Case Highlights Gut Microbiome Alteration as Potential Treatment for PsA

A patient with psoriatic arthritis (PsA) was able to discontinue her disease-modifying antirheumatic drugs (DMARDs) because of sustained remission of her rheumatic symptoms after receiving fecal microbiota transplantation (FMT) for Clostridium difficile (C difficile) infection, according to a case report published in Clinical and Experimental Rheumatology.

The investigators reported on the case of a 59-year-old woman who had been diagnosed with PsA in 2004, along with recurrent active spondyloarthropathy and polyarthritis, which manifested as sacroiliac joint pain and stiffness, and synovitis of the small joints of the feet, left ankle, and right knee. The woman presented to the Queen Elizabeth Hospital, South Australia, Australia,  in July 2016 with diarrhea of up to 20 bowel movements per day, having recently completed a course of orally administered clindamycin for presumed facial cellulitis. At the time of presentation, her medication regimen included methotrexate 25 mg/week, hydroxychloroquine 200 mg twice daily, leflunomide 10 mg daily, folic acid, and paracetamol.

The patient underwent a flexible sigmoidoscopy, which revealed diffuse moderate inflammation in the sigmoid colon with pseudomembranous plaques. Biopsies detected acute active mucosal inflammation with no evidence of chronicity. She was diagnosed with C difficile colitis, for which intravenous metronidazole was administered, followed by vancomycin. Even with 6 days of antibiotic treatment, the patient continued to experience persistent diarrhea with >10 bowel movements per day, a fever of 38.1℃, and a rise in her C-reactive protein (CRP) level to 140 mg/L. Ultimately, the decision was made to administer FMT via colonoscopy. At 3 days post-FMT, the patient’s symptoms improved, with a reduction in stool frequency to once per day, no additional fever, and normal CRP levels.

In the weeks after FMT was administered, she reported a dramatic improvement in her symptoms. Upon review at 1 month, 4 months, and 10 months post-FMT, the patient attained recognized minimal disease activity for her PsA (4, 5), with minimal morning stiffness, no sacroiliac joint stiffness, a tender and swollen joint count of 0, and normal inflammatory biomarkers, while not receiving any DMARDs.

At 13 months post-FMT, the patient reported an increase in disease activity with diffuse arthritis and increased morning stiffness, which coincided with an episode of traveler’s diarrhea. The patient was reluctant to restart immunosuppression due to fear of infection, so a compromise of oral methotrexate 10 mg/week was commenced, with a partial response.

This is apparently the first case report of FMT being linked to the attainment of minimal disease activity in a patient with PsA. Clinical trials are warranted that  are designed to modulate the gut microbiome with the use of FMT or defined microbial consortia in order to further explore these possibilities.

Reference

Selvanderan SP, Goldblatt F, Nguyen NQ, Costello SP. Faecal microbiota transplantation for Clostridium difficile infection resulting in a decrease in psoriatic arthritis disease activity. Clin Exp Rheumatol. 2019;37(3):514-515.