Early responses to H7N9 in southern Mainland China

Background

There have been few studies of pulmonary actinomycosis, which is an uncommon anaerobic infection. Consequently, the optimal therapeutic regimen, appropriate duration of treatment, long-term prognosis, and factors predicting prognosis are not well established.

Methods

We retrospectively reviewed the medical records of histopathologically confirmed cases of pulmonary actinomycosis seen between November 2003 and December 2012.

Results

The study included 68 patients with a mean age of 58.4?±?11.6 years. Of the 68, initial surgery was performed in 15 patients (22.1%), while the remaining 53 (77.9%) received antibiotic therapy initially. In the initial antibiotic group, 45/53 (84.9%) were cured without relapse (median antibiotic duration 5.3 months). 5/53 (9.4%) patients were refractory medically (median antibiotic duration 9.7 months), and 3/53 (5.7%) experienced a recurrence (median time to relapse 35.3 months). In the initial surgery group, 14/15 (93.3%) were cured and treatment failure occurred in one (6.7%). In the multivariate analysis, the absence of an antibiotic response at 1 month was the only independent factor associated with a poor treatment outcome, with an adjusted odds ratio of 49.2 (95% CI, 3.34–724.30). There was no significant difference in treatment outcome based on the size of the parenchymal lesion, comorbidities, whether intravenous antibiotics were used, antibiotic therapy duration, or whether the initial treatment was surgical.

Conclusions

Antibiotic treatment with or without surgery was effective for treatment of pulmonary actinomycosis. Nevertheless, treatment failure or recurrence occurred in a considerable proportion of patients, especially those resistant to the initial antibiotic treatment.     

A survey of thoracic actinomycosis

We have reviewed the case notes of 19 patients with thoracic actinomycosis. The median age at presentation was 42 (range 9-66) years, 15 were male and 12 were urban residents. Cough, sputum production, chest pain and weight loss were the commonest symptoms. Six patients reported haemoptysis. In contrast with the classical appearances of thoracic actinomycosis, only four patients had cutaneous abnormalities, and only one patient had radiological evidence of bone involvement. The provisional diagnosis was bronchial carcinoma in nine patients, and in seven patients the diagnosis of actinomycosis was only made after resection of the lesion, in two cases by pneumonectomy. The median delay between presentation and diagnosis was 3.5 (range 1-24) weeks. Two patients developed extrathoracic complications, but all patients made a full recovery after receiving antibiotic therapy for a median of 6 (range 1-24) weeks. Thoracic actinomycosis is rare, but should still be considered in the differential diagnosis of a pulmonary lesion thought to be malignant.     

Duration of antibiotic therapy for cholangitis after successful endoscopic drainage of the biliary tract

BACKGROUND: Drainage of the obstructed biliary tree is the mainstay of therapy for patients with acute cholangitis; antibiotic therapy is complementary. It is unknown whether it is necessary to continue therapy with antibiotics once biliary drainage is achieved and signs of systemic inflammation have subsided. METHODS: Patients who presented with acute cholangitis and were successfully treated at ERCP were studied retrospectively. Patients were followed for 6 months after ERCP. RESULTS: Eighty patients fulfilled study criteria. In 46% of patients blood cultures grew microorganisms. All patients recovered from the episode under study. Antibiotic therapy after ERCP was given for a median duration of 3 days (range: 0-42). Forty-one patients received antibiotic therapy for 3 days or less, 19 for 4 or 5 days, and 20 patients longer than 5 days. The 3 groups were well-matched. In none of the patients did the index episode of cholangitis result in a secondary complication not present at the time of ERCP. The percentage of patients with recurrent cholangitis (24%) was not statistically different for the 3 groups (p = 0.80). CONCLUSIONS: Short-duration antibiotic therapy (3 days) appears sufficient when adequate drainage is achieved and fever is abating.     

CD4+ cell-count-guided treatment interruptions in chronic HIV-infected patients with good response to highly active antiretroviral therapy

OBJECTIVE: To evaluate the safety of treatment interruption guided by CD4+ cell count in HIV-infected patients followed up prospectively. METHODS: Patients on highly active antiretroviral therapy with CD4+ cell counts > 500 x 10(6) cells/l discontinued therapy with instructions to start therapy again before their CD4+ count dropped below 200 x 10(6) cells/l. Any patients who resumed therapy would be eligible to interrupt treatment again once their CD4+ cell count increased above 500 x 10(6) cells/l. RESULTS: Data on 71 HIV infected patients is reported. Their median nadir CD4+ cell count before antiretroviral treatment was 352 x 10(6) cells/l [interquartile range (IQR), 294-445 x 10(6) cells/l]. The median CD4+ cell count at the time of first interruption was 790 x 10(6) cells/l (IQR, 657-1041 x 10(6) cells/l). The median follow-up after starting the first treatment interruption was 28.3 months (IQR, 21.4-37.0 months). During the follow-up 49 patients restarted therapy and 22 patients remain off therapy; 24 patients have interrupted therapy twice, nine patients have interrupted therapy three times and six patients four times. No AIDS-defining illnesses occurred during the follow-up. The median duration of the first interruption was 15 months (IQR, 6-26 months). The overall reduction of time on therapy was 71.1%. The duration of the first interruption and the reduction of time on therapy were related to nadir CD4+ cell count. The patients who resumed HAART rapidly regained CD4+ cells and achieved viral suppression. CONCLUSION: If carefully monitored, treatment interruptions guided by CD4+ cell count in patients with an initially high CD4+ cell counts are clinically safe, decrease exposure to the drugs and do not reduce the efficacy of therapy when this is re-started.     

Malignomsuspekte pulmonale Raumforderung

A 31-year-old patient presented with chronic cough and thoracic pain. A pulmonary mass was seen on chest x-ray, and pulmonary segmental resection was done. Histopathologically, a pulmonary abscess cavity due to actinomycosis was found. Three months later, recurrence of actinomycosis at the thoracic wall was observed. Antibiotic therapy with penicillin was administered. Five months later, with the patient receiving continued antibiotic therapy, a thoracic wall abscess and fistula was diagnosed. Four weeks after abscess drainage and repeat intravenous antibiotic therapy, the patient was symptom-free and had remained symptom-free at 10 months of follow-up.     

Antibody responses to Borrelia burgdorferi in patients with antibiotic-refractory, antibiotic-responsive, or non-antibiotic-treated Lyme arthritis

OBJECTIVE: To compare the pattern of antibody responses to Borrelia burgdorferi in patients with antibiotic-refractory, antibiotic-responsive, or non-antibiotic-treated Lyme arthritis as an indirect measure of spirochetal persistence or eradication. METHODS: At least 3 serial serum samples from 41 patients with antibiotic-refractory arthritis and 23 patients with antibiotic-responsive arthritis, and samples from 10 non-antibiotic-treated, historical control patients were tested for IgG reactivity with B burgdorferi sonicate and 4 differentially expressed outer surface lipoproteins of the spirochete, by enzyme-linked immunosorbent assay. RESULTS: Among non-antibiotic-treated patients, antibody titers to B burgdorferi antigens remained high throughout a 2-5-year period of arthritis. In contrast, in patients with antibiotic-responsive arthritis, in whom joint swelling usually resolved during a 1-month course of oral antibiotic therapy, the median antibody titers to most of the spirochetal antigens remained steady or decreased during the first 1-3 months after starting antibiotic therapy. In patients with antibiotic-refractory arthritis, who had persistent joint swelling for a median duration of 10 months despite 2-3 months of oral or intravenous antibiotics, the median titers to most antigens increased slightly during the first 1-3 months. However, by 4-6 months after starting antibiotic therapy, reactivity with all antigens declined similarly in both antibiotic-treated groups. CONCLUSION: Whereas the antibody titers to B burgdorferi remained high in non-antibiotic-treated patients, the titers declined similarly 4-6 months after starting therapy in patients with antibiotic-responsive or antibiotic-refractory arthritis, suggesting that synovial inflammation persisted in patients with antibiotic-refractory arthritis after the period of infection.     

Assessing efficacy of high-frequency chest wall oscillation in patients with familial dysautonomia

STUDY OBJECTIVE: To determine the benefits of daily use of high-frequency chest wall oscillation (HFCWO) in familial dysautonomia (FD) patients with lung disease. DESIGN: Pulmonary function tests, chest radiographs, and blood tests were performed on entry to the study. A retrospective chart review of 12 months prior to entry provided baseline data regarding respiratory illnesses, medications, doctor visits, hospitalizations, and absenteeism. Daily logs provided prospective data on these parameters as well as HFCWO usage. Evaluations were performed at 1, 3, 6, 9, and 12 months for pulse oximetry, spirometry, and log review. At the exit evaluation, blood tests and chest radiographs were repeated. PATIENTS: Fifteen FD patients with history of lung disease requiring daily inhalation therapy (7 female and 8 male; age range, 11 to 33 years) were enrolled in a 1-year clinical trial of HFCWO therapy. Two subjects withdrew after 3 months and 6 months, respectively. Each individual served as his/her own control. RESULTS: Oxygen saturation improved by 1 month (median, 97.5%; interquartile range [IQR], 96 to 98%; vs median, 94%; IQR, 89 to 96%) and was sustained at exit evaluation (median, 98%; IQR, 98 to 98%) [p = 0.004]. Median FVC and peak expiratory flow rate (PEFR) were the pulmonary function measures with sustained improvement from baseline to exit (p = 0.02 and p = 0.03, respectively). When retrospective and prospective data were compared, all measured health outcomes improved significantly, including pneumonias (p = 0.0156), hospitalizations (p = 0.0161), antibiotic courses (p = 0.0005), antibiotic days (p = 0.0002), doctor visits (p = 0.0005), and absenteeism (p = 0.0002). CONCLUSION: In this limited study of FD patients, HFCWO effected significant improvements in all measured health outcomes and oxygen saturation; FVC and PEFR were the pulmonary function measures demonstrating sustained improvement.     

Actinomycosis of the central nervous system

Actinomyces species are rare but treatable causes of CNS infection. Differentiation of actinomycosis from nocardiosis is crucial to the selection of appropriate antimicrobial therapy. A review of 70 cases of CNS actinomycosis was conducted in an effort to characterize clinicopathologic features and identify patients with a high risk of death from infection. Types of lesions included brain abscess (67%), meningitis or meningoencephalitis (13%), actinomycoma (7%), subdural empyema (6%), and epidural abscess (6%). Most infections developed from distant sites (lung, 19 cases; abdomen, four; pelvis, three) or contiguous foci (ear, sinus, and cervicofacial region, 21 cases). For nonmeningitic infection, signs and symptoms were generally those of a space-occupying lesion and were indistinguishable from the manifestations of other pyogenic infections except for a longer interval before diagnosis. Risk factors included dental caries; dental infection; recent tooth extraction; head trauma; gastrointestinal tract surgery; chronic otitis, mastoiditis, or sinusitis; chronic osteomyelitis; tetralogy of Fallot; and actinomyces infection of an intrauterine device. Optimal management combined adequate surgical drainage with prolonged antibiotic therapy (mean duration, 5 months). Overall mortality from treated infection was 28%; 54% of survivors had neurologic sequelae. Features correlated with a poor prognosis were disease onset greater than 2 months before diagnosis and treatment, no antibiotic treatment, no surgery, and needle aspiration drainage of abscess lesions.     

Resumption of oral intake following percutaneous endoscopic gastrostomy

Background and Aims:  Percutaneous endoscopic gastrostomy (PEG) provides enteral nutrition to patients who cannot swallow. Few studies have prospectively evaluated its long-term outcomes or eventual resumption of oral intake.
Methods:  Consecutive PEG patients were prospectively recruited from a tertiary hospital over 12 months and followed until all had met the primary endpoints of death or resumption of oral diet with PEG extubation. Data was collected by standardised periodic phone interview.
Results:  Forty patients (24 males, median age 74 years) were followed for up to 8.4 years (median 5.3 months, interquartile range [IQR] 13.6 months). The end-of-study mortality rate was 70% (median 6.8 months, IQR 19.9 months) and the only predictor of mortality was head injury as the indication for PEG (Cox regression HR 5.90, 95% CI: 1.2–28.4). At two years following PEG, 30% of patients had resumed oral intake (median 2.9 months, IQR 7.2 months) and 19% remained on PEG-feeding. Predictors of resumption of oral intake were the ability to tolerate some oral intake at 3 months (HR: 248.5, 95% CI: 8.7–7065.3) and 6 months (HR: 6.3, 95% CI: 1.03–38.9) but not at 12 months. Cumulative survival was highest for ear nose and throat (ENT) tumour and worst for acute head injury (log rank P  = 0.048).
Conclusions:  Half of all PEG patients remained alive at 2 years using PEG or have resumed full oral intake. A supervised trial of oral intake at 3 or 6 months may help predict eventual resumption of per oral diet.     

Relationship of sputum color to nature and outpatient management of acute exacerbations of COPD

STUDY OBJECTIVES: To stratify COPD patients presenting with an acute exacerbation on the basis of sputum color and to relate this to the isolation and viable numbers of bacteria recovered on culture. DESIGN: Open, longitudinal study of sputum characteristics and acute-phase proteins. SETTING: Patients presenting to primary-care physicians in the United Kingdom. Patients were followed up as outpatients in specialist clinic. PATIENTS: One hundred twenty-one patients with acute exacerbations of COPD were assessed together with a single sputum sample on the day of presentation (89 of whom produced a satisfactory sputum sample for analysis). One hundred nine patients were assessed 2 months later when they had returned to their stable clinical state. INTERVENTIONS: The expectoration of green, purulent sputum was taken as the primary indication for antibiotic therapy, whereas white or clear sputum was not considered representative of a bacterial episode and the need for antibiotic therapy. RESULTS: A positive bacterial culture was obtained from 84% of patients sputum if it was purulent on presentation compared with only 38% if it was mucoid (p < 0.0001). When restudied in the stable clinical state, the incidence of a positive bacterial culture was similar for both groups (38% and 41%, respectively). C-reactive protein concentrations were significantly raised (p < 0.0001) if the sputum was purulent (median, 4.5 mg/L; interquartile range [IQR], 6. 2 to 35.8). In the stable clinical state, sputum color improved significantly in the group who presented with purulent sputum from a median color number of 4.0 (IQR, 4.0 to 5.0) to 3.0 (IQR, 2.0 to 4. 0; p < 0.0001), and this was associated with a fall in median C-reactive protein level to 2.7 mg/L (IQR, 1.0 to 6.6; p < 0.0001). CONCLUSIONS: The presence of green (purulent) sputum was 94.4% sensitive and 77.0% specific for the yield of a high bacterial load and indicates a clear subset of patient episodes identified at presentation that is likely to benefit most from antibiotic therapy. All patients who produced white (mucoid) sputum during the acute exacerbation improved without antibiotic therapy, and sputum characteristics remained the same even when the patients had returned to their stable clinical state.     

Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency

OBJECTIVE: The best method for determining hydrocortisone replacement therapy is not well defined. This study aimed to assess interindividual variability in cortisol pharmacokinetics and to investigate whether measurement of salivary cortisol provides a useful alternative to plasma concentration measurements. DESIGN: Intravenous (IV) and oral crossover. PATIENTS: Twenty-seven patients with primary or secondary adrenal insufficiency who had been on stable replacement therapy for at least 3 months. MEASUREMENTS: Plasma and salivary concentrations of cortisol were measured up to 8 h following administration of hydrocortisone. RESULTS: After IV administration, Cmax ranged from 715 to 8313 nmol/l, area under the curve (AUC) from 1112 to 12 177 nmol h/l and cortisol clearance had a median (range) of 0.267 (0.076-0.540) l/h/kg. After oral administration, Cmax ranged from 422 to 1554 nmol/l, AUC 1081-5471 nmol h/l and oral clearance had a median (range) of 0.267 (0.081-0.363) l/h/kg. There was no clear relationship between paired saliva and plasma cortisol concentrations after IV or oral dosing. Plasma and salivary AUC(2-8 h) after IV administration were highly correlated (r2 = 0.77) but differences between predicted and measured plasma AUCs ranged from 3% to 90%. There was a poor correlation between plasma and saliva AUC(2-6 h) after oral administration (r2 = 0.16). CONCLUSIONS: The wide interindividual variability in plasma and salivary profiles of cortisol following the administration of IV and oral hydrocortisone to patients with adrenal insufficiency and the poor correlation between salivary and plasma measurements suggest that salivary cortisol measurements cannot be used for individual hydrocortisone dosage adjustment.     

Urgent cardiac resynchronization therapy in patients with decompensated chronic heart failure receiving inotropic therapy. A case series

BACKGROUND: It remains unknown whether patients with severe decompensated class IV heart failure (HF) receiving intravenous inotropic treatment benefit from cardiac resynchronization therapy (CRT). METHODS: We identified patients who underwent urgent CRT implantation due to decompensated class IV HF necessitating intravenous inotropic therapy. RESULTS: Of 10 patients with chronic ischemic cardiomyopathy (median QRS duration of 170 ms), CRT implantation was associated with symptomatic improvement in 8 patients. The mortality rate was 50% during a median follow-up of 9.5 months, with a median CRT-to-death duration of 6 months. CONCLUSIONS: CRT was feasible among class IV patients receiving inotropic treatment and was associated with clinical improvement.     

Impact of initial aggressive drug treatment with a combination of disease-modifying antirheumatic drugs on the development of work disability in early rheumatoid arthritis: a five-year randomized followup trial

OBJECTIVE: To compare the efficacy of therapy with a combination of disease-modifying antirheumatic drugs (DMARDs) versus therapy with a single DMARD in the prevention of work disability in patients with early rheumatoid arthritis (RA). METHODS: In the Finnish Rheumatoid Arthritis Combination Therapy trial, 195 patients with recent-onset RA were randomly assigned to receive either combination therapy with DMARDs (sulfasalazine, methotrexate, hydroxychloroquine) plus prednisolone or single therapy with a DMARD with or without prednisolone. After 2 years, the drug treatment strategy was no longer restricted. At baseline, 162 patients (80 in the combination-treatment group and 82 in the single-treatment group) were still working or at least available for work. After 5 years of followup, data on all sick leave and retirement were obtained from social insurance registers or case records. The main outcome for each patient was the cumulative duration of all sick leaves and RA-related disability pensions, divided by the observation period during which the patient was not retired because of another disease or because of age. RESULTS: The cumulative duration of work disability per patient-observation year was significantly lower in those randomized to combination therapy than in those randomized to single therapy: median 12.4 days (interquartile range [IQR] 0-54) versus 32.2 days (IQR 6-293) (P = 0.008, sex- and age-adjusted P = 0.009). This was mainly due to the difference in sick leaves (i.e., work disability periods 相似文献   

Slow response to vancomycin or vancomycin plus rifampin in methicillin-resistant Staphylococcus aureus endocarditis

OBJECTIVE: To determine the median response time to therapy with vancomycin alone or with vancomycin plus rifampin in patients with methicillin-resistant Staphylococcus aureus (MRSA) endocarditis. DESIGN: Cohort analysis of a randomized study. SETTING: University medical center. PATIENTS: Forty-two consecutive patients with MRSA endocarditis were randomly assigned to receive either vancomycin (group I) or vancomycin plus rifampin (group II) for 28 days. MEASUREMENTS: Clinical signs and symptoms were recorded, and blood cultures were obtained daily to determine the duration of bacteremia. MAIN RESULTS: The median duration of bacteremia was 9 days (7 days for group I and 9 days for group II). The median duration of fever for all patients and for each treatment group was 7 days. Six patients failed therapy, including three patients who died 5, 6, and 9 days after therapy was started, respectively. The other three patients who failed therapy required valve surgery on days 2, 22, and 27, respectively. Although patients had sustained bacteremia, no unusual complications were seen in either treatment group, and most patients responded to continued antibiotic therapy. CONCLUSIONS: Slow clinical response is common among patients with MRSA endocarditis who are treated with vancomycin or vancomycin plus rifampin. Nevertheless, few complications appear to be related solely to this sustained bacteremia.     

Early Recovery After Abdominal Rectopexy with Multimodal Rehabilitation

PURPOSE: Abdominal rectopexy without sigmoid resection is usually associated with a hospital stay of four to ten days. Recent developments have shown that a multimodal rehabilitation program with epidural analgesia and early oral feeding and mobilization will reduce hospital stay after colonic resection. The aim of this study was to describe the results after abdominal rectopexy with a multimodal rehabilitation program. METHODS: Thirty-one consecutive patients with rectal prolapse, median age 69 (range, 24-85) years and including 14 patients of American Society of Anesthesiologists physical status III to IV, were scheduled for abdominal rectopexy with a multimodal rehabilitation program including 48 hours thoracic epidural analgesia or patient-controlled anesthesia (3 patients), early oral nutrition and mobilization, and a planned two-day postoperative hospital stay. Follow-up was done at two months postoperatively. RESULTS: All patients except one tolerated normal diet and were mobilized to the same level as before surgery on the first postoperative day. Bowel movement was reestablished at a median of Day 2, and median postoperative hospital stay was three (mean, 4.4) days. At two months follow-up 16 percent were incontinent vs. 74 percent before surgery. Constipation was noted in 43 percent before surgery vs. 28 percent at two months follow-up. CONCLUSION: Median hospital stay after abdominal rectopexy may be reduced to three days with postoperative multimodal rehabilitation.     

Oral antimicrobial therapy for adults with osteomyelitis or septic arthritis

We conducted a retrospective review of 21 adult patients with osteomyelitis and septic arthritis who were treated with high doses of oral antimicrobial agents, usually after an initial course of intravenous therapy. The mean duration of parenteral and oral therapy was 3.6 days and 43.0 days, respectively. Absorption of oral antibiotics was assessed by determining the trough serum bactericidal titers for the infecting organism; whenever feasible, the dosages were adjusted to achieve trough titers greater than or equal to 1:8. The follow-up period ranged from six to 66 months (mean, 42.4 months). Eighteen of 21 patients had no clinical signs of recurrence after initial therapy. One patient with an infected joint prosthesis developed recurrent infection, and two patients had recurrences accompanied by sequestra. The mean duration of hospitalization was 13.4 days, and the mean duration of outpatient treatment was 31.9 days.     

Systemic sclerosis and interstitial lung disease: a pilot study using pulse intravenous methylprednisolone and cyclophosphamide to assess the effect on high resolution computed tomography scan and lung function

OBJECTIVE: To document the effectiveness, including the longterm effect, of a course of intravenous (IV) pulses of methylprednisolone (MP) and cyclophosphamide (CYC) in patients with scleroderma (SSc) who had evidence of lung inflammation on high resolution computer tomographic (HRCT) scan of the chest. METHODS: Fourteen consecutive patients with SSc and lung involvement were treated with 6 pulses of IV MP (10 mg/kg) and IV CYC (15 mg/kg) given at 3-4 weekly intervals. HRCT scans and lung function tests were performed at baseline and after the 6th pulse. Further lung function tests were repeated at 12 months and annually thereafter. RESULTS: Modified Rodnan skin scores improved significantly by 35% from a median baseline score of 17 (IQR 14-26.5) to a posttreatment score of 13 (IQR 10.5-18.5; p = 0.0058). HRCT scan scores improved significantly (p = 0.04). Twelve of 13 patients experienced either improvement or stabilization of the HRCT score. Median DLCO and lung volumes remained stable during the first 12 months. After a median followup of 26 months (IQR 19-43), 67% of patients experienced deterioration in DLCO. Median deterioration was 23% (IQR 44-0.6), with the median rate of deterioration of the predicted value of the DLCO/month being 0.87% (IQR 1.24-0.02). The treatment was safe and well tolerated. CONCLUSION: This IV regimen stabilized lung disease in patients with SSc. When treatment was stopped, or reduced in intensity, a deterioration in lung function occurred in the majority of patients. Rate of deterioration of DLCO may be a useful marker for determining the intensity of treatment. These findings have implications for treating lung disease and designing clinical trials in patients with SSc.     

Drug survival and reasons for discontinuation of intramuscular methotrexate: a study of 212 consecutive patients switching from oral methotrexate

OBJECTIVES: To assess the drug survival and reasons for discontinuation of intramuscular methotrexate (imMTX) in rheumatological patients who had switched to imMTX from oral methotrexate (oMTX). METHODS: Data from 212 consecutive patients who switched from oMTX to imMTX therapy at our outpatient clinic between April 1997 and January 2004 were collected retrospectively through survey of case records. Data included reason for discontinuation of oMTX, disease activity parameters, duration of imMTX therapy, and, in patients who withdrew, the reason for discontinuation of imMTX. RESULTS: The main reasons for switching from oMTX to imMTX were lack of efficacy (66%) and adverse events (28%). After 6 months, 114 patients (54%) were still receiving imMTX therapy, and their median serum C-reactive protein (CRP) and the percentage of patients who had received glucocorticoids during the previous 6 weeks had decreased (p<0.001). The median survival of imMTX therapy was 7.5 months (interquartile range 3-17). Twenty per cent of the patients received imMTX for more than 24 months. Of the 212 patients, 41% and 9% stopped imMTX therapy because of lack of efficacy and adverse events, respectively. Of the patients who had stopped oMTX because of adverse events, 22% also withdrew from imMTX because of adverse events. CONCLUSION: Half of the patients benefited from switching from oral to intramuscular methotrexate for at least 6 months, but only a minority adhered to the treatment for years. Lack of efficacy was the most frequent reason for discontinuation, while adverse events were rare.     

Antibody responses to Borrelia burgdorferi in patients with antibiotic‐refractory,antibiotic‐responsive,or non–antibiotic‐treated lyme arthritis

Objective

To compare the pattern of antibody responses to Borrelia burgdorferi in patients with antibiotic‐refractory, antibiotic‐responsive, or non–antibiotic‐treated Lyme arthritis as an indirect measure of spirochetal persistence or eradication.

Methods

At least 3 serial serum samples from 41 patients with antibiotic‐refractory arthritis and 23 patients with antibiotic‐responsive arthritis, and samples from 10 non–antibiotic‐treated, historical control patients were tested for IgG reactivity with B burgdorferi sonicate and 4 differentially expressed outer surface lipoproteins of the spirochete, by enzyme‐linked immunosorbent assay.

Results

Among non–antibiotic‐treated patients, antibody titers to B burgdorferi antigens remained high throughout a 2–5‐year period of arthritis. In contrast, in patients with antibiotic‐responsive arthritis, in whom joint swelling usually resolved during a 1‐month course of oral antibiotic therapy, the median antibody titers to most of the spirochetal antigens remained steady or decreased during the first 1–3 months after starting antibiotic therapy. In patients with antibiotic‐refractory arthritis, who had persistent joint swelling for a median duration of 10 months despite 2–3 months of oral or intravenous antibiotics, the median titers to most antigens increased slightly during the first 1–3 months. However, by 4–6 months after starting antibiotic therapy, reactivity with all antigens declined similarly in both antibiotic‐treated groups.

Conclusion

Whereas the antibody titers to B burgdorferi remained high in non–antibiotic‐treated patients, the titers declined similarly 4–6 months after starting therapy in patients with antibiotic‐responsive or antibiotic‐refractory arthritis, suggesting that synovial inflammation persisted in patients with antibiotic‐refractory arthritis after the period of infection.