THU0437 Disease Modifying Effect of Tuberculosis on Coexistent Systemic Vasculitis in Rheumatoid Arthritis – A Retrospective Clinicopathologic Study of 234 Autopsy Patients
Authors: M. Bély, Á. Apáthy
Journal: Annals of the Rheumatic Diseases (2013)

<h3>Background</h3> Coexisting associated diseases modify the features of <i>rheumatoid arthritis</i> (<b>RA</b>) by presenting atypical clinical manifestations and vice versa (1). The atypical signs and symptoms may lead to incorrect diagnosis or late recognition of the complications or of the associated diseases. <h3>Objectives</h3> The <b>aim</b> of this study was to determine the influence of tuberculosis (<b>Tb</b>) or specifically of miliary disseminated tuberculosis (<b>mTb</b>) on the prevalence and mortality of systemic autoimmune vasculitis (<b>SV</b>) in <b>RA</b>. <h3>Methods</h3> A randomized autopsy population of <b>234</b> in-patients with <b>RA</b> was studied. <b>RA</b> was diagnosed clinically according to the <b>ARA</b> criteria. <b>SV</b>, and <b>Tb</b> or <b>mTb</b> were histologically diagnosed post mortem. A relationship between <b>SV</b>, and associated <b>Tb</b> or <b>mTb</b> was determined by c²-tests. <h3>Results</h3> Post-primary fibrous, or fibrocaseous <b>Tb</b> accompanied <b>RA</b> in <b>27</b> (11.5%) of 234 patients. <b>Twelve</b> of 27 post-primary <b>Tb</b> cases were histologically fibrocaseous, and <b>15</b> of 27 revealed only fibrous tuberculotic scars. In <b>8</b> of 27 patients tuberculosis was accompanied by active (<b>miliary</b>) <b>dissemination</b>, in <b>19</b> patients it was not. <b>SV</b> complicated <b>RA</b> in <b>51 (21.8</b>%<b>)</b> of 234 patients. Three types of <b>vasculitis</b> were observed: <b>non-specific</b>, <b>fibrinoid necrotic</b>, and <b>granulomatous</b>. <b>Non-specific</b> vasculitis was present in all of 51 patients, <b>fibrinoid necrotic</b> vasculitis in 20 of 51, and <b>granulomatous</b> vasculitis in 12 of 51 <b>RA</b> patients with <b>SV</b>. <b>SV</b> led to death in 23 (9.8%) of 51 patients The statistical links between <b>prevalence</b> and <b>mortality</b> of <b>SV</b> (with or without granulomatous character), and coexistent <b>Tb</b> or <b>mTb</b> accompanying <b>RA</b> are summarized in Table. Fibrinoid necrotic vasculitis not correlated with <b>Tb</b> or <b>mTb</b>; not indicated in Table (*means negative value of association’s coefficient). <h3>Conclusions</h3> The <b>significant and positive correlation</b> between <b>Tb</b> (especially of its fibrocaseous form) or <b>mTb</b>, and <b>vasculitis</b> means a positive influence of <b>Tb</b> on <b>prevalence</b> of <b>vasculitis</b> in <b>RA</b>. Miliary dissemination of <b>Tb</b> promote the lethal outcome of vasculitis as a complication. The close relationship between <b>granulomatous vasculitis</b> and <b>Tb</b> is due to the disease modifying effect of <b>Tb</b> or <b>mTb</b> (1). <b>Tb</b> is one of the most important associated diseases accompanying <b>RA</b>. In our autopsy population <b>only one case of Tb with mTb and a lethal outcome was clinically recognized.</b> The steroid, immunosuppressive or anti- TNF-alpha treatment of <b>RA</b> markedly increases the risk of activation of inactive fibrous or fibrocaseous tuberculosis. The granulomatous type of systemic vasculitis is an important diagnostic histologic feature of disseminated miliary tuberculosis in <b>RA</b> patients. <b>Tb</b> or <b>mTb</b> (endogenous exacerbation of post-primary tuberculosis) <b>must be excluded clinically in case of histologically detected granulomatous type of vasculitis</b> <h3>References</h3> <b>Apáthy Á, Bély M</b>: Co-morbidity in Rheumatoid Arthritis: Influence of Associated Diseases on the Prevalence of Co-existent Complications of RA. Ann Rheum Dis 2009; 68(Suppl. 3): 407-408 <h3>Disclosure of Interest</h3> None Declared