Faculty Bibliography

Human immunodeficiency virus (HIV) infection can result in several autoimmune illnesses, including psoriasis, psoriatic arthritis (PsA), and polyarteritis nodosa (PAN). We describe a patient who presented with PsA refractory to both synthetic and biologic disease-modifying antirheumatic drugs (DMARDs), who then developed PAN while on antitumor necrosis factor (TNF) therapy. The onset ofvasculitic disease led to the discovery of the HIV infection, and manifestations of both PsA and PAN remitted with the introduction of highly active antiretroviral therapy. To our knowledge, this is the first casewhere both PsA and PAN developed in an HIV-positive patient. Our review focuses on the pathogenesis, presentation, and treatment of HIV related psoriasis, PsA, and PAN. This unusual case underscores the need to remain vigilant for underlying HIV infection in immunosuppressed patients, and serves as a reminder ofthe unusual autoimmune manifestations the virus can provoke.

Antinuclear antibody (ANA) test results frequently affect the course of patients' evaluations, diagnosis, and treatment, but different laboratory centers may yield conflicting results. This study investigated the degree of agreement between laboratory results in a group of subjects who had ANA testing performed at two commercial laboratories. This was a chart review study, in which all ANA tests ordered by the authors from one commercial laboratory over a 4-year period were queried. Corresponding patient charts were reviewed, and if ANA testing had also been performed at the second commercial laboratory, subjects were entered into the study. The primary measurement was agreement between paired ANA results, and we performed sensitivity analysis using varying criteria defining agreement (criteria A to criteria D [strictest to most lenient definition of agreement]). Other data captured included relevant data obtained through the course of evaluation (e.g., presenting complaints, exam findings, other laboratory data) and final diagnoses. Of 101 paired ANA tests, there was 18 % agreement according to the strictest criteria and 42 % according to the most lenient. Of the seven subjects with ANA-associated rheumatic disease, none of the paired tests were in agreement according to criteria A (two agreed according to criteria D). Our findings demonstrate poor agreement between paired ANA tests performed at two commercial laboratories. The low level of agreement may have far-reaching clinical implications. Specifically, this finding calls into question the reliability of ANA testing as it is currently performed and suggests that results may in part depend upon the laboratory center to which patients are referred.

Across the globe, both gout and hyperuricemia have become increasingly common over the last few decades. The burden of gouty disease is made heavier by its association with several comorbid conditions, including hypertension, cardiovascular disease, and chronic kidney disease. Accruing evidence from prospective studies suggests that gout is an independent risk factor for developing cardiovascular disease and for higher cardiovascular mortality. While asymptomatic hyperuricemia does not seem to be an independent risk factor for cardiovascular disease, increasing data implicates hyperuricemia as a risk factor for developing incidental hypertension. Important questions that remain unanswered include whether addressing asymptomatic hyperuricemia forestalls the onset of hypertension, and whether treating gout with urate-lowering agents improves cardiovascular outcomes. This article reviews the most recent data regarding the relationship between hyperuricemia, gout, hypertension, and cardiovascular disease, as well as emerging evidence as to whether treatment of hyperuricemia and gout improves cardiovascular outcomes.

Thromboangiitis obliterans, or Buerger's disease, is a non-atherosclerotic, segmental, inflammatory disease affecting the small- and medium-sized vessels of the distal extremities. Other than discontinuation of tobacco, there is no standard-of-care treatment. Although two randomized trials have demonstrated a role for intravenous iloprost, no oral drug has yet been demonstrated to be effective in treating thromboangiitis obliterans. We present the first three reported cases of thromboangiitis obliterans successfully treated with phosphodiesterase type 5 inhibitors, followed by a discussion of the rationale for the use of these agents in thromboangiitis obliterans.

Pegloticase is a powerful but underutilized weapon in the rheumatologist's armamentarium. The drug's immunogenicity leads to neutralizing antibody formation and rapid loss of efficacy in roughly one-half of all patients, which remains an impediment to broader use. New data, however, suggest that drug survival might improve with concomitant immunosuppressive agent (s), which merits further study. Efficacy appears to be unchanged when pegloticase is infused at 3-week (rather than 2-week) intervals. Stretching the time between infusions may also improve patient adherence and allow for earlier identification of transient responders.