Rheumatology Unit, Department of Internal Medicine, University of Modena and Reggio Emilia, Medical School, Modena, Italy.
Autoimmun Rev. 2013 Oct;12(12):1150-9. doi: 10.1016/j.autrev.2013.06.017. Epub 2013 Jun 29.
Intravesical instillation of BCG (ivBCG) is an effective and safe immunotherapy of bladder carcinoma but it may have, as side effect, a reactive arthritis (ReA). The authors describe 5 cases observed during their own clinical experience along with the updated review of the literature on this topic.
Seventy-three papers were present in the world literature, each reporting almost 1 case for a total of 112 patients. However, the review focused on 61 papers, selected on the basis of reporting suitable for a correct clinical evaluation; thus, a total of 89 patients, including the cases observed in our clinic, were carefully analyzed.
Among the 89 patients identified 73 were males and 16 females. Europe is the geographical area with the higher number of reports, namely 80.6% of the papers including 74.2% of the patients. The Mediterranean area accounts for 62.9% of the papers and 59.6% of the cases. The symptoms of ReA appeared after a mean number of instillations of 5.8. Polyarthritis was present in 55.1%, oligoarthritis in 37.0% and monoarthritis in 7.9%. Polyarthritis was symmetric in 51.0% and asymmetric in 49.0% of the cases; oligoarthritis was symmetric in 33.3% and asymmetric in 66.7% of the cases. Overall, an asymmetric distribution of arthritis was present in 59.6%. Knee and ankle were the joints most frequently involved. The antigen HLA B27 was positive in 42.6%. The synovial fluid analysis was defined as flogistic-aseptic in 71.9% of the patients. Arthritis was recovered within 6months in 93.2% of the cases and in 70.5% of the patients within the first two months. NSAIDs and corticosteroids, alone or in conjunction with other drugs, are used in 65.1% and in 40.4% of the cases, respectively. The clinical features of ivBCG ReA are compared with ReA from other triggering agents, from which it differs for some clinical aspects and overlaps for others.
Compared with a previous report, this review allows to modify some figures of this topic as a reduced prevalence of polyarthritis (from 70% to 55.1%) and of spinal and sacroiliac involvement; polyarthritis remains the more frequent clinical pattern of ivBCG ReA that, however, is characterized by rather asymmetrical distribution and involvement of the large joints of lower limbs. A definite linkage to HLA B27 is present, although without prognostic value. Moreover, arthritis is aseptic, has a latency time from antigen exposure, and is associated with extra-articular features as commonly observed in ReA from other triggering agents. Arthritis is usually benign and rarely develops into a chronic form. NSAIDs and/or corticosteroids are largely effective. Noteworthy, the overall clinical picture of arthritis triggered by ivBCG emerging from this updated review is comparable to that of ReA from other bacterial agents.
经膀胱内灌注卡介苗（ivBCG）是治疗膀胱癌的有效且安全的免疫疗法，但可能会产生不良反应——反应性关节炎（ReA）。作者描述了在自己的临床实践中观察到的 5 例病例，并结合该主题的最新文献综述进行了介绍。
世界文献中有 73 篇论文报道，每篇论文报告了近 1 例病例，总共有 112 例患者。然而，该综述侧重于 61 篇论文，这些论文是基于适合进行正确临床评估的报告而选择的；因此，总共对 89 例患者，包括在我们诊所观察到的病例进行了仔细分析。
在确定的 89 例患者中，73 例为男性，16 例为女性。欧洲是报告数量最多的地区，占论文的 80.6%，其中包括 74.2%的患者。地中海地区占论文的 62.9%，病例占 59.6%。ReA 的症状出现在平均 5.8 次灌注后。55.1%的患者出现多发性关节炎，37.0%的患者出现少关节炎，7.9%的患者出现单关节炎。51.0%的多发性关节炎呈对称性，49.0%的多发性关节炎呈不对称性；33.3%的少关节炎呈对称性，66.7%的少关节炎呈不对称性。总体而言，59.6%的关节炎呈不对称分布。膝关节和踝关节是最常受累的关节。HLA B27 抗原阳性率为 42.6%。71.9%的患者的关节液分析为炎症性-无菌性。93.2%的患者在 6 个月内关节炎得到缓解，70.5%的患者在头两个月内得到缓解。65.1%的患者单独或联合使用非甾体抗炎药和皮质类固醇，40.4%的患者使用皮质类固醇。ivBCG ReA 的临床特征与其他触发因素引起的 ReA 进行了比较，在某些临床方面存在差异，而在其他方面存在重叠。
与之前的报告相比，本次综述可以修改该主题的一些数据，如多发性关节炎的患病率降低（从 70%降至 55.1%），以及脊柱和骶髂关节受累减少；多发性关节炎仍然是 ivBCG ReA 更常见的临床类型，但具有更为不对称的分布和下肢大关节受累的特点。与 HLA B27 有明确的关联，但没有预后价值。此外，关节炎是无菌性的，有从抗原暴露到发病的潜伏期，并且与其他触发因素引起的关节炎一样，与关节外表现有关。关节炎通常是良性的，很少发展为慢性形式。非甾体抗炎药和/或皮质类固醇通常非常有效。值得注意的是，从本次更新的综述中出现的由 ivBCG 引发的关节炎的整体临床特征与其他细菌引起的 ReA 相似。
