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Prevention of bacterial infection, which is a leading cause of morbidity in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), is a priority. However, the safety and immunogenicity of the pneumococcal vaccine in such patients remain controversial. We evaluated the currently available pneumococcal vaccine in patients with RA or SLE. Pneumococcal vaccination was not associated with an appreciable deterioration in any clinical or laboratory measure of disease activity in either group. One month after vaccination, patients in both groups had significant increases in geometric mean concentrations of pneumococcal polysaccharide-specific IgG to all 7 serotypes tested, as did control subjects. However, 14 (33.3%) of 42 patients with RA and 5 (20.8%) of 24 patients with SLE responded either to none or to only 1 of the 7 polysaccharides. Pneumococcal vaccination is generally safe and immunogenic in patients with RA or SLE, but a subset of patients may remain unprotected by the currently available vaccine.

Diacerein, a drug for the treatment of OA, was shown to be an effective treatment for symptoms in patients with knee OA. Taking into account both efficacy and safety, the optimal daily dosage of diacerein for patients with knee OA is 100 mg/day (50 mg twice daily).

These preliminary results are encouraging and suggest a promising role of infliximab in the treatment of extraintestinal symptoms of Crohn's disease.

Objective-To report on four patients with autoimmune disorders who developed acute myocardial infarction (MI) during or soon after treatment with high dose intravenous immunoglobulins (IVIG) and to determine the clinical profile of patients prone to this complication. Methods-The clinical history of the four patients is reported with details concerning age, sex, indication for IVIG treatment, risk factors, timing of the MI and outcome. The relevant medical literature has been reviewed. Results-The patients, three men and one woman, aged 42-67, received IVIG treatment for diVerent autoimmune disorders. All had a history of atherosclerosis or previous risk factors such as hypertension, stroke, hyperlipidaemia and obesity. Two of the patients suVered a MI after the first infusion of IVIG while the others-after the 5th and 15th pulses. MI occurred during the infusion in two patients and after a few days in the others. All the patients recovered from the acute event. These observations are in concert with sporadic cases of IVIG related thrombosis reported in the medical literature. Conclusion-In patients with vascular risk factors such as old age, hypertension, history of stroke or coronary artery disease, the possibility of IVIG related vascular complications should be considered and IVIG prescribed with a cautious reweighted risk/benefit consideration. (Ann Rheum Dis 2000;59:77-80) High dose intravenous immunoglobulin (IVIG) treatment is being increasingly used in a wide range of autoimmune disorders such as Kawasaki, 1 neuroimmunological disorders, [2][3][4] dermatomyositis, 5 vasculitis 6 immune cytopenia and other conditions. 7 8 IVIG have been considered a safe medication, with minor adverse events such as headache, nausea and myalgias, occurring in less than 10% of patients.9 10 With the wider use of IVIG, the reported rate of side eVects has increased, 11 some of them being potentially fatal. 12We describe four patients with autoimmune disorders who developed acute myocardial infarction (MI) a few days after receiving IVIG. Case reports CASE 1The patient is a 60 year old man with relapsing polychondritis of three years duration manifesting as extreme fatigue, recurrent episodes of chondritis of the ears, hoarseness, livedo reticularis, migratory arthritis and myalgias, episcleritis and vestibular neuropathy with vertigo and sensorineural deafness. He had documented arterial hypertension for the past two years. Laboratory tests disclosed an increased erythrocyte sedimentation rate (ESR) (120 mm 1st h) and normocytic normochromic anaemia (Hb 10 g/dl). Immunological tests including anticardiolipin antibodies were negative. The patient was initially treated (at another centre) with prednisone (1 mg/kg) and monthly intravenous cyclophosphamide (800 mg/m 2 ), but repeated attempts to lower the prednisone dose below 25 mg/d resulted in acute exacerbations. Parenteral methotrexate 30 mg/week was prescribed. During this treatment he developed right hemiparesis with evidence of cerebral lacunar infarction on...

Impaired handling of apoptotic cells has been suggested as an important factor in the development of systemic lupus erythematosus (SLE), and a role for complement in the removal of apoptotic cells was shown recently. We studied the in vitro function of macrophages from 40 patients with SLE and their matched controls in the removal of heterologous apoptotic cells opsonized by iC3b. Interaction index of apoptotic cells opsonized by iC3b was significantly lower in patients with SLE and averaged 71% ± 37 of that of healthy individuals (p < 0.002) and 69% ± 35 of patients with rheumatoid arthritis (p < 0.007). SLE patients had increased apoptosis of both freshly isolated monocytes (p < 0.001) and maturing macrophages (p < 0.04) that led to decreased density of monocyte-derived macrophages. Apoptosis was inhibited by adding soluble Fas receptor indicating Fas-mediated apoptosis. As demonstrated in both healthy controls and patients with SLE, decreased macrophage density by itself caused significant decreased uptake of apoptotic cells by the remaining macrophages. Maintaining normal density in SLE patients either by an increased initial density or by using soluble Fas restored the interaction capacity of the individual macrophages in the majority of patients. We concluded that impaired in vitro interaction of iC3b-opsonized apoptotic cells with macrophages from patients with SLE was mainly associated with Fas-dependent accelerated apoptosis of the monocytes/macrophages. Accelerated apoptosis of phagocytes may represent a novel in vitro mechanism of impairment of interaction with apoptotic cells that, apart from reducing the number of professional phagocytes, alters the function of the remaining macrophages.

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Zintona EC was as effective as placebo during the first 3 months of the study, but at the end of 6 months, 3 months after crossover, the ginger extract group showed a significant superiority over the placebo group.