An understanding of the cytokine cascade in a rheumatoid joint has led to the development of new therapeutic options, including drugs targeting tumor necrosis factor-alpha (TNF-alpha). The safety profile of these agents in patients with hepatitis-induced liver disease, however, remains a concern because of risks associated with immune suppression. To examine the effect of three different TNF-alpha antagonists, infliximab, etanercept, and adalimumab, on serum transaminases and hepatitis viral load in patients with rheumatoid arthritis (RA) and concurrent hepatitis B (HBV) or hepatitis C (HCV). Medical records of 11 patients with diagnosis of RA and documented seropositivity for hepatitis B or hepatitis C were retrospectively reviewed for worsening of hepatic inflammation and viral proliferation as measured by a rise in aspartate aminotransferase (AST) or alanine aminotransferase (ALT) and viral load while using these agents. Three patients had RA with concurrent chronic HBV and eight patients had RA with concurrent chronic HCV. Seven patients remained on a single anti-TNF-alpha agent and four patients switched to a second anti-TNF-alpha agent due to treatment failure. Two patients showed a transient elevation in AST and/or ALT from normal, but in all 11 patients, AST and ALT levels were within one time the upper range of normal at the conclusion of the study. No significant increase in viral load was seen except one patient who showed a fourfold increase from baseline. Our case series supports results obtained from previous studies examining the safety of anti-TNF-alpha agents in patients with underlying hepatic disease. Use of these agents in patients with HBV or HCV may be associated with a transient transaminitis but appears to be safe overall. In both groups, frequent monitoring of serum transaminase levels and viral load is essential.

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Tumor necrosis factor (TNF)-alpha antagonists successfully modulate the pathogenesis of rheumatoid arthritis (RA). However, little is known about the effect of TNF-alpha blockade on the histology of chronic viral hepatitis. We describe the cases of two patients with RA, one with concurrent chronic hepatitis B virus and the other with hepatitis C virus infection who, as part of their evaluation, underwent liver biopsies while undergoing treatment with a TNF-alpha antagonist.

Limited information exists on treatment of rheumatoid arthritis in a patient with coexisting human immunodeficiency virus (HIV) infection. We report a case of a patient with rheumatoid arthritis who then became HIV positive. His HIV viral load was controlled with antiretroviral therapy, but he continued to have active rheumatoid arthritis despite therapy with hydroxychloroquine, sulfasalazine, and corticosteroids. Because of unremitting rheumatoid disease, we are now treating him with a TNFalpha inhibitor, and his rheumatoid disease activity has decreased from 28 swollen and tender joint count to less than 5.

Surface immunoglobulin-bearing cells were selected from suspensions of human tonsil cells by the reverse immune cytoadherence technique. The method employed a hybrid antibody directed against Ig on lymphoid cells and against ferritin bound to sheep red blood cells (SRBC). Only 6% of the cells formed rosettes. When subjected to electron microscopy they were shown to consist of a morphologically heterogeneous population of cells. However, most cells in the center of rosettes showed ribosome-associated endoplasmic reticulum (RER) and polyribosomes. Usually these organelles were located in close proximity to membrane sites where a 400–600 A bridge was resolved between the lymphocyte and the ferritin particle on the SRBC. The bridge is postulated to consist at least in part of Ig. Only 50% of the plasma cells formed rosettes and bridges could not be resolved. The surface of the plasma cells within rosettes differed from that of plasma cells which had not reacted with ferritin-coated sheep erythrocytes. The incidence of plasma cells and γ-globulin-bearing lymphoid cells was corroborated with the help of fluorescent antibody techniques.