Intestinal microsporidiosis: a hidden risk in rheumatic disease patients undergoing anti-tumor necrosis factor therapy combined with disease-modifying anti-rheumatic drugs?

Abstract

OBJECTIVE:Immunosuppressed patients are at risk of microsporidiosis, and this parasitosis has an increased rate of dissemination in this population. Our objective was to evaluate the presence of microsporidiosis and other intestinal parasites in rheumatic disease patients undergoing anti-tumor necrosis factor/disease-modifying anti-rheumatic drug treatment.METHODS:Ninety-eight patients (47 with rheumatoid arthritis, 31 with ankylosing spondylitis and 11 with psoriatic arthritis) and 92 healthy control patients were enrolled in the study. Three stool samples and cultures were collected from each subject.RESULTS:The frequency of microsporidia was significantly higher in rheumatic disease patients than in control subjects (36 vs. 4%, respectively; p<0.0001), as well as in those with rheumatic diseases (32 vs. 4%, respectively; p<0.0001), ankylosing spondylitis (45 vs. 4%, respectively; p<0.0001) and psoriatic arthritis (40 vs. 4%, respectively; p<0.0001), despite a similar social-economic class distribution in both the patient and control groups (p = 0.1153). Of note, concomitant fecal leukocytes were observed in the majority of the microsporidia-positive patients (79.5%). Approximately 80% of the patients had gastrointestinal symptoms, such as diarrhea (26%), abdominal pain (31%) and weight loss (5%), although the frequencies of these symptoms were comparable in patients with and without this infection (p>0.05). Rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis disease activity parameters were comparable in both groups (p>0.05). The duration of anti-tumor necrosis factor/disease-modifying anti-rheumatic drugs and glucocorticoid use were also similar in both groups.CONCLUSION:We have documented that microsporidiosis with intestinal mucosa disruption is frequent in patients undergoing concomitant anti-tumor necrosis factor/disease-modifying anti-rheumatic drug therapy. Impaired host defenses due to the combination of the underlying disease and the immunosuppressive therapy is the most likely explanation for this finding, and this increased susceptibility reinforces the need for the investigation of microsporidia and implementation of treatment strategies in this population.

Enteric Protozoa in the Developed World: a Public Health Perspective

“…Many identical genotypes of E. bieneusi from humans and animals are known (81), raising concerns over waterborne, food-borne, and zoonotic transmission. The importance of this parasite in human infections increased as it became a cause of opportunistic infections in HIV/AIDS and other immunosuppressed patients during the 1980s (6,29,114,248,315). However, with increasing access to antiretroviral therapy, infection rates in HIV/AIDS patients have reduced significantly (390,448), with prevalences ranging from 0 to 42% (13).…”

Intestinal microsporidiosis: prevalence and genetic study of Egyptian isolates

“…Moreover, El-Sobky and El-Nahas [20] reported microsporidia in a diarrheic group (23%) more than in a non-diarrheic group (5.7%). Concerning the other symptoms higher positive results of 80% were reported by Aikawa et al [29] among rheumatic patients who complained of diarrhea (29%), abdominal pain (32%) and weight loss (6%). Out of the 20 immune competent individuals in our study, 50% were symptomatic with various complaints, and the other 50% had no apparent gastrointestinal complaints.…”

Methotrexate exposure and risk of strongyloidiasis

“…Additional articles that reported data on Strongyloides relevant to the use of methotrexate or other immunosuppressive therapy but did not meet study inclusion criteria are reported in Table .…”

“…Numerically, more patients experienced dissemination or hyperinfection in the high-dose group (75% vs. 52% P = ns; Table 1). Additional articles that reported data on Strongyloides relevant to the use of methotrexate or other immunosuppressive therapy but did not meet study inclusion criteria are reported in Table 3 [16][17][18][19][20][21].…”