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Eosinophilia Predicts Poor Clinical Outcomes in Recent-Onset Arthritis: Results from the ESPOIR Cohort

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Eosinophilia Predicts Poor Clinical Outcomes in Recent-Onset Arthritis: Results from the ESPOIR Cohort Early arthritis RMD Open: first published as 10.1136/rmdopen-2015-000070 on 15 July 2015. Downloaded from EXTENDED REPORT Eosinophilia predicts poor clinical outcomes in recent-onset arthritis: results from the ESPOIR cohort Dewi Guellec,1 Morgane Milin,1 Divi Cornec,1,2 Gabriel J Tobon,3 Thierry Marhadour,1 Sandrine Jousse-Joulin,1,2 Gilles Chiocchia,4 Olivier Vittecocq,5 Valérie Devauchelle-Pensec,1,2 Alain Saraux1,2 To cite: Guellec D, Milin M, ABSTRACT et al Key messages Cornec D, . Eosinophilia Objectives: To determine the prevalence of predicts poor clinical eosinophilia in patients with recent-onset arthritis outcomes in recent-onset What is already known about this subject? suggestive of rheumatoid arthritis (RA) and to describe arthritis: results from the ▸ A few early studies in rheumatoid arthritis (RA) ESPOIR cohort. RMD Open their features and outcomes. suggested that eosinophilia might predict greater 2015;1:e000070. Methods: We performed an ancillary study of data disease severity but suffered from a number of doi:10.1136/rmdopen-2015- from a French prospective multicentre cohort study drawbacks. 000070 monitoring clinical, laboratory and radiographic data in patients with inflammatory arthritis of 6 weeks to What does this study add? ▸ Eosinophilia is rare in recent-onset arthritis. ▸ Prepublication history for 6 months duration. We determined the proportion of Eosinophilia was mild and transient in most this paper is available online. patients with eosinophilia, defined as a count >500/ To view these files please mm3, at baseline and after 3 years. Features of patients patients. Patients with mild baseline eosinophilia visit the journal online with and without baseline eosinophilia were compared. might respond worse to the treatment than the remainder, as they had higher patient-assessed (http://dx.doi.org/10.1136/ Results: Baseline eosinophilia was evidenced in 26 of disease activity, morning stiffness intensity, rmdopen-2015-000070). 804 (3.2%) patients; their mean eosinophil count was 3 health assessment questionnaire (HAQ) scores, 637.7±107/mm . Baseline eosinophilia was ascribed to Received 15 January 2015 and disease-modifying antirheumatic drug atopic syndrome in 6 of 26 (23.1%) patients. After Revised 7 March 2015 (DMARD) use after 3 years. http://rmdopen.bmj.com/ Accepted 22 March 2015 3 years, patients with eosinophilia had higher Health Assessment Questionnaire scores (0.9 vs 0.5, How might this impact on clinical practice? p=0.004), higher patient visual analogue scale activity ▸ This study allows the clinician to interpret eosi- score and morning stiffness intensity (p=0.05), and niophilia in a context of early arthritis. were more often taking disease-modifying antirheumatic drugs (p=0.02). Baseline eosinophilia was not associated with presence of extra-articular fl manifestations. in ammatory arthritis, as the results may provide valuable information on the cause of Conclusions: Eosinophilia is rare in recent-onset on September 29, 2021 by guest. Protected copyright. arthritis suggestive of RA, and is usually directly arthritis as well as on any comorbidities. An related to the rheumatic disease. Our data suggest that eosinophil count ≥500/mm3 is considered patients with mild eosinophilia at diagnosis could abnormal. The most common causes of respond worse to the treatment than those without. peripheral-blood eosinophilia are atopic syn- drome in industrialised countries and hel- minth infections worldwide.1 Other causes include various infections, tumours, dysim- mune disorders and drugs. Idiopathic hyper- SIGNIFICANCE AND INNOVATIONS eosinophilic syndrome is a very uncommon ▸ Eosinophilia is rare in recent-onset arth- cause of eosinophilia, generally characterised ritis suggestive of rheumatoid arthritis, by sustained eosinophilia and end-organ – and is usually directly related to the joint involvement.1 3 disease. Peripheral-blood eosinophilia is uncommon For numbered affiliations see ▸ end of article. Mild eosinophilia at diagnosis of in rheumatic diseases but may occur in recent-onset arthritis is a marker of poor dermatomyositis, rheumatoid arthritis (RA), ’ Correspondence to response to the treatment. progressive systemic sclerosis and Sjögren s 4–7 Dr Alain Saraux; A complete blood count (CBC) is performed syndrome. Differential diagnoses in [email protected] routinely during the initial work up for early patients with RA and eosinophilia include Guellec D, et al. RMD Open 2015;1:e000070. doi:10.1136/rmdopen-2015-000070 1 RMD Open RMD Open: first published as 10.1136/rmdopen-2015-000070 on 15 July 2015. Downloaded from concomitant vasculitis and hypersensitivity reactions to Study design – therapeutic agents.8 11 Few studies have addressed the At inclusion into the ESPOIR cohort, all patients under- prevalence and significance of eosinophilia in inflamma- went a standardised interview; a general physical exam- tory joint disease. A few early studies in RA suggested ination; laboratory tests including a CBC; viral that eosinophilia might predict greater disease severity serological tests (parvovirus B19, hepatitis B and C but suffered from a number of drawbacks such as small viruses, and HIV); immunological tests (ELISAs for IgM, sample size, selection bias and use of relative values IgG and IgA rheumatoid factors, and tests for anticitrul- – instead of absolute values to define eosinophilia.12 15 linated peptide antibodies and antinuclear antibodies); Most of the recent studies in patients with RA or a HLA DR phenotype determination; a cytokine profile variety of rheumatic diseases found no evidence that (interleukin-1 receptor (IL-1R) α, IL-6, IL-10, monocyte eosinophilia was associated with disease severity or com- chemoattractant protein 1 (MCP-1), IL-4, IL-17, inter- plications. However, the patients in these studies did not feron (IFN) γ, tumour necrosis factor (TNF) α, IL-16 have recent-onset disease, and were not naive to corticos- and IL-2); urine tests; and radiographs of the chest, teroids or disease-modifying antirheumatic drugs pelvis, hands and feet in the posteroanterior view, and (DMARDs).16 17 feet in the oblique view.19 Each patient was evaluated by Thus, two important questions remain unanswered. an ESPOIR study rheumatologist every 6 months for One is whether eosinophilia in a patient with 2 years, then once a year for at least 10 years. recent-onset arthritis is related to the joint disease or Monitoring was stopped if a diagnosis other than RA was should prompt investigations for another cause. The established. The rheumatologists used 0–100 visual ana- other is whether eosinophilia predicts the outcome of logue scales (VAS) to rate the certainty with which they the joint disease. diagnosed RA and established the absence of a better We conducted a study designed to answer these two alternative diagnosis. All evaluations were free of charge. questions. Our primary objective was to determine the A set of radiographs was obtained for each patient at prevalence of eosinophilia in patients with recent-onset baseline, then every 6 months at each rheumatologist arthritis, suggestive of RA or consistent with RA. Our sec- visit. The set included posteroanterior views of the ondary objectives were to delineate the features of hands, wrists and feet, as well as oblique views of the patients with eosinophilia at baseline, and 3 years later, feet. They were sent to the coordinating centre for inde- particularly their treatments, comorbidities and final pendent interpretation by a rheumatologist (GJT) who diagnoses; and to determine whether baseline eosino- had no information about the patients. For each radio- philia predicted subsequent disease activity, disease graph, the reader followed a standardised procedure to severity, the development of extra-articular manifesta- assess the number of erosions according to the van der fi tions including vasculitis and/or comorbidities. Heijde-modi ed Sharp system for posteroanterior views http://rmdopen.bmj.com/ of the hands and feet. We computed the rate of erosion progression over the first year (difference between scores METHODS at 12 months and at baseline) and over the next 2 years This study was approved by the institutional review (difference between scores at 36 and 12 months).20 board of the Montpellier University Hospital, the coord- Baseline eosinophilia was defined as a count ≥500/ inating centre for this nationwide study. Before inclu- mm3. We determined the prevalence of eosinophilia at sion, all patients gave their written informed consent to baseline and after 3 years, as well as the proportion of participate in the study. patients with persistent eosinophilia. We compared clin- on September 29, 2021 by guest. Protected copyright. ical, biological and immunological features in patients Study population with and without eosinophilia at baseline and after The French Society for Rheumatology established a 3 years. We also compared the two groups in terms of nationwide, longitudinal, prospective cohort, the baseline radiographic structural damage and rates of ESPOIR cohort, to enable investigations of the diagnosis, structural damage progression during the first year and outcome markers, epidemiology, pathogenesis and the next 2 years. In patients with eosinophilia, we deter- medico-economics of early arthritis and RA.18 Primary mined the cause of eosinophilia, comorbidities, final care physicians and rheumatologists referred patients diagnoses, and occurrence of extra-articular manifesta- with early arthritis to hospitals
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