He began with an overview of ocular inflammatory diseases, including uveitis and Blau syndrome, the rarest form of uveitis.
“There are different diseases for the front and the back of the eye,” explained Dr. Rosenbaum, “and uveitis affects the middle of the eye.” Blau syndrome, which affects children, is caused by a mutation in a gene called NOD2. Blau is closely related to Crohn’s disease, but no patient has ever presented with both.
Dr. Rosenbaum outlined the clinical considerations of tubulo-interstitial nephritis with uveitis (TINU). “You ought to recognize this, but you’ve probably never heard of it,” he says. It presents with a bilateral, sudden onset anterior uveitis; a variable degree of vitreous involvement; fever, myalgias, and fatigue; and a high sed rate, anemia, mildly abnormal liver function, and abnormal urinalysis. TINU is “far more common than we thought,” he said, but it responds well to corticosteroids.
Recent studies have revealed a link between uveitis and juvenile idiopathic arthritis (JIA). For example, a Johns Hopkins study found that 36% of JIA patients had affected eyesight and 24% were legally blind. Other unpublished research points to a link between anti-neutrophil cytoplasmic antibody (ANCA) testing and scleritis. Fourteen out of 101 patients with scleritis had a positive ANCA test.
“About 40% of patients with scleritis have a systemic immunologic disease such as rheumatoid arthritis,” said Dr. Rosenbaum. “And scleritis is rarely the initial manifestation of that systemic disease. Consequently, lab tests such as [antinuclear antibody] or [rheumatoid factor] have little role in the evaluation of these patients.”
In covering treatment for uveitis, Dr. Rosenbaum focused on the most extensively tested biologics, including TNF inhibitors, alpha interferon, and the anti–IL-2 receptor daclizumab. TNF inhibitors have been tested most thoroughly and shown to be remarkably effective when used off-label. Specifically, infliximab was studied by three different groups and found to be quite potent. However, “reduction of TNF may be more toxic in uveitis,” warned Dr. Rosenbaum, “so use it very cautiously.” He also pointed out that infliximab is not FDA approved for childhood uveitis, perhaps because the dose used in tests was not high enough.
“Monoclonal antibodies to TNF hold great promise in treating uveitis,” said Dr. Rosenbaum, “but they should be used with great caution.”
Holistic Management of Central Pain
In her presentation, “Fibromyalgia,” Leslie J. Crofford, MD, chief of rheumatology and director of the Center for the Advancement of Women’s Health at the University of Kentucky in Lexington, focused on treating pain syndromes. Patients with these syndromes are primarily interested relieving chronic pain and the chronic fatigue that accompanies it.
