The Latest on Vaccinations, Leprosy & Lyme Disease

Hugh Sitton / OFFSET BY shutterstocK

CHICAGO—Keith Winthrop, MD, MPH, professor of public health and preventive medicine at the Oregon Health & Science University School of Medicine, Portland, Ore., began the vaccination session at the 2018 ACR/ARHP Annual Meeting with a review of vaccination timing and targets. He presented a clinically relevant snapshot of the vaccines rheumatologists should consider and emphasized that, in general, vaccines are underutilized in the rheumatology population. He first discussed the inactivated annual influenza vaccine, which he recommended for all rheumatological patients.

Healthcare providers have a choice of a high-dose flu vaccine or adjuvanted flu vaccine. The high-dose flu vaccine is indicated for patients older than 65 years of age. Research has shown it provides 24% greater efficacy against flu than the standard vaccine.¹ Unfortunately, patients with rheumatoid arthritis (RA) may not respond as well. Nevertheless, preliminary research suggests that seroprotection with the high-dose vaccine in patients with RA is superior to the alternatives, and the argument could be made that even younger people with RA should receive the high-dose flu vaccine.

Dr. Winthrop also addressed the common concerns that immunosuppressive agents may further limit the efficacy of the vaccines. He began by reassuring the audience that most disease-modifying anti-rheumatic drugs (DMARDs) do not affect the efficacy of influenza vaccination. That said, new research indicates people who stopped methotrexate for two weeks prior to vaccination experienced superior seroprotection. Moreover, few patients with RA flared when off methotrexate, which suggests stopping methotrexate might be a nice strategy to improve seroprotection.

Dr. Winthrop described the two pneumococcal polysaccharide vaccines on the market: PPSV23, which protects against 23 types of pneumococcal bacteria, and PCV13, a conjugate vaccine that protects against 13 types of pneumococcal bacteria.

A few studies have examined seroprotection in immunosuppressed patients. Patients on tofacitinib who received PCV13 experienced a multifold titer rise.² The same was true for patients on baricitinib, who also experienced a robust rise in antibody titer, although not as high as those on tofacitinib.³ Dr. Winthrop explained that this difference in response may be because the patients on tofacitinib were younger and had psoriasis, whereas the patients in the baricitinib study had RA and were older. Dr. Winthrop also noted that patients in these studies were likely on methotrexate, which meant they responded even though they were immunosuppressed. Despite this, he does try to suspend methotrexate before vaccinating. Dr. Winthrop concluded his talk by stating the “best time to vaccinate is when the patient is in front of you and you are thinking about it.”

‘I think Lyme disease is going to come up in your practice no matter where you are practicing.’ —Robert A. Kalish, MD

Leprosy

Vikas Agarwal, MD, professor at the Sanjay Gandhi Postgraduate Institute of Medical Sciences, India, took the stage to speak about leprosy and other mycobacterial arthritis. He explained that Mycobacterium leprae causes a chronic granulomatous disease associated with leprosy, and emphasized that leprosy is not just limited to endemic zones, but can appear in areas supposedly free of leprosy—it has even been reported in Louisiana. Dr. Agarwal explained that suspicion is key for early diagnosis of leprosy, and the clinical features of arthritis can be easily identified by careful evaluation of these patients.

Leprosy has a classic presentation in the skin that includes macules, plaques and papules/nodules. Patients may also suffer swollen hand and foot syndrome with acute onset symmetric polyarthritis. One important clue for diagnosing mycobacterial arthritis is the presence of swollen hand and feet syndrome with painful diffuse pitting edema and nodules along the tendons.

Another potentially useful way of distinguishing between RA and mycobacterial arthritis is anti-cyclic citrullinated peptide (anti-CCP) antibody testing, which is more likely to be positive in patients with RA than in patients with mycobacterial arthritis.

Dr. Agarwal concluded his presentation by stating that the mainstay treatment for mycobacterial arthritis is anti-tuberculosis drug therapy, which should run for 12–18 months.

Lyme Disease

Robert A. Kalish, MD, director of rheumatology education at Tufts Medical Center in Boston, gave a presentation on Lyme disease, noting, “I think Lyme disease is going to come up in your practice no matter where you are practicing.”

He explained that Lyme disease includes Lyme arthritis, post-Lyme syndrome and chronic Lyme disease. It is transmitted by a bite from an adult deer tick, which is approximately the size of a sesame seed. He emphasized that these ticks are spreading throughout the U.S. In some cases, patients may not have only Lyme disease, but also co-infections and autoimmune syndromes that follow infection. Dr. Kalish reminded the audience to consider other infections that could be transmitted via deer tick, including emerging viral infections.

Lyme disease presents with a classic bullseye on the skin, followed by secondary lesions that are flat. It is diagnosed by serologic testing; although some physicians use IgM antibodies, IgG seems to be a more reliable and specific marker, because IgM antibodies appear two to four weeks post-infection and peak at three to six weeks post-infection, disappearing by six months.

Healthcare providers should treat patients with early localized and disseminated infection with 10–21 days of oral antimicrobial therapy (i.e., doxycycline, amoxicillin and cefuroxime axetil). A 14-day course of oral doxycycline is recommended for treatment of early neurologic Lyme disease in ambulatory patients, and a four-week course is recommended for patients with arthritis. Patients who are highly immunocompromised may require a minimum of six weeks of antibiotics.

Lara C. Pullen, PhD, is a medical writer based in the Chicago area.

References

1. 1. DiazGranados CA, Robertson CA, Talbot HK, et al. Prevention of serious events in adults 65 years of age or older: A comparison between high-dose and standard-dose inactivated influenza vaccines. Vaccine. 2015 Sep 11;33(38):4988–4993.
2. 2. Winthrop KL, Korman N, Abramovits W, et al. T-cell-mediated immune response to pneumococcal conjugate vaccine (PCV-13) and tetanus toxoid vaccine in patients with moderate-to-severe psoriasis during tofacitinib treatment. J Am Acad Dermatol. 2018 Jun;78(6):1149–1155.
3. 3. Caporuscio S, Ieraci R, Valesini G, et al. Anti-polysaccharide and anti-diphtheria protective antibodies after 13-valent pneumococcal conjugate vaccination in rheumatoid arthritis patients under immunosuppressive therapy. Clin Immunol. 2018 Oct;195:18–27.