acyclovir and Arthritis--Rheumatoid

This clinical report is presented to describe how results of vestibular function testing were considered along with other medical history to develop a management plan that was ultimately successful.. The patient underwent audio-vestibular assessment including comprehensive audiogram, videonystagmography, cervical vestibular evoked myogenic potential, and postural stability testing.. Results from initial testing were most consistent with uncompensated peripheral vestibular dysfunction affecting the right superior vestibular nerve. These results, considered along with history and symptoms, supported vestibular neuritis. After a second vertigo event, we became concerned about the potential temporal association between the patient's rheumatoid arthritis treatment and symptom onset. It is established that treatment for rheumatoid arthritis can exacerbate latent viral issues, but this has not specifically been reported for vestibular neuritis. There are reports in the literature in which patients successfully used viral suppressant medication to decrease viral activity while they were able to continue benefiting from immunosuppressive therapy. We hypothesized that, if the current patient's vestibular neuritis events were related to her treatment for rheumatoid arthritis, she may also benefit from use of viral suppressant medication while continuing her otherwise successful immunosuppressive intervention.. Patients treated with biologic disease-modifying antirheumatic drugs are more susceptible to viral issues, and this may include vestibular neuritis. For the current case, identifying this possibility and recommending viral suppressant medication allowed her to continue with successful treatment of rheumatoid arthritis while avoiding additional vertigo events.

Topics: Acyclovir; Antirheumatic Agents; Arthritis, Rheumatoid; Biological Products; Female; Humans; Middle Aged; Prognosis; Recurrence; Risk Assessment; Severity of Illness Index; Treatment Outcome; Valacyclovir; Valine; Vertigo; Vestibular Function Tests; Vestibular Neuronitis

Cigarette smoking is the leading cause of preventable death in the United States. Smoking adversely affects many organ systems, but especially the lung. Carcinoma of the lung and chronic obstructive pulmonary disease account for most smoking-associated respiratory morbidity and mortality, and their association with smoking is both well established and widely recognized. Cigarette smoking also is associated with differences in the incidence, severity, or natural history of a broad array of other respiratory illnesses, ranging from the common cold to pneumothorax, pulmonary hemorrhage, and various interstitial lung diseases. Interestingly, while the general effect of smoking on respiratory diseases is adverse, in the cases of sarcoidosis and hypersensitivity pneumonitis smoking may actually be associated with a decrease in the incidence of disease. In this article, the author briefly discusses some of the pulmonary and systemic effects of smoking that might mediate its effects on an array of lung diseases, then comprehensively reviews less common or less well-recognized smoking-affected lung diseases such as pulmonary infections, spontaneous pneumothorax, Goodpasture's syndrome, eosinophilic granuloma and other interstitial lung diseases, and pulmonary metastatic disease.

Topics: Acyclovir; Alveolitis, Extrinsic Allergic; Antiviral Agents; Arthritis, Rheumatoid; Asbestosis; Bronchiolitis; Chickenpox; Eosinophilic Granuloma; Humans; Lung Diseases; Lung Neoplasms; Pneumonia, Bacterial; Pneumonia, Viral; Pneumothorax; Pulmonary Fibrosis; Respiratory Tract Infections; Risk Factors; Smoking

A man in his 70s with rheumatoid arthritis presented with seizures and coma and was transferred to our emergency department. Two months prior to admission, he started to take tofacitinib 10 mg/day. On admission, we noted a rash with a blister on the forehead, and herpes zoster was diagnosed. Cerebrospinal fluid examination suggested meningitis. An MRI of the brain showed no abnormality. Based on these findings, he was suspected with herpes zoster meningitis. We discontinued tofacitinib and treated the patient with intravenous acyclovir for 2 weeks. He regained complete consciousness, but right forehead skin lesion, severe vision loss in the right eye and right facial nerve paralysis remained as sequelae. Six weeks after admission, we restarted tofacitinib with oral valaciclovir as antiviral prophylaxis. Two years after admission, we administered Shingrix, an adjuvant recombinant vaccine for herpes zoster, and discontinued oral valaciclovir.

Topics: Acyclovir; Antiviral Agents; Arthritis, Rheumatoid; Herpes Zoster; Humans; Male; Piperidines; Pyrimidines

When skin abnormalities in patients extend over several dermatomes, disseminated herpes zoster should be suspected. This complication is most often seen in immunocompromised patients.. An 87-year-old patient came to the dermatology outpatient clinic with several vesicles scattered over her body. She was being treated with methotrexate for rheumatoid arthritis. Upon physical examination, we found groups of vesicles in the area of the maxillary nerve as well as several solitary vesicles scattered over her body. We made the diagnosis of 'disseminated herpes zoster'. PCR test of fluid from one of the vesicles found Varicella zoster virus. We treated the patient with intravenous acyclovir for 48 hours after which we treated her with oral acyclovir for another 8 days. We temporarily halted methotrexate. Outpatient follow-up found that the patient's skin abnormalities had diminished significantly.. The risk of disseminated herpes zoster depends on several factors. Use of immunosuppressants is often not the only contributing factor. Risk of disseminated herpes zoster in a patient who is being treated with methotrexate depends on age, comorbidities and co-medication of the patient.

Topics: Acyclovir; Aged, 80 and over; Antiviral Agents; Arthritis, Rheumatoid; Female; Herpes Zoster; Herpesvirus 3, Human; Humans; Immunocompromised Host; Methotrexate; Risk Factors

To describe a series of 5 patients with herpes simplex virus keratitis (HSK) and rheumatoid arthritis (RA) under immunosuppressive treatment.. Retrospective study. Detailed data were obtained regarding symptoms and signs at the initial evaluation, treatment, microbiological diagnostic tests, evolution, and outcomes.. Five patients with HSK and RA were identified. Bilateral involvement occurred in 2 patients (40%). Epithelial keratitis was diagnosed in 5 eyes. Three eyes showed severe melting with eye perforation. Gram-positive bacterial co-infections were common in the group with stromal keratitis. We did not find differences in the evolution of the disease based on anti-rheumatoid treatment.. The characteristics of HSK in patients with RA differed from HSK in immunocompetent patients. The stromal keratitis cases were very aggressive and difficult to manage, with perforation and gram-positive bacterial co-infection as frequently associated conditions. Prophylactic therapy at standard doses was unsuccessful to avoid recurrences.

Topics: Acyclovir; Aged; Antiviral Agents; Arthritis, Rheumatoid; Corneal Stroma; DNA, Viral; Female; Herpesvirus 1, Human; Humans; Immunosuppressive Agents; Keratitis, Herpetic; Male; Opportunistic Infections; Polymerase Chain Reaction; Retrospective Studies

Rituximab is a widely used biologic agent, which has shown favourable results in the treatment of vasculitis. But immunosuppressive treatment also bears the risk of severe complications.. A patient with rheumatoid arthritis, progressive scleromalacia, and acute retinal necrosis on therapy with rituximab is reported.. For the first time, a correlation between rituximab and acute retinal necrosis in a patient with progressive rheumatoid scleromalacia is shown.. Although rituximab is a promising biologic agent for the treatment of autoimmune diseases, it bears the risk of reactivation of viral infections, including the onset of acute retinal necrosis.

Topics: Acyclovir; Antiviral Agents; Aqueous Humor; Arthritis, Rheumatoid; Drug Therapy, Combination; Eye Infections, Viral; Female; Glucocorticoids; Herpes Simplex; Herpesvirus 1, Human; Humans; Immunosuppressive Agents; Middle Aged; Prednisone; Retinal Necrosis Syndrome, Acute; Rituximab; Scleritis; Virus Activation

Topics: Acyclovir; Aged; Anti-Inflammatory Agents; Antiviral Agents; Arthritis, Rheumatoid; Buttocks; Cellulitis; Eosinophilia; Female; Herpes Genitalis; Humans; Prednisone; Pregabalin; Valacyclovir; Valine

This report describes the clinical presentation and management of a rare case of herpes simplex virus infection in the larynx of a patient treated with methotrexate.. We report a case of a clinically suspicious laryngeal lesion in an 82-year-old woman who started methotrexate treatment for rheumatoid arthritis. Shortly afterwards she developed dysphonia, which worsened over four months. On microlaryngoscopy, there was bilateral erythema and ulceration of the vocal folds. No other mucocutaneous lesions or systemic features were present. Biopsies revealed herpes simplex virus infection of the vocal folds; there was complete resolution with oral aciclovir. A brief literature review for this rare entity is presented and the diagnostic challenges arising from under-recognition of atypical presentations are discussed.. To our knowledge, this is the first report of a rare complication of herpes simplex virus infection in the context of methotrexate-induced immunosuppression. It may present therapeutic challenges for conditions which rely on immunosuppressive treatments.

Topics: Acyclovir; Aged, 80 and over; Antiviral Agents; Arthritis, Rheumatoid; Female; Herpes Simplex; Humans; Immunosuppressive Agents; Laryngeal Diseases; Methotrexate

A 75-year-old woman with rheumatoid arthritis (RA) who was receiving methotrexate (MTX) therapy developed Epstein-Barr virus (EBV)-associated CD8(+) T-cell lymphoproliferative disorder (LPD) and meningoencephalitis. She was successfully treated with acyclovir and corticosteroids plus MTX cessation. T-cell LPD is relatively rare in RA patients receiving MTX. To our knowledge, this is the first report of CD8(+) T-cell LPD with EBV genome occurring during MTX therapy for RA. EBV infection should be carefully monitored to assess severe EBV-associated complications.

Topics: Acyclovir; Aged; Antirheumatic Agents; Antiviral Agents; Arthritis, Rheumatoid; CD8-Positive T-Lymphocytes; Epstein-Barr Virus Infections; Female; Gene Rearrangement, beta-Chain T-Cell Antigen Receptor; Herpesvirus 4, Human; Humans; Immunocompromised Host; Immunophenotyping; Lymph Nodes; Lymphoproliferative Disorders; Meningoencephalitis; Methotrexate; Methylprednisolone

Topics: Acyclovir; Aged; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Antirheumatic Agents; Antiviral Agents; Arthritis, Rheumatoid; Female; Herpes Zoster; Humans; Receptors, Interleukin-6; Treatment Outcome; Virus Activation

Tumor necrosis factor-alpha (TNFalpha)-blocking agents are immunomodulating agents introduced for treatment of a variety of chronic inflammatory disease conditions. Adverse effects include an increased incidence of infections. Clinically, these infections often have atypical presentations that may hamper prompt diagnosis. In our report of a patient on etanercept therapy for rheumatoid arthritis, the correct diagnosis was delayed because disseminated herpes zoster was clinically mimicking vasculitis. Initially assuming rheumatoid vasculitis, immunosuppression was increased, resulting in worsening of skin lesions. Only an extended work-up, including a skin biopsy and viral cultures, established the correct diagnosis. Management of varicella zoster virus (VZV) infection primarily focuses on early initiation of antiviral therapy to control VZV replication. Therapy with intravenous acyclovir followed by oral valacyclovir allowed complete resolution of acute skin changes. In immunosuppressed patients, the possibility of infection with atypical presentation must always be kept in mind, and that this might mimic other disease conditions. Broad differential diagnosis and an extended diagnostic workup help in establishing the correct diagnosis.

Topics: Acyclovir; Aged; Antiviral Agents; Arthritis, Rheumatoid; Biopsy; Diagnosis, Differential; Drug Therapy, Combination; Etanercept; Female; Herpes Zoster; Humans; Immunoglobulin G; Immunosuppressive Agents; Receptors, Tumor Necrosis Factor; Rheumatoid Vasculitis; Risk Factors; Treatment Outcome; Valacyclovir; Valine

To assess the rate of occurrence and outcomes of herpes zoster in patients taking TNFalpha antagonists.. Retrospective review of the medical records of 300 patients who received TNFalpha antagonists to treat chronic inflammatory joint disease.. We identified 9 (9/300, 3%) patients who experienced herpes zoster, 6 women and 3 men, with rheumatoid arthritis (n=7) or ankylosing spondylitis (n=2). The drug was infliximab in 4 patients, adalimumab in 2 patients, and etanercept in 3 patients, including 2 patients with a prior history of infliximab therapy (for 12 and 36 months, respectively). Mean treatment duration at the occurrence of herpes zoster was 27 months (range, 6-42 months).. Glucocorticoid therapy (n=7) and methotrexate therapy (n=6) were the only risk factors identified in our study. Mean follow-up was 26 months. All 9 patients achieved a full recovery with antiviral treatment and interruption of the TNFalpha antagonist. One patient experienced a recurrence after resuming TNFalpha antagonist therapy.. The scant data in the literature suggest a higher risk of herpes zoster with anti-TNFalpha antibodies than with the soluble receptor. The role for concomitant treatments (glucocorticoids and methotrexate) should be taken into account.

Topics: Acyclovir; Adalimumab; Adult; Aged, 80 and over; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Antirheumatic Agents; Antiviral Agents; Arthritis, Rheumatoid; Drug Therapy, Combination; Etanercept; Female; Glucocorticoids; Herpes Zoster; Humans; Immunoglobulin G; Immunosuppressive Agents; Infliximab; Male; Methotrexate; Middle Aged; Receptors, Tumor Necrosis Factor; Retrospective Studies; Risk Factors; Spondylitis, Ankylosing; Tumor Necrosis Factor-alpha; Valacyclovir; Valine

Topics: Acyclovir; Adalimumab; Adult; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Antirheumatic Agents; Antiviral Agents; Arthritis, Rheumatoid; Chickenpox; Female; Humans

Topics: Acyclovir; Administration, Topical; Aged; Aminoquinolines; Antiviral Agents; Arthritis, Rheumatoid; Drug Resistance, Viral; Emollients; Female; Foscarnet; Herpes Genitalis; Humans; Imiquimod; Infusions, Intravenous; Treatment Outcome; Trifluridine; Valacyclovir; Valine

To report 2 cases of herpes simplex keratitis misdiagnosed as rheumatoid arthritis (RA)-related peripheral ulcerative keratitis (PUK), where isolation of the herpes simplex virus (HSV) led to a complete modification in management.. This is a case report.. Two patients with RA presented with painful red right eyes. Ocular examination in both revealed an ulcer involving the peripheral cornea. The adjacent conjunctiva was infected, and the underlying sclera appeared inflamed. A diagnosis of corneal PUK secondary to RA was therefore made. The first patient had corneal scrapes taken for routine microbiological examination, which included polymerase chain reaction (PCR) for HSV. In the second patient, despite systemic immunosuppressive therapy, the ulcer progressed to involve deeper stroma and more central cornea. The conjunctiva adjacent to the ulcer was resected, and healthy conjunctival tissue was mobilized to cover the peripheral corneal ulcer. Resected conjunctival and corneal tissue was histopathologically assessed. In the first patient, PCR for HSV yielded a positive result. This prompted treatment with immediate systemic and topical acyclovir. The ulcer responded well to treatment. In the second patient, histopathological assessment and electron microscopy identified HSV. Treatment with topical trifluorothymidine and steroids was started, and a good recovery was made.. Treatment of PUK is with systemic immunosuppressive therapy, and such therapies have serious side effects. PUK may have an occult cause in RA, and a search for a secondary agent may be beneficial. In particular, occult HSV infection must be ruled out before commencing immunosuppressive therapy.

Topics: Acyclovir; Aged; Antiviral Agents; Arthritis, Rheumatoid; Cornea; Corneal Ulcer; Diagnosis, Differential; Diagnostic Errors; Female; Follow-Up Studies; Herpesvirus 1, Human; Humans; Keratitis, Herpetic; Male; Microscopy, Electron, Transmission; Middle Aged; RNA, Viral; Trifluridine

A young man developed a serious disseminated varicella infection, necessitating antiviral treatment, after being treated with anti-tumor necrosis factor-alpha therapy for rheumatoid arthritis.

Topics: Acyclovir; Adult; Antibodies, Monoclonal; Arthritis, Rheumatoid; Chickenpox; Follow-Up Studies; Humans; Immunocompromised Host; Infliximab; Injections, Intravenous; Male; Risk Assessment; Severity of Illness Index; Tumor Necrosis Factor-alpha

A rheumatoid arthritis (RA) patient treated with low-dose methotrexate (MTX) therapy suffered from hemophagocytic syndrome (HPS) associated with B-cell lymphoma (B-LAHS). Administration of acyclovir and intravenous immunoglobulin promptly resolved laboratory test abnormalities accompanied with HPS. Moreover, hemophagocytic histiocytes and lymphoma cells in the bone marrow disappeared without anti-cancer therapy. Two months after reintroduction of MTX for RA flare, lymphoma re-grew rapidly without bone marrow involvement and HPS. Two cycles of combination chemotherapy induced the lymphoma to a complete remission/unconfirmed (CRu), but then the chemotherapy was discontinued due to severe side effects. In this case, on the basis of RA and MTX induced immunosuppressive state, Epstein-Barr virus (EBV) infection was associated with the development of HPS and lymphoma. Anti-viral therapy alone was effective against HPS and lymphoma at initial presentation and improved her general condition. This case indicates that anti-cancer therapy should be preceded by anti-viral therapy and withdrawal of immunosuppressive therapy in patients under immunosuppressive therapy, as long as the clinical situation permits.

Topics: Acyclovir; Aged; Antirheumatic Agents; Antiviral Agents; Arthritis, Rheumatoid; Epstein-Barr Virus Infections; Female; Herpesvirus 4, Human; Histiocytosis, Non-Langerhans-Cell; Humans; Lymphoma, B-Cell; Methotrexate; Syndrome

Topics: Acyclovir; Arthritis, Rheumatoid; Humans