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Rheumatoid arthritis associated with ulcerative colitis
  1. J A MOSQUERA-MARTINEZ
  1. Rua ILLA de Tambo-96
  2. Poio-Pontevedra
  3. 36005 Spain
  4. andrea{at}dragonet.es
    1. F BOYER,
    2. E FONTANGES,
    3. P MIOSSEC
    1. Departments of Immunology and Rheumatology
    2. Hôpital Edouard Herriot
    3. Lyon, France

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      I was interested to read the letter on “Rheumatoid arthritis associated with ulcerative colitis” by Boyer et al published recently in theAnnals,1 and would like to make the following comments. Studies in patients with established Crohn's disease (CD) have generally supported the predominance of Th1 responses.2 3 In ulcerative colitis, although enhanced humoral immunity has been described, evidence for classical Th2 predominance remains to be demonstrated. On the other hand, it has been shown that interleukin 15 is overexpressed in the inflamed mucosa of patients with inflammatory bowel disease at the level of macrophages.4 Similar findings have been reported in patients with rheumatoid arthritis (RA).5

      As shown in this case, it is sometimes quite difficult to distinguish by clinical manifestations alone between two diseases which start almost at the same time. However, the presence of a positive rheumatoid factor and DR1 genotype are arguments for RA. The existence of polymorphisms affecting other genes may take place in such type of arthritis.6

      Results obtained with anti-tumour necrosis factor monoclonal antibody to prevent mucosal inflammation in CD,7 suggest that such an approach may also be of interest in this unusual situation.

      References

      Authors' reply

      We thank Dr Mosquera-Martinez for his letter and are happy that our report has stimulated active discussion and suggestions.1-1 Indeed, control of disease was difficult even when combining methotrexate 15 mg/week IM, salazopyrine 3 g/day, and prednisone 10 mg/day. The patient still had active arthritis affecting wrists and hands with an erythrocyte sedimentation rate (ESR) of 47 mm/1st h. Furthermore, she also had active colitis, and current treatment prevented surgery for colon anastomosis.

      Accordingly, infliximab was started following the now classical rheumatoid arthritis protocol.1-2 Seven months later, steroids could be stopped. Surgery for permanent colon anastomosis could then be performed with success and with no healing delays. When last seen in July 2001, she showed major improvement, with no pain at night and no morning stiffness. She had gained weight and had no sign of active colitis. The ESR was 26 mm/1st h and C reactive protein <4 mg/l.

      Such follow up extends the concept of common mechanisms between rheumatoid arthritis and ulcerative colitis. Both diseases appear to depend, at least in part, on the contribution of tumour necrosis factor α.

      References

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