Infliximab, a tumor necrosis factor (TNF) antagonist, is associated with tuberculosis (TB), but it is unknown whether this phenomenon is true of all TNF antagonists. We reviewed 25 cases of TB due to another TNF antagonist, etanercept, that were reported to the US Food and Drug Administration (FDA) between November 1998 and March 2002. Such cases are sometimes incomplete and are subject to underreporting. Fifteen patients received other immunosuppressive medications. The median interval between the receipt of the first dose of etanercept and the diagnosis of TB was 11.5 months. Thirteen patients had extrapulmonary TB at the time of diagnosis. Diagnosis was made on the basis of culture results for 12 patients, biopsy findings for 9, and sputum staining for 4. There were 2 deaths, 1 of which was directly attributed to TB. The estimated number of TB cases reported to the FDA for each person-year of treatment with etanercept (i.e., the "reporting rate") among patients with rheumatoid arthritis (RA) was ~10 cases/100,000 patient-years of exposure. Clinicians considering etanercept for patients with RA should be alert to the possibility of the occurrence of TB, sometimes with an unusual extrapulmonary presentation. It is unclear whether etanercept therapy increases the risk of TB beyond the elevated TB rates already documented for patients with RA.

Elevated cTnT, but not cTnI, was highly associated with CK in patients with IIM despite the absence of myocardial ischemia.

No abstract

Septic arthritis refers to an infection in a joint due to a bacterial, mycobacterial, or fungal cause. Joint infections are a serious cause of morbidity and mortality and constitute a true musculoskeletal emergency. The estimated incidence of septic arthritis in the general population is between 2 and 6 cases per 100,000 people per year. The most common presentation is an acute monoarthritis. Identification of organisms in the synovial fluid is the criterion standard for diagnosis. Synovial fluid aspiration should be performed prior to initiating antibiotics. While no diagnostic cutoff exists for synovial fluid white blood cell count, increasing leukocytosis is associated with a higher likelihood of an infectious cause of arthritis, and patients commonly present with values greater than 50,000/μL. The cornerstones of treating septic bacterial arthritis are adequate drainage and antimicrobials. Joint drainage is always recommended in septic arthritis; however, no clear guidelines or strong evidence exist to guide the preferred method of drainage. Options for joint drainage include daily needle aspiration, arthroscopy, or open surgical drainage via arthrotomy.

In our series, we found a strong correlation between CK and serum transaminases. Serum transaminases were elevated in 80% of patients at the time of presentation and normalized in 85% of the patients at the time of CK normalization. Appropriate recognition of these laboratory changes in IIM may help reduce unnecessary hepatic evaluation, delayed diagnosis, unnecessary avoidance of second line immunosuppressants, and misdiagnosis of primary liver disease.