Patients with rheumatoid arthritis and gold-induced pneumonitis express two high-risk major histocompatibility complex patterns

Gold salts, D-penicillamine and allopurinol

Gold salts have been used in the treatment of patients with rheumatoid arthritis since 1927 [1]. After a controlled study, the Empire Rheumatism Council [2], confirmed the effectiveness of gold salts for the treatment of rheumatoid arthritis. Even today, chrysotherapy has remained one of the major therapeutic modalities in the second line treatment of progressive rheumatoid arthritis. Gold salts are also used in the treatment of pemphigus vulgaris [3] and bronchial asthma [4]. Before the introduction of an orally administered gold compound, auranofin (triethylphosphine gold tetra-acetyl glycopyranoside), to clinical use [5-7], parenterally administered gold salts, such as sodium aurothiomalate and gold thioglucose comprised chrysotherapy. The frequency and severity of the side effects for patients treated with parenteral gold versus those given oral gold preparations are significantly different [8-10]. With introduction of newer parental DMARDs, toxicity has been reduced using combination therapy [10a, 10b].

Eosinophilic pneumonia (EP) associated with rheumatoid arthritis in which drug-induced eosinophilic pneumonia could be ruled out

A 72 year-old man. He was diagnosed with rheumatoid arthritis in 2002. In January 2005 he noted productive cough and fever; he was diagnosed as eosinophilic pneumonia (EP). We discontinued administration of bucillamine and methotrexate and started to treat with oral prednisolone 30 mg daily. To rule out drug-induced EP, prednisolone was tapered by 10 mg per week. Consolidation occurred in the right lower lobe when prednisolone was decreased to 5 mg daily. After increasing the dose of prednisolone to 30 mg daily again, consolidation was promptly resolved. It was considered to be important to rule out drug-induced EP.

Beryllium disease

Berylliosis is an environmental chronic inflammatory disorder of the lung caused by inhalation of insoluble beryllium (Be) dusts and characterized by the accumulation of CD4+ T cells and macrophages in the lower respiratory tract. In response to Be inhalation, noncaseating granuloma formation and, eventually, fibrosis. The immunopathogenic process is maintained by Be-specific lung CD4+ T-lymphocytes. Consistent with the disease immunopathology, these Be-specific T cells have a T-helper 1 phenotype producing interleukin-2 and interferon-gamma, the macrophage-activating cytokine driving the granulomatous reaction. Previous studies have demonstrated that the glutamic acid in position 69 of the human leukocyte antigen class II b chain is strongly associated with increased susceptibility to Be in exposed workers, suggesting that human leukocyte antigen gene markers may be used as epidemiological probes to identify population groups at higher risk.

Prognostic significance of complement alleles Bf and C4 in early rheumatoid arthritis

The prognostic significance of class III major histocompatibility complex complement components, factor B (Bf), C4A and C4B, were studied in a 3-year prospective study of 73 patients with early RA. Patients with C4B null allele had higher disease activity with more radiological progression than patients with C4A null allele or patients without null allele. C4B null allele also associated with increased susceptibility to side effects from antirheumatic treatment. The Bf phenotypes did not associate with the severity of RA. C4B null allele may have prognostic significance in determining a special subgroup of RA patients with a more complicated course of the disease.

Antirheumatic drug reactions in the lung

Drug-induced lung disease during treatment with antirheumatic drugs should be considered in all patients receiving these agents who develop new pulmonary symptoms. When a potential drug-related reaction is identified, the possible offending agents should be discontinued, appropriate respiratory support initiated, and a thorough investigation for other causes of respiratory disease launched to exclude infection or other pulmonary processes. Lung biopsy may be needed to define the disorder completely. In patients with acute pneumonitis, the use of corticosteroids should be considered. Although significant morbidity and even mortality may occur with drug-induced pulmonary events, proper and prompt evaluation and treatment of these disorders can often result in complete resolution of the pulmonary disease.

Poor prognosis in patients with rheumatoid arthritis hospitalized for interstitial lung fibrosis

Fifty-seven patients with rheumatoid arthritis (RA) were treated in hospital for diffuse interstitial lung fibrosis. Although interstitial fibrosis (either on the basis of lung function tests or chest roentgenograms or both) is fairly common among patients with RA, according to this study interstitial fibrosis of sufficient extent or severity to warrant hospitalization was rare: incidence of hospitalization due to the lung disease in RA patients was one case per 3,500 patient-years. Eight patients had a largely reversible lung disease associated with drug treatment (gold, D-penicillamine or nitrofurantoin.) The remaining 49 had interstitial fibrosis of unknown cause. Causes for hospitalization were respiratory and general symptoms in 38, but infiltrations on routine chest roentgenographic examinations alone in eleven patients. Forty-five out of the 49 patients had crackles on auscultation. The most typical findings in lung function tests were restriction and a decreased diffusion capacity. These 49 patients showed a poor prognosis, with a median survival of 3.5 years and a five-year survival rate of 39 percent.

Association between restriction fragment length variants of the complement C4 genes and MHC haplotypes

DNA polymorphism of the human major histocompatibility complex (MHC)-linked complement C4 genes was studied using restriction enzymes XbaI and TaqI, and Southern hybridization. The results show that some, but not all, C4 phenotypes can be divided into subtypes. Analysis of MHC haplotypes indicates that in each extended MHC haplotype, i.e. in the haplotypes having a particular combination of HLA and complotype phenotypes in significant linkage disequilibrium, the C4 genes always produce just one 'conserved' restriction enzyme fragment pattern, while in the other haplotypes the C4 genes are more heterogeneous. Furthermore, the findings provide preliminary evidence for a C4B gene duplication, and suggest that the C4 genes may often be 'corrected' alike.