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Letter to the Editor Letter to the Editor Successful response to tion and erosions (Fig. 1). ra, while classic polyarteritis nodosa gener- infliximab in a patient with A diagnosis of uSpA was established (3). ally affects arteries in the skin causing nod- Treatment with indomethacin (150 mg/day) ules. undifferentiated spondy- and sulphasalazine (3 g/day) was prescribed The presence of vasculitis prompted us to loarthropathy coexisting without success. Due to this methotrexate consider the use of infliximab in this patient with polyarteritis nodosa-like (17.5 mg/week) was added, but only partial with uSpA. The dramatic improvement of cutaneous vasculitis improvement was obtained. Two years after both the rheumatic manifestations and vas- the diagnosis of uSpA he developed palpa- culitic complications observed in our case Sirs, ble purpuric skin lesions on his legs. Biopsy supports the potential use of anti-TNF- The search for an effective treatment for of the cutaneous lesions disclosed a necro- alpha therapy in uSpA patients with severe patients with active and severe spondylo- tizing arteritis involving small and medium- complications refractory to classic thera- arthropathy is an important issue for rheu- sized arteries with fibrinoid necrosis and pies. matologists (1). Recently, Brandt et al. inflammatory infiltrate in the artery wall. At showed the efficacy of the monoclonal anti- that time, laboratory parameters including C. GARCIA-PORRUA, MD, PhD TNF-alpha antibody infliximab in patients hepatic and renal function tests, rheumatoid M.A. GONZALEZ-GAY, MD, PhD* with active and severe undiff e r e n t i a t e d factor, ANA, anti-DNA, C3, C4, anticardi- Rheumatology Division, Hospital Xeral-Calde, spondyloarthropathy (uSpA) (2). With this olipin antibodies, cryoglobulins, and c) Dr. Ochoa s/n, 27004 Lugo, Spain. report we would like to demonstrate the A N C A were negative or normal. Chest *To whom correspondence should be addressed. efficacy of infliximab therapy in a patient radiograph and abdominal ultrasonography with polyarteritis nodosa-like cutaneous were also normal. References vasculitis in the setting of uSpA. A diagnosis of polyarteritis nodosa-like 1. BRANDT J, SIEPER J, BRAUN J: Infliximab in In 1998, a 45-year-old man presented at the vasculitis was made and treatment with the treatment of active and severe ankylosing outpatient Rheumatology Clinic because of methotrexate (15 mg/week) plus infliximab spondylitis. Clin Exp Rheumatol 2002; 20 arthritis of the right knee. He also com- (5 mg/Kg) was commenced. With this ther- (Suppl. 28): S106-10. 2. B R A N D T J, HAIBEL H, REDDIG J, SIEPER J, plained of a 6-month-history of early morn- apy rapid improvement of both cutaneous lesions and clinical symptoms of spondy- BRAUN J : Successful short term treatment of ing back pain and stiffness that was relieved severe undifferentiated spondyloarthropathy by exercise, and a 7-year history of epi- loarthropathy was achieved. Eighteen with the anti-tumor necrosis factor-alpha mon- sodes of bilateral inflammation at the inser- months after the onset of this combination oclonal antibody infliximab. J Rheumatol tion of the Achilles tendon. The patient therapy, the patient remains asymptomatic 2002; 29:118-22. denied a family history of spondyloarth- on treatment with methotrexate (15 3. DOUGADOS M, VAN DER LINDEN S, JUHLIN R r o p a t h y, psoriasis or inflammatory bowel mg/week) and infliximab (5 mg/kg every 2 et al.: The European Spondylarthropathy disease. He did not recall episodes of ure- months). Study Group preliminary criteria for the classi- thritis, conjunctivitis, uveitis or diarrhea. Although the efficacy of anti-TNF-alpha fication of spondylarthropathy. A rt h r i t i s Rheum 1991; 34: 1218-27. On physical examination reduced lumbar therapy in ankylosing spondylitis and psori- atic arthritis has been proved, more studies 4. BRAUN J, SIEPER J: Therapy of ankylosing spine motion, right knee arthritis and bilat- spondylitis and other spondyloarthritides: are needed to confirm the efficacy of this eral Achilles tendinitis were observed. established medical treatment, anti-TNF-alpha Arthrocentesis of his right knee yielded an therapy for other spondyloarthropathy sub- therapy and other novel approaches. Arthritis inflammatory synovial fluid (4,250 leuko- sets (4). We have recently reported a suc- Res 2002; 4: 307-21. c y t e s / m m3 with 75% polymorphonuclear cessful response to infliximab therapy in a 5. G A R C I A - P O R R U A C, GONZALEZ-GAY M A: cells and 25% mononuclear cells) with nor- patient with refractory mononeuritis multi- Successful treatment of refractory mononeuri- mal glucose levels, absence of micro-crys- plex due to rheumatoid vasculitis (5). A tis multiplex secondary to rheumatoid arthritis tals and negative cultures. ESR and C reac- wide spectrum of vasculitic syndromes can with the anti-tumour necrosis factor alpha tive protein were 51 mm/1st hour and 22 involve the skin. Polyarteritis nodosa can monoclonal antibody infliximab R h e u m a t o l - ogy (Oxford) 2002; 41: 234-5. mg/L (normal < 5), respectively. Rheuma- be localized to the skin and subjacent tis- toid factor, antinuclear antibodies and sues or, more commonly, can involve multi- HLA-B27 were negative. Plain pelvis radi- ple organ systems. The presence of purpura ograph did not confirm the presence of might have led to a diagnosis of microscop- sacroiliitis. However, plain radiographs of ic polyangiitis, as this vasculitis affects ves- the calcaneus showed bilateral spur forma- sels smaller than arteries and causes purpu- Fig. 1. Advanced changes in en- thesopatic lesions: erosions and calcaneal spur. S-138.
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