a systematic review

OBJECTIVE

To assess the relative efficacy of subsequent biologic therapies in patients with RA who have had an inadequate response to prior therapy with a TNF-α inhibitor.

METHODS

A systematic review was conducted using the MEDLINE, Embase and Cochrane Library databases and abstract lists from the European League Against Rheumatism, American College of Rheumatology and British Society of Rheumatology congresses. Searches covered the period from May 2009 (August 2009 for MEDLINE) to January 2011. Therapies considered were abatacept, adalimumab, etanercept, infliximab and rituximab, used at European licensed standard dose regimens.

RESULTS

Four full publications and 41 congress abstracts met the criteria for inclusion. Significant improvements in RA signs and symptoms were reported for TNF inhibitors (individual agents or groups of agents, depending on the study) and for abatacept and rituximab. Rituximab was also associated with significantly improved radiographic outcomes. No head-to-head randomized controlled trials directly comparing different agents were published during the search period. Comparative data from registries and other observational studies suggest that rituximab is at least as effective as an alternative TNF inhibitor, and in some studies significantly more effective, in TNF inadequate responders.

CONCLUSIONS

RA patients with an inadequate response to one or more TNF inhibitors derive significant clinical benefit from subsequent therapy with an alternative TNF inhibitor or with rituximab or abatacept. Prospective randomized controlled trials are needed to help physicians in the best choice of further therapy for their patients.

Abatacept treatment for rheumatoid arthritis

Significant advances in our understanding of RA and its management have been made in the past decade, resulting in earlier intervention with biologic DMARDs, particularly in patients with evidence of aggressive, erosive disease. Here, one such biologic therapy, the T-cell co-stimulation modulator abatacept, is discussed, exploring clinical evidence published to date on its use in patients with very early arthritis/early RA who are MTX naïve, and in patients with established RA and an inadequate response to MTX or TNF antagonists. Data from relevant clinical trials are overviewed, discussing the clinical efficacy of abatacept in early disease, the clinical outcomes over long-term treatment in different patient populations and the effects of abatacept on structural damage. Findings from integrated safety analyses of abatacept clinical trial data, representing 10 366 patient-years of exposure are described, and clinically important safety events, including serious infections, malignancies and autoimmune events, are highlighted. It is concluded that abatacept represents an effective treatment option with an established safety profile across different patient populations, including patients with both early and erosive RA and those with established disease. Furthermore, efficacy data from studies in patients with early disease suggest that the risk–benefit profile of abatacept may be more favourable when introduced earlier in the treatment paradigm.

Vasculitis-like Syndromes

Vasculitis often presents a diagnostic challenge as the disease processes may have varied presentations. This article reviews some vasculitis-like "mimics," particularly emphasizing viral and bacterial infections, drug-related disorders, various malignancies, and other autoimmune disorders, all of which may have a similar clinical presentation. This article also highlights recent advances and the importance of accurate diagnosis and therapy.