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Mortezaei K, Gonzales SAB, Arkfeld DG. Clinical Image: Eczema herpeticum in a patient with rheumatoid arthritis and dry eye syndrome. ACR Open Rheumatol 2024; 6:137. [PMID: 38148274 PMCID: PMC10933631 DOI: 10.1002/acr2.11632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 12/28/2023] Open
Affiliation(s)
- Kiana Mortezaei
- Keck Medicine of University of Southern CaliforniaLos AngelesCA
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Gonzales SAB, Alexopoulos C, Arkfeld DG. Potential Benefits of Psilocybin for Lupus Pain: A Case Report. Curr Rheumatol Rev 2024; 20:97-99. [PMID: 37670693 DOI: 10.2174/1573397119666230904150750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/02/2023] [Accepted: 08/09/2023] [Indexed: 09/07/2023]
Abstract
INTRODUCTION Outcomes of treatment for patients with Lupus have shown overall improvement and benefit from the more aggressive use of immunosuppressants and biological agents through a treat-to-target approach. However, chronic musculoskeletal pain can be refractory to treatment despite the use of non-steroidal anti-inflammatory drugs, corticosteroids, and other analgesic agents, leading to patient dissatisfaction. The concept of new neural pathways from psilocybin usage has been proposed in a variety of pain syndromes; however, it is not trialed for patients with Lupus pain. CASE PRESENTATION The patient was a 67-year-old male with positive anti-dsDNA antibody Lupus with a predominance of chronic polyarticular joint pain treated with hydroxychloroquine and non-steroidal anti-inflammatory drugs without pain relief. Pain dramatically improved after a one-time macro-dosing of 6 grams of Psilocybin cubensis in Oregon, which he expected would only provide a sense of enlightenment. After 12 months, he continued without debilitating joint pain. CONCLUSION The serotonin-2A receptor's activation triggers an array of neurophysiological reactions that disrupt the functional connections in areas of the brain that are associated with chronic pain. These neuroplastic effects can generate healthy connections, resulting in long-lasting pain relief. However, this is a process that has not been fully analyzed. While there is anecdotal evidence to suggest the therapeutic benefits for autoimmune diseases, including rheumatoid arthritis and psoriasis, there is no specific research that explores its use for lupus-related pain. Since this is the first case that shows the benefit of psilocybin in a patient with Lupus, further studies on macro-dosing psilocybin to treat Lupus pain are warranted.
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Affiliation(s)
- Sofia Audrey B Gonzales
- Department of Rheumatology, University of Southern California, 1520 San Pablo St Los Angeles, CA90033-5310, United States
| | - Christine Alexopoulos
- Department of Rheumatology, University of Southern California, 1520 San Pablo St Los Angeles, CA90033-5310, United States
| | - Daniel G Arkfeld
- Department of Rheumatology, University of Southern California, 1520 San Pablo St Los Angeles, CA90033-5310, United States
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Peng MG, Zukin LM, Wallace WD, Sibug Saber ME, Arkfeld DG, Chang JR. Arteritic Anterior Ischemic Optic Neuropathy and Central Retinal Artery Occlusion in Polyarteritis Nodosa. J Neuroophthalmol 2023; Publish Ahead of Print:00041327-990000000-00378. [PMID: 37335682 DOI: 10.1097/wno.0000000000001911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Affiliation(s)
- Micalla G Peng
- USC Keck School of Medicine (MGP), Los Angeles, California; Keck Medicine of USC (LMZ, JRC), Roski Eye Institute, Los Angeles, California; Department of Pathology (WDW, MESS) and Division of Rheumatology (DGA), Keck Medicine of USC, Los Angeles, California
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Wise LM, Arkfeld DG. A patient with primary Sjogren’s syndrome, cystic lung disease, and MALT lymphoma treated successfully with rituximab: a case-based review. Clin Rheumatol 2019; 39:1357-1362. [DOI: 10.1007/s10067-019-04886-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 12/17/2022]
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Metyas S, Chen CL, Yeter K, Solyman J, Arkfeld DG. Low Dose Naltrexone in the Treatment of Fibromyalgia. Curr Rheumatol Rev 2018; 14:177-180. [PMID: 28325149 DOI: 10.2174/1573397113666170321120329] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 09/15/2016] [Accepted: 03/07/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND ConclusionFibromyalgia is a chronic pain disorder characterized by diffuse musculoskeletal pain, fatigue, sleep disturbance and cognitive impairment. OBJECTIVE A significant number of fibromyalgia patients do not respond adequately to the current drugs approved by the Food and Drug Administration (FDA) for fibromyalgia treatment including pregabalin, milnacipran, duloxetine. Thus, there is still a need for adjunctive therapies. METHOD Naltrexone is an opioid receptor antagonist used to treat alcohol and opioid dependence. It is hypothesized that low dose naltrexone causes transient blockade of opioid receptors centrally resulting in a rebound of endorphin function which may attenuate pain in fibromyalgia. RESULTS Two small prospective pilot studies have previously shown that treatment with low dose naltrexone may be an effective, safe, and inexpensive treatment for fibromyalgia. CONCLUSION This prospective study lends further support to the preliminary body of evidence that naltrexone is a well tolerated and likely effective treatment option in the community setting. Further large prospective controlled trials are still needed.
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Affiliation(s)
- Samy Metyas
- Rheumatology, University of Southern California - Keck School of Medicine, Covina, United States
| | - Christina L Chen
- Rheumatology, University of Southern California - Keck School of Medicine, Covina, United States
| | - Karen Yeter
- Rheumatology, University of Southern California - Keck School of Medicine, Covina, United States
| | - John Solyman
- Rheumatology, Research Associate, Covina, United States
| | - Daniel G Arkfeld
- Rheumatology, University of Southern California - Keck School of Medicine, Covina, United States
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Edman MC, Janga SR, Meng Z, Bechtold M, Chen AF, Kim C, Naman L, Sarma A, Teekappanavar N, Kim AY, Madrigal S, Singh S, Ortiz E, Christianakis S, Arkfeld DG, Mack WJ, Heur M, Stohl W, Hamm-Alvarez SF. Increased Cathepsin S activity associated with decreased protease inhibitory capacity contributes to altered tear proteins in Sjögren's Syndrome patients. Sci Rep 2018; 8:11044. [PMID: 30038391 PMCID: PMC6056496 DOI: 10.1038/s41598-018-29411-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/11/2018] [Indexed: 02/08/2023] Open
Abstract
Cathepsin S (CTSS) activity is elevated in Sjögren's Syndrome (SS) patient tears. Here we tested whether protease inhibition and cystatin C (Cys C) levels are reduced in SS tears, which could lead to enhanced CTSS-driven degradation of tear proteins. CTSS activity against Cys C, LF and sIgA was tested in SS or healthy control tears. Tears from 156 female subjects (33, SS; 33, rheumatoid arthritis; 31, other autoimmune diseases; 35, non-autoimmune dry eye (DE); 24, healthy controls) were analyzed for CTSS activity and Cys C, LF, and sIgA levels. Cys C and LF showed enhanced degradation in SS tears supplemented with recombinant CTSS, but not supplemented healthy control tears. CTSS activity was significantly increased, while Cys C, LF and sIgA levels were significantly decreased, in SS tears compared to other groups. While tear CTSS activity remained the strongest discriminator of SS in autoimmune populations, combining LF and CTSS improved discrimination of SS beyond CTSS in DE patients. Reductions in Cys C and other endogenous proteases may enhance CTSS activity in SS tears. Tear CTSS activity is reconfirmed as a putative biomarker of SS in an independent patient cohort while combined LF and CTSS measurements may distinguish SS from DE patients.
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Affiliation(s)
- Maria C Edman
- Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Srikanth R Janga
- Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Zhen Meng
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Mercy Bechtold
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alexander F Chen
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Chongiin Kim
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Luke Naman
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Arunava Sarma
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Neha Teekappanavar
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alice Y Kim
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sara Madrigal
- Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Simranjit Singh
- Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Elizabeth Ortiz
- Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Stratos Christianakis
- Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel G Arkfeld
- Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Wendy J Mack
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Martin Heur
- Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William Stohl
- Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Rheumatology, Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA
| | - Sarah F Hamm-Alvarez
- Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, Los Angeles, University of Southern California, Los Angeles, CA, USA.
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Abstract
Fibromyalgia (FM) is a characterized by generalized pain with widespread tender points in specific areas and is frequently accompanied by fatigue, stiffness, and a non-restorative sleep pattern. In the current retrospective study, we identified a subgroup of FM patients who had clinically important markers of inflammation. The study also explored the use of the original American College of Rheumatology (ACR) criteria in the diagnosis of FM. Our data suggested there was a distinct subset of patients with FM who had positive ESR, CRP, ANA and RF; a group that we considered representative of inflammatory FM. None of the FM patients in this study developed a documented coexisting autoimmune illness during the retrospective review period. The existence of FM subgroups further puts into question the already controversial use of either the new or old ACR classification criteria in the diagnosis of FM, as they do not address the issue of systemic inflammation which appears to be significant.
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Affiliation(s)
- Samy K Metyas
- Clinical Professor of rheumatology at USC. 150 N 3rd ave, Covina, Ca 91723, USA
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Escalante P, Kooda KJ, Khan R, Aye SS, Christianakis S, Arkfeld DG, Ehresmann GR, Kort JJ, Jones BE. Diagnosis of latent tuberculosis infection with T-SPOT(®).TB in a predominantly immigrant population with rheumatologic disorders. Lung 2014; 193:3-11. [PMID: 25318864 DOI: 10.1007/s00408-014-9655-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 10/07/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE The objective of this study is to compare how likely positive tuberculin skin test (TST) and T-SPOT(®).TB (TSPOT) results predict risk factors for tuberculosis in a predominantly immigrant patient population at risk of latent TB infection (LTBI) and with rheumatologic conditions requiring immunomodulatory therapy (IMT). METHODS Prospective study conducted at a referral rheumatology clinic. Inclusion criteria included patients on various IMT, including immunosuppressive drugs that could predispose to TB progression. We studied risk factors associated with LTBI, test results, and tests' agreement. RESULTS We studied 101 patients. Eighty (79.2 %) were from countries where TB is prevalent and Bacille Calmette-Guérin vaccination is placed routinely. Seventy-four (73.3 %) had rheumatoid arthritis and 92 (90.7 %) were on IMT. Among patients with both TST and TSPOT results, 25 (30.9 %) were TST(+) and 20 (24.7 %) had TSPOT(+) results. Fifteen patients (18.5 %) had TST(+)/TSPOT(+) results, and 51 (63.0 %) had TST(-)/TSPOT(-) results (agreement = 81.5 %; kappa = .54 [95 % CI, .34-.74; P < .001]). Each TSPOT(+) and TST(+) results were independently associated with immigrant status and prior residence in a TB prevalent country after adjustment for immunosuppressive therapy: Adjusted OR(TSPOT+)=6.6 (95 % CI, 1.2-123.3; P = .027); and adjusted OR(TST+)=11.2 (95 % CI, 2.0-209.5; P = .003). Seven out of 10 TST(+)/TSPOT(-) cases had a TST ≥15 mm induration, including three cases with history of TST conversion. CONCLUSIONS TST(+) and TSPOT(+) results predict risk factors associated with LTBI independent of immunosuppressive IMT. Some TST(+)/TSPOT(-) results were unlikely to be false-negatives. The combined use of TST and TSPOT appears to be a reasonable diagnostic strategy to evaluate for LTBI in this population.
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Affiliation(s)
- Patricio Escalante
- Division of Pulmonary and Critical Care Medicine and Mayo Clinic Center for Tuberculosis, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA,
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9
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Hamm-Alvarez SF, Janga SR, Edman MC, Madrigal S, Shah M, Frousiakis SE, Renduchintala K, Zhu J, Bricel S, Silka K, Bach D, Heur M, Christianakis S, Arkfeld DG, Irvine J, Mack WJ, Stohl W. Tear cathepsin S as a candidate biomarker for Sjögren's syndrome. Arthritis Rheumatol 2014; 66:1872-81. [PMID: 24644101 DOI: 10.1002/art.38633] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 03/13/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The diagnosis of Sjögren's syndrome (SS) in routine practice is largely a clinical one and requires a high index of suspicion by the treating physician. This great dependence on clinical judgment frequently leads to delayed diagnosis or misdiagnosis. Tear protein profiles have been proposed as simple and reliable biomarkers for the diagnosis of SS. Given that cathepsin S activity is increased in the lacrimal glands and tears of NOD mice (a murine model of SS), the aim of this study was to explore the clinical utility of using tear cathepsin S (CTSS) activity as a biomarker for SS. METHODS A method to measure CTSS activity in tears eluted from Schirmer's test strips was developed and validated. Schirmer's tests were performed and CTSS activity measurements were obtained in 278 female subjects, including 73 with SS, 79 with rheumatoid arthritis, 40 with systemic lupus erythematosus, 10 with blepharitis, 31 with nonspecific dry eye disease, and 12 with other autoimmune diseases, as well as 33 healthy control subjects. RESULTS The median tear CTSS activity in patients with SS was 4.1-fold higher than that in patients with other autoimmune diseases, 2.1-fold higher than that in patients with nonspecific dry eye disease, and 41.1-fold higher than that in healthy control subjects. Tear CTSS levels were equally elevated in patients with primary SS and those with secondary SS, independent of the Schirmer's test strip values or the levels of circulating anti-SSA or anti-SSB antibodies. CONCLUSION Markedly high levels of tear CTSS activity are suggestive of SS. CTSS activity in tears can be measured in a simple, quick, economical, and noninvasive manner and may serve as a novel biomarker for autoimmune dacryoadenitis during the diagnostic evaluation for SS.
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Affiliation(s)
- Samy Metyas
- Department of Medicine - Rheumatology; Keck School of Medicine; University of Southern California; Los Angeles California USA
| | | | | | - Karen C. Yeter
- Department of Medicine - Rheumatology; Keck School of Medicine; University of Southern California; Los Angeles California USA
| | - Daniel G. Arkfeld
- Department of Medicine - Rheumatology; Keck School of Medicine; University of Southern California; Los Angeles California USA
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Metyas S, Tawadrous M, Yeter KC, Arkfeld DG. Neurosarcoidosis mimicking multiple sclerosis successfully treated with methotrexate and adalimumab. Int J Rheum Dis 2013; 17:214-6. [PMID: 24576278 DOI: 10.1111/1756-185x.12122] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Samy Metyas
- Department of Medicine-Rheumatology, Keck School of Medicine, University of Southern California, Los Angeles
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12
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Affiliation(s)
- Karen C. Yeter
- Department of Medicine-Rheumatology; Keck School of Medicine; University of Southern California; Los Angeles California USA
| | - Elizabeth C. Ortiz
- Department of Medicine-Rheumatology; Keck School of Medicine; University of Southern California; Los Angeles California USA
| | - Daniel G. Arkfeld
- Department of Medicine-Rheumatology; Keck School of Medicine; University of Southern California; Los Angeles California USA
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Affiliation(s)
- Karen C. Yeter
- Department of Medicine - Rheumatology; Keck School of Medicine; University of Southern California; CA; USA
| | - Daniel G. Arkfeld
- Department of Medicine - Rheumatology; Keck School of Medicine; University of Southern California; CA; USA
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14
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Bassiouni H, Zaki K, Elshorbagi M, Mustapha A, Tantawi R, Ali H, Metyas S, Arkfeld DG. Relating bone marrow oedema to hs-CRP in knee osteoarthritis. Indian Journal of Rheumatology 2010. [DOI: 10.1016/s0973-3698(10)60530-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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15
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Arkfeld DG, Weitz IC. Immune thrombocytopenia in patients with connective tissue disorders and the antiphospholipid antibody syndrome. Hematol Oncol Clin North Am 2010; 23:1239-49. [PMID: 19932431 DOI: 10.1016/j.hoc.2009.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
It has been theorized that immune thrombocytopenia (ITP) is a syndrome characterized by various defects in immune regulation, resulting in a common phenotype, decreased blood platelets, and symptoms of mucocutaneous bleeding. Most often, successful treatment of the underlying connective tissue disorder with corticosteroids or other disease-modifying agents can simultaneously improve concurrent thrombocytopenia. The best evidence to date would support the targeting of treatment to the connective tissue disorder, expecting a simultaneous improvement in the platelet count. Due to the frequent relapses associated with many of the connective tissue disorders and the frequent use of immunosuppressant agents, splenectomy should be undertaken only in highly refractory patients. Differentiating the varying immunopathic etiologies that contribute to development of connective tissue disorders may lead to a better understanding of the mechanisms of thrombocytopenia in a subset of these patients. The use of target therapies to treat connective tissue disorders has the potential of reducing the risk of the development of ITP or, conversely, inducing the development of immune thrombocytopenia.
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Affiliation(s)
- Daniel G Arkfeld
- Division of Rheumatology and Immunology, University of Southern California-Keck School of Medicine, HMR 711, 2011 Zonal Avenue, Los Angeles, CA 90033, USA.
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Abstract
Abstract
Objective
Rheumatoid arthritis (RA) is an autoimmune disease that targets the synovium. The autoantigens involved in the autoantibody responses in RA are unknown. A targeted proteomics approach was used to identify proteins in RA synovial fluid (SF) that are recognized by autoantibodies in RA sera.
Methods
RA SF, depleted of abundant proteins, was fractionated by two-dimensional liquid chromatography (chromatofocusing followed by reverse phase HPLC). Protein arrays constructed from these fractions were probed with RA and normal control sera, and proteins within reactive fractions were identified by mass spectrometry. The reactivity of RA sera to an identified peptide was confirmed by ELISA.
Results
RA sera specifically reacted to a SF fraction containing fibrin. Mass spectrometry analyses established the presence of a citrullinated arginine at position 271 of the fibrin fragment present in RA SF. A synthetic peptide corresponding to fibrin residues 259–287, containing the citrulline substitution at Arg 271, was recognized by 10 of 12 RA sera, but by two of 18 normal control sera and one of 10 systemic lupus erythematosus sera.
Conclusion
Proteomics methodology can be used to directly characterize post-translational modifications in candidate autoantigens isolated from sites of disease activity. The finding that RA sera contain antibodies to the citrullinated fibrin 259–287 peptide may ultimately lead to improved diagnostic tests for RA and/or biomarkers for disease activity.
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Arkfeld DG. Higher gonorrhea rates among African Americans than among White persons in the United States. Ann Intern Med 2008; 148:482; author reply 482. [PMID: 18347355 DOI: 10.7326/0003-4819-148-6-200803180-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Affiliation(s)
- Daniel G. Arkfeld
- From the University of Southern California Keck School of Medicine, Los Angeles, CA 90033
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20
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Affiliation(s)
- Daniel G. Arkfeld
- From University of Southern California Keck School of Medicine, Los Angeles, CA 90033
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Abstract
Increasing awareness of the importance of aberrant B cell regulation in autoimmunity has driven the clinical development of novel B cell-directed biologic therapies with the potential to treat a range of autoimmune disorders. The first of these drugs-rituximab, a chimeric monoclonal antibody against the B cell-specific surface marker CD20-was recently approved for treating rheumatoid arthritis in patients with an inadequate response to other biologic therapies. The aim of this review is to discuss the potential use of rituximab in the management of other autoimmune disorders. Results from early phase clinical trials indicate that rituximab may provide clinical benefit in systemic lupus erythematosus, Sjögren's syndrome, vasculitis, and thrombocytopenic purpura. Numerous case reports and several small pilot studies have also been published reporting the use of rituximab in conditions such as myositis, antiphospholipid syndrome, Still's disease, and multiple sclerosis. In general, the results from these preliminary studies encourage further testing of rituximab therapy in formalized clinical trials. Based on results published to date, it is concluded that rituximab, together with other B cell-directed therapies currently under clinical development, is likely to provide an important new treatment option for a number of these difficult-to-treat autoimmune disorders.
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Affiliation(s)
- D G Arkfeld
- Division of Rheumatology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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Metyas S, La D, Arkfeld DG. The use of the tumour necrosis factor antagonist infliximab in heart transplant recipients: two case reports. Ann Rheum Dis 2007; 66:1544-5. [PMID: 17934084 DOI: 10.1136/ard.2007.070383] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Oliveira B, Arkfeld DG, Weitz IC, Shinada S, Ehresmann G. Successful Rituximab Therapy of Acquired Factor VIII Inhibitor in a Patient With Rheumatoid Arthritis. J Clin Rheumatol 2007; 13:89-91. [PMID: 17414538 DOI: 10.1097/01.rhu.0000260656.05638.f7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acquired factor VIII deficiency due to antibody inhibition can result in life-threatening hemorrhage. Rarely such antibody inhibition of factor VIII can be associated with other autoimmune disorders including rheumatoid arthritis. We present the first case of a patient with active rheumatoid arthritis and refractory bleeding diatheses due to a factor VIII inhibitor who was successfully treated with rituximab. A 61-year-old Caucasian female with rheumatoid arthritis unresponsive to multiple therapies developed an acute hematoma while having a peripheral catheter placed. Her aPTT was prolonged at 61.4 with low factor VIII activity and an inhibitor level for factor VIII of 2.0 Bethesda Units. She received rituximab 375 mg/m in 4 weekly doses. Normalization of the aPTT and resolution of the bleeding occurred in 2 weeks. After 45 days, the levels of factor VIII inhibitor and factor VIII activity were <0.4 BU/mL and 130%, respectively. After 1 year, the aPTT remained normal and there was no further bleeding. An added benefit was the substantial improvement in her rheumatoid arthritis. Treatment of acquired factor VIII inhibitors in rheumatoid arthritis should be guided by the levels of the inhibitor. Patients with low levels of the inhibitor may respond to rituximab monotherapy, whereas higher levels may necessitate combination therapies. The dual benefit of RA disease control and resolution of bleeding makes rituximab therapy compelling in the rare patient who presents with these 2 disorders.
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Affiliation(s)
- Bruno Oliveira
- Division of Rheumatology, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA
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Rubenstein E, Arkfeld DG, Metyas S, Shinada S, Ehresmann S, Liebman HA. Rituximab treatment for resistant antiphospholipid syndrome. J Rheumatol 2006; 33:355-7. [PMID: 16465669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Antiphospholipid syndrome (APS) and catastrophic antiphospholipid syndrome (CAPS) can be challenging to treat. As they are rare, clinicians are not often exposed to these complex diseases. For the patient resistant to standard treatments new therapeutic directions can be perplexing, especially in the context of ongoing thromboses and bleeding episodes. We describe 3 patients, 2 with APS and one with CAPS, resistant to conventional medications, who responded to treatment with rituximab, an anti-CD20 monoclonal antibody. Since rituximab infusion, all the patients have had stable platelet counts and no further episodes of bleeding or thromboses.
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Affiliation(s)
- Elyse Rubenstein
- Division of Rheumatology and Division of Hematology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, 90033, USA
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Lacson SM, Metyas SK, Arkfeld DG. Hip Arthroplasty in a 101-Year-Old Patient. J Clin Rheumatol 2005; 11:180. [PMID: 16357745 DOI: 10.1097/01.rhu.0000165282.60312.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Arkfeld DG, Rubenstein E. Quest for the Holy Grail to cure arthritis and osteoporosis: emphasis on bone drug delivery systems. Adv Drug Deliv Rev 2005; 57:939-44. [PMID: 15876396 DOI: 10.1016/j.addr.2005.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Accepted: 02/11/2005] [Indexed: 11/30/2022]
Abstract
The number of new medications to treat and even prevent arthritis and osteoporosis has expanded dramatically in recent years. Where once there were only surgical options to treat such end-stage diseases, there are now treatments targeted at the early steps in musculoskeletal pathophysiology. The use of different modalities to maximize drug access to specific bone tissues has created a golden opportunity for mechanistic studies in drug delivery systems for treating osteoporosis and other musculoskeletal diseases. This theme issue provides a timely analysis of the challenges and accomplishments in delivering medicine to the target sites in the musculoskeletal system and also provides a preview of what may come in the future for musculoskeletal medicine. As the number of animal studies and clinical trials is on the rise, the possibility to prevent or even cure the aforementioned disorders has never been closer.
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Affiliation(s)
- Daniel G Arkfeld
- Division of Rheumatology, Keck School of Medicine, University of Southern California, HMR 711, 2011 Zonal Ave., Los Angeles, CA 90033, USA.
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Oh J, Arkfeld DG, Horwitz DA. Development of Crohn's disease in a patient taking etanercept. J Rheumatol 2005; 32:752-3. [PMID: 15801037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
In addition to its well known proinflammatory effects, tumor necrosis factor-alpha (TNF-a) has complex effects on the growth, differentiation, and death of immune cells. TNF antagonists have had dramatic effects on the suppression of rheumatoid arthritis and other rheumatic inflammatory diseases. However, TNF inhibition of RA has led to an increased incidence of drug induced anti-dsDNA production, with cases of systemic lupus erythematosus as well as exacerbations of multiple sclerosis. While etanercept does not generally alter the course of Crohn's disease we describe a rare instance where this agent may have contributed to the development of clinically significant inflammatory bowel disease.
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Affiliation(s)
- Jenny Oh
- Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California 90032, USA
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Affiliation(s)
- Andrew E Hendifar
- Keck School of Medicine, University of Southern California, Los Angeles, 90033, USA
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Metyas S, Arkfeld DG, Forrester DM, Ehresmann GR. Infliximab Treatment of Familial Mediterranean Fever and Its Effect on Secondary AA Amyloidosis. J Clin Rheumatol 2004; 10:134-7. [PMID: 17043487 DOI: 10.1097/01.rhu.0000128856.13595.eb] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe a patient with a long history of familial Mediterranean fever who developed proteinuria as a result of secondary AA amyloidosis. In this patient, the inflammatory process, including recurrent attacks of arthritis, abdominal pain, nephrotic syndrome secondary to amyloidosis, and high sedimentation rate, was rapidly suppressed by treatment with infliximab and there was remarkable improvement of the proteinuria.Because TNF-alpha is a proinflammatory cytokine that plays a major role in FMF and secondary amyloid, it is an appropriate target for therapy. Our case is the first case of reactive systemic amyloidosis secondary to familial Mediterranean fever, which responded favorably to infliximab.
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Affiliation(s)
- Samy Metyas
- LAC+USC Medical Center, Los Angeles, California, USA
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Tan SM, Xu D, Roschke V, Perry JW, Arkfeld DG, Ehresmann GR, Migone TS, Hilbert DM, Stohl W. Local production of B lymphocyte stimulator protein and APRIL in arthritic joints of patients with inflammatory arthritis. Arthritis Rheum 2003; 48:982-92. [PMID: 12687540 DOI: 10.1002/art.10860] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine whether synovial fluid (SF) levels and cell-surface expression of B lymphocyte stimulator (BLyS) protein and SF levels of APRIL are elevated in patients with inflammatory arthritis (IA). METHODS Same-day blood and SF samples from 89 patients with 103 knee effusions (81 knees with IA and 22 with noninflammatory arthritis [NIA]) were evaluated for BLyS protein and APRIL levels by enzyme-linked immunosorbent assay. Blood and SF mononuclear cells were double-stained for surface BLyS protein and surface CD14 (monocyte marker) and were analyzed by flow cytometry. Complete blood cell counts and SF nucleated cell counts were performed by the clinical hematology laboratory. RESULTS BLyS protein levels were higher in SF than in corresponding serum samples from both IA and NIA patients. SF BLyS protein levels, but not surface expression of BLyS protein, were disproportionately elevated in IA patients. APRIL levels were higher in SF than in corresponding serum samples from most IA patients but not NIA patients. SF BLyS protein and APRIL levels correlated with each other, and each correlated with SF monocyte, lymphocyte, neutrophil, and total nucleated cell counts. Although SF and serum BLyS protein levels correlated with each other, SF and serum APRIL levels did not, suggesting that SF BLyS protein levels are more dependent upon systemic factors than are SF APRIL levels. Moreover, in 8 patients who underwent sequential arthrocenteses, changes in SF BLyS protein levels did not immutably parallel changes in SF APRIL levels, indicating their differential regulation. CONCLUSION BLyS protein and APRIL are locally produced in inflamed joints. Their respective SF levels are differentially regulated, suggesting that they serve different functions. Together, their local production may foster survival and/or expansion of B cells that produce pathogenic autoantibodies and/or promote local T cell activation and consequent joint destruction.
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Affiliation(s)
- Soon-Min Tan
- Los Angeles County + University of Southern California Medical Center, 90033, USA
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Moreland LW, Schiff MH, Baumgartner SW, Tindall EA, Fleischmann RM, Bulpitt KJ, Weaver AL, Keystone EC, Furst DE, Mease PJ, Ruderman EM, Horwitz DA, Arkfeld DG, Garrison L, Burge DJ, Blosch CM, Lange ML, McDonnell ND, Weinblatt ME. Etanercept therapy in rheumatoid arthritis. A randomized, controlled trial. Ann Intern Med 1999; 130:478-86. [PMID: 10075615 DOI: 10.7326/0003-4819-130-6-199903160-00004] [Citation(s) in RCA: 885] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In a phase II study, etanercept (recombinant human tumor necrosis factor receptor [p75]:Fc fusion protein) safely produced rapid, dose-dependent improvement in rheumatoid arthritis over 3 months. OBJECTIVE To confirm the benefit of etanercept therapy of longer duration and simplified dosing in patients with rheumatoid arthritis. DESIGN Randomized, double-blind, placebo-controlled trial with blinded joint assessors. SETTING 13 North American centers. PATIENTS 234 patients with active rheumatoid arthritis who had an inadequate response to disease-modifying antirheumatic drugs. INTERVENTION Twice-weekly subcutaneous injections of etanercept, 10 or 25 mg, or placebo for 6 months. MEASUREMENTS The primary end points were 20% and 50% improvement in disease activity according to American College of Rheumatology (ACR) responses at 3 and 6 months. Other end points were 70% ACR responses at 3 and 6 months and other measures of disease activity at 3 and 6 months. RESULTS Etanercept significantly reduced disease activity in a dose-related fashion. At 3 months, 62% of the patients receiving 25 mg of etanercept and 23% of the placebo recipients achieved 20% ACR response (P < 0.001). At 6 months, 59% of the 25-mg group and 11% of the placebo group achieved a 20% ACR response (P < 0.001); 40% and 5%, respectively, achieved a 50% ACR response (P < 0.01). The respective mean percentage reduction in the number of tender and swollen joints at 6 months was 56% and 47% in the 25-mg group and 6% and -7% in the placebo group (P < 0.05). Significantly more etanercept recipients achieved a 70% ACR response, minimal disease status (0 to 5 affected joints), and improved quality of life. Etanercept was well tolerated, with no dose-limiting toxic effects. CONCLUSIONS Etanercept can safely provide rapid, significant, and sustained benefit in patients with active rheumatoid arthritis.
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Affiliation(s)
- L W Moreland
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 35294-7201, USA
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Stohl W, Arkfeld DG. Treatment of rheumatoid arthritis. N Engl J Med 1996; 335:821-2; author reply 822-3. [PMID: 8778593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Liebling MR, Arkfeld DG, Michelini GA, Nishio MJ, Eng BJ, Jin T, Louie JS. Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction. Arthritis Rheum 1994; 37:702-9. [PMID: 8185697 DOI: 10.1002/art.1780370514] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To analyze synovial fluid (SF) for the presence of Neisseria gonorrhoeae DNA using the polymerase chain reaction (PCR). METHODS We used a modified, nested PCR to detect the presence of N gonorrhoeae DNA in 41 samples of SF obtained from 10 patients with clinical gonococcal arthritis whose SF samples were sterile by culture and from 27 controls, including 11 patients with Reiter's syndrome. Results obtained using this method were compared with those obtained using the GEN-PROBE system, an RNA-DNA hybridization technique. RESULTS With nested PCR, N gonorrhoeae DNA was detected in 11 of 14 SF samples obtained from patients with culture-negative clinical gonococcal arthritis but in none of the 11 SF samples from Reiter's syndrome patients. The specificity of this technique was 96.4%, with a sensitivity of 78.6%. The rate of false-positive results was 3.6%. The GEN-PROBE technique was unable to detect N gonorrhoeae ribosomal RNA in any of the samples. CONCLUSION These findings demonstrate the potential utility of the PCR in confirming the clinical diagnosis of gonococcal arthritis as well as providing insight into the pathogenesis of this disorder in patients whose SF are sterile by standard culture techniques. PCR may also prove helpful in differentiating N gonorrhoeae arthritis from acute Reiter's syndrome.
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Affiliation(s)
- M R Liebling
- Division of Rheumatology, Harbor-UCLA Medical Center, Torrance, CA 90509
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