To date, hepatotoxicity with anti-TNF therapy has been associated with concomitant liver-toxicity drugs, infection or malignant diseases. We report the case of one patient with spondyloarthropathty who presented severe liver dysfunction related to infliximab. After the second infusion serum controls showed an slightly increase of transaminases. Before the administration of fifth infusion, infliximab therapy was stopped due to severe liver damage (AST 327 mU/ml, ALT 656 mU/mL, GGT 140 mU/mL, alkaline phosphate 227 mU/mL). Ten weeks after infliximab discontinuation serum concentrations of liver blood tests were normal but ankylosing spondylitis symptoms had relapsed. Therefore, he was treated with etanercept with a rapid and sustained improvement. Serum concentrations of albumin, AST, ALT, GGT and alkaline phosphate were followed and did not change for five months.

RA patients treated with TCZ show lower plasma concentrations of Lp(a) compared with patients without BT.

LETTERS 567 true that some newspapers or broadcasters may truncate or warp one of our stories by using parts of it out of context, we do our best to identify such offenders and try to set the record straight, though we are not always successful.As far as the auranofin story is concerned, we were misinformed by a drug company representative, whom we later learned was in no position to know the true facts about the likelihood of this drug being released in the near future. Our attempts to confirm his statement by contacting the senior investigator making the report at the ARA meeting were unsuccessful, and we were again misled by someone else on this point. We were eventually able to obtain the true facts in time to correct the story given out to the wire services but too late to reach newspapers, magazines, and other media which had been sent the advance story by mail. We apologize for this mistake and will try to be even more diligent in avoiding such errors in the future.Criticism such as that from Dr. Hanauer does us good by making us acutely aware of the heavy responsibility we have to patients, professionals, and the public to provide objective stories on controversial, everchanging subjects. FREDERIC C. MCDUFFIE, MD Senior Vice President for CHARLES C. BENNETT Medical Affairs Vice President for Public Arthritis Foundation Atlanta, Georgia and Professional Education Septic arthritis caused by Serrutiu murcescens To the Editor:Since its discovery, Serratia marcescens has been considered a saprophyte and a relatively avirulent microorganism; however, its pathogenicity has become increasingly apparent in the last several decades. S marcescens infection can be found at many sites, with localization at the joint level one of the rarer forms.We have found 24 cases in the literature of septic arthritis produced by S marcescens (1-12). All of these studies reported on patients with chronic systemic diseases, drug addiction, or intravenous, arterial, or urinary catheters or endotracheal tubes; or on prolonged patient treatment with antibiotics, steroids, and immunosuppressive agents. In a patient we studied, however, none of these conditions were present.A 17-year-old man presented with pain of 3 years duration upon flexion of the left knee. His history revealed no trauma or other outstanding features. Two weeks before the current hospitalization, the patient was treated with 4 steroid injections (betamethasone 3 mg each) into the left knee. Seven days later, he presented with swelling, redness, local heat, pain, temperature increase to 38°C effusion upon tension of the left ankle with functional impairment that had increased until the time of his hospitalization, and slight pain upon passive mobilization of the left knee. Results of the remainder of the physical examination were normal.The blood count demonstrated 9,500 white blood cells (WBC) with a small left shift and an erythrocyte sedimentation rate of 50-80 mm/hour. Alkaline phosphatase was 110 pm/ml (normal 80 pm/ml); urine analysis, SGOT, SGPT, total bilirub...

Background Up to 50% of cases of juvenile spondyloarthritis (JSpA) begin in childhood, with clinical features that distinguish them from their adult counterparts, such as more frequent peripheral involvement, and more severe and disabling outcome. Although descriptions of JSpA in worldwide different populations are scarce, it has been suggested that clinical expression could different in Spanish and Mexican populations. Objectives To compare the pattern of musculoskeletal involvement among Spanish and Mexican patients with JspA. Methods We conducted a descriptive study based on baseline data of MexESpA study, comprising a binational cohort distributed in 10 Spanish centers (n = 95) and 6 Mexican (n = 33). Analyzed data were demographic characteristics, musculoskeletal manifestations, metrology, HLA-B27 and diagnosis. Results 65% of Spanish children were boys, while in Mexico were 85%. Mean age at onset was higher in Mexican population (12 ± 3 years) than Spanish (10 ± 4 years), with a greater duration of symptoms in the latter group. 94% of Spanish patients were Caucasian, while in Mexico predominated white-Indian (64%). Frequency of HLA-B27 was higher in Spain (47%) than Mexico (27%), as well as family history of SpA (45% and 18%, respectively). Almost all children in both countries had some type of musculoskeletal symptom (95% in Spain and 94% in Mexico). However, the pattern was different between both countries. In Spain predominated peripheral arthritis affecting lower extremities and in Mexico peripheral enthesitis, followed by peripheral arthritis and inflammatory pain. No differences in the number of tender, swollen or limited joints. In Spain 9% had some axial entheses affected and 44% some peripheral, while in Mexico, these percentages were much higher, 36% and 85% respectively. No significant differences were found in metrology and average modified Schober in both populations was 6 cm. There was also no significant difference in the C-HAQ, or BASDAI and BASFI indexes, although values were slightly higher in Mexico. Among the diagnoses at baseline, more patients in the Mexican cohort had ankylosing spondylitis in (61%) than in the Spanish (7%), and conversely, undifferentiated and psoriatic JSpA were more prevalent in the Spanish patients (46% and 36%, respectively) than in Mexicans (36% and 3%, respectively). Conclusions Results show a different pattern of musculoskeletal involvemente between Spain and Mexico. Differences could be related to several aspects including social and environmental factors, age of onset and different JSpA subtypes. However, probably the main explanatory factor is genetic background, with a higher frequency of HLA-B27 in Spanish patients, while there is a stronger association with HLA-DRB1*08 and LMP-2 in Mexican patients, which predispose to more severe manifestations in this group. Disclosure of Interest None Declared

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