amphotericin-b and Arthritis--Rheumatoid

We report a case of Coccidioidomycosis of the cranium that presented as a cystlike structure with adjoining bone destruction in a 40-year-old patient with underlying rheumatoid arthritis that was treated with a combination of lipid amphotericin B and longterm fluconazole. We also discuss the common risk factors and presentations of this unusual extra-pulmonary form of Coccidioidomycosis.

Topics: Adult; Amphotericin B; Antifungal Agents; Arthritis, Rheumatoid; Coccidioides; Coccidioidomycosis; Drug Therapy, Combination; Female; Fluconazole; Humans; Osteomyelitis; Radiography; Risk Factors; Skull

Topics: Adalimumab; Aged; Amphotericin B; Antibodies, Monoclonal, Humanized; Antiprotozoal Agents; Antirheumatic Agents; Arthritis, Rheumatoid; Bone Marrow Examination; Drug Substitution; Glucocorticoids; Humans; Immunocompromised Host; Leishmaniasis, Visceral; Male; Methylprednisolone; Predictive Value of Tests; Risk Factors; Treatment Outcome

Paracoccidioidomycosis (PCM) is a systemic mycosis caused by Paracoccidioides brasiliensis, which is endemic in many regions of Latin America. We describe the case of a 60-year-old man from a region endemic for PCM who presented with a long history of left hip pain. He had been treated over the past 3 years with immunosuppressive drugs (methotrexate, leflunomide, and adalimumab) for rheumatoid arthritis (RA). A hip radiograph showed lytic bone lesions, and a chest radiograph showed an expansive excavated lesion in the left lung, suggestive of a lung cancer with bone metastases. A left hip joint biopsy was inconclusive, but histological analysis of a surgical lung biopsy specimen was consistent with P. brasiliensis infection. Treatment with intravenous amphotericin B (50 mg/day) and hydrocortisone (25 mg/day) was initiated. However, increasing hip pain resulted in the amputation of the left lower limb, and the analysis of the surgical specimen revealed a diagnosis of bone sarcoma. Postoperatively, the patient developed sepsis and died approximately 1 month later. To our knowledge, this is the first report of PCM in a patient with RA who had been treated with immunosuppressive drugs, in particular TNF-α blocking agents. The atypical presentation (left hip pain alone) emphasizes the importance of considering PCM in the differential diagnosis of patients with pulmonary lesions and osteolytic lesions who live in a region endemic for PCM. This case report also demonstrates that health professionals in these regions must pay close attention to patients receiving immunosuppressive drugs because of the possibility of reactivating quiescent P. brasiliensis lesions.

Topics: Adult; Amphotericin B; Antifungal Agents; Arthritis, Rheumatoid; Bone Neoplasms; Fatal Outcome; Female; Humans; Immunocompromised Host; Immunosuppressive Agents; Latin America; Lung; Lung Neoplasms; Male; Middle Aged; Paracoccidioides; Paracoccidioidomycosis; Postoperative Complications; Sarcoma; Sepsis

Mucormycosis (zygomycosis) is a rare, aggressive, invasive fungal infection that usually afflicts immunosuppressed patients. Indolent presentations are rare, especially in the setting of immune suppression.. Case report and review of the pertinent English-language literature.. A 64-year-old male patient with diabetes mellitus and rheumatoid arthritis, treated chronically with infliximab, presented with toothache, headache, and right facial numbness. Therapy with intravenous glucocorticoids and antibiotics resulted in transitory improvement before his referral to a tertiary-care center, where imaging studies and biopsy revealed rhinocerebral mucormycosis. Four weeks after initial presentation, a radical right maxillectomy, followed by long-term therapy with amphotericin B lipid complex, resulted in clinical improvement. Five reconstructive procedures were required to obliterate the facial defect and restore contour. Although biopsies during the reconstructive procedures revealed persistent fungal colonization, there was no clinical recurrence during nearly five years of followup.. Indolent rhinocerebral mucormycosis is rare and is seldom survived by immunosuppressed patients. Multimodal therapy with surgical debridement and antifungal chemotherapy is required for an optimal outcome. Discontinuance of immunosuppressive therapy, if possible, is a cornerstone of management.

Topics: Amphotericin B; Antibodies, Monoclonal; Antifungal Agents; Arthritis, Rheumatoid; Diabetes Complications; Drug Combinations; Humans; Infliximab; Male; Maxillary Sinus; Middle Aged; Mucormycosis; Phosphatidylcholines; Phosphatidylglycerols

We describe a patient with a 10-year history of rheumatoid arthritis who developed septic arthritis of the knee secondary to Candida albicans. Joint sterilization was obtained by debridement and 865 mg. of IV amphotericin B. We review 23 other cases of candidal arthritis in adults with specific reference to disease recognition and treatment.

Topics: Aged; Amphotericin B; Arthritis, Infectious; Arthritis, Rheumatoid; Candidiasis; Female; Humans; Knee Joint

Topics: Amphotericin B; Anti-Inflammatory Agents; Antifungal Agents; Arthritis, Rheumatoid; Diagnosis, Differential; Echinocandins; Humans; Hydrocortisone; Lipopeptides; Lung; Lung Diseases, Fungal; Male; Micafungin; Middle Aged; Pyrimidines; Tomography, X-Ray Computed; Treatment Outcome; Triazoles; Voriconazole

Topics: Amphotericin B; Antiprotozoal Agents; Arthritis, Rheumatoid; Bone Marrow; Bone Marrow Examination; Cryoglobulinemia; Cryoglobulins; Female; Humans; Immunocompromised Host; Incidental Findings; Leishmaniasis, Visceral; Middle Aged

We report 2 cases of visceral leishmaniasis in Dutch patients after a stay in Greece and the former Yugoslavia, respectively. Patient A, a 69-year-old woman, was referred to our department with abdominal pain. Additional examinations were suggestive of chronic liver disease. After a liver biopsy, which demonstrated hepatic granulomas, we admitted the patient due to a sudden onset of cyclic fever. Patient B, a 50-year-old woman, was admitted with cyclic fever and abdominal pain. We treated the patient with IV antibiotics and discontinued the methotrexate treatment for her rheumatoid arthritis. Both patients were diagnosed with visceral leishmaniasis and treated with liposomal amphotericin-B. Patient A, an immunocompetent patient, had stayed in Greece for prolonged periods. Patient B had lived in the former Yugoslavia until 1999, and her methotrexate use had likely activated an asymptomatic Leishmania infection. Visceral leishmaniasis, a potentially lethal protozoan disease, should be considered in patients who have travelled in Southern Europe.

Topics: Abdominal Pain; Aged; Amphotericin B; Antiprotozoal Agents; Arthritis, Rheumatoid; Female; Greece; Humans; Leishmania infantum; Leishmaniasis, Visceral; Methotrexate; Middle Aged; Netherlands; Travel; Treatment Outcome; Yugoslavia

Topics: Aged; Amphotericin B; Antiprotozoal Agents; Arthritis, Rheumatoid; Fatigue; Female; Fluorescent Antibody Technique, Indirect; Hepatomegaly; Humans; Immunosuppressive Agents; Leishmania; Leishmaniasis, Visceral; Methotrexate; Splenomegaly; Tomography, X-Ray Computed

A 64-year-old man was admitted with fever, weight loss, fatigue and night sweats. He was known to have rheumatoid arthritis and had been taking methotrexate for 1 year. He had worked in Saudi Arabia until 1994 and had been living in Spain for 6 months every year. Clinical examination showed an enlarged spleen. Routine investigations showed pancytopaenia. Serial blood cultures were negative. CT scan confirmed splenomegaly and was otherwise unremarkable. Bone marrow biopsy revealed Leishmania amastigote consistent with a diagnosis of visceral leishmaniasis. After discussing with the hospital for tropical diseases (HTD), he was started on liposomal amphotericin B. Following two infusions of amphotericin B, he started improving as his fever, night sweats and weakness had settled. He was then discharged and followed up in HTD clinic 4 weeks later where he was found to be consistently improving.

Topics: Amphotericin B; Antiprotozoal Agents; Arthritis, Rheumatoid; Biopsy; Humans; Leishmaniasis, Visceral; Male; Middle Aged; Tomography, X-Ray Computed; White People

Topics: Aged; Amphotericin B; Antifungal Agents; Antirheumatic Agents; Arthritis, Rheumatoid; Azathioprine; Female; Granulocyte Colony-Stimulating Factor; Humans; Invasive Pulmonary Aspergillosis; Itraconazole; Leukopenia; Methyltransferases; Mutation; Tomography, X-Ray Computed; Treatment Outcome

Visceral leishmaniasis (VL) is a relatively rare occurrence in rheumatoid arthritis (RA) patients treated with tumor necrosis factor-alpha (TNF-alpha) antagonists, corticosteroids and methotrexate, or methotrexate alone. A review of the literature revealed that only one case of VL in an RA patient treated with methotrexate has been previously published. We describe an additional case, that of a 65-year-old female with RA being treated with methotrexate, who presented with fever, abdominal discomfort, splenomegaly and pancytopenia. A diagnosis of VL was ultimately established, after a splenectomy was performed. Because RA is characterized by immune cell dysfunction and dysregulation, which potentially predisposes patients to infection, it is unclear whether this serious opportunistic infection can be solely attributable to the methotrexate, an immunosuppressive medication that also increases the risk of infection.

Topics: Aged; Amphotericin B; Animals; Antiprotozoal Agents; Antirheumatic Agents; Arthritis, Rheumatoid; Female; Humans; Leishmania; Leishmaniasis, Visceral; Methotrexate; Splenectomy; Treatment Outcome

Topics: Acinetobacter baumannii; Acinetobacter Infections; Adult; Amphotericin B; Anti-Bacterial Agents; Antifungal Agents; Arthritis, Rheumatoid; Colitis, Ulcerative; Combined Modality Therapy; Drainage; Fatal Outcome; Gastrointestinal Diseases; Humans; Ileal Diseases; Intestinal Perforation; Intraoperative Complications; Jejunal Diseases; Liposomes; Male; Mucormycosis; Peritonitis; Postoperative Complications; Shock, Septic; Triazoles

It has been reported that anti-tumor necrosis factor-alpha therapy increases the risk of opportunistic infections including rare case reports of leishmaniasis. Here we report a case of latent cutaneous leishmaniasis, which was provoked by anti-tumor necrosis factor-alpha therapy in a patient with rheumatoid arthritis.

Topics: Adult; Amphotericin B; Animals; Anti-Bacterial Agents; Antibodies, Monoclonal; Antiprotozoal Agents; Antirheumatic Agents; Arthritis, Rheumatoid; Biopsy; Female; Humans; Leishmania; Leishmaniasis, Cutaneous; Nasal Mucosa; Nose; Treatment Outcome; Tumor Necrosis Factor-alpha

Topics: Aged; Amphotericin B; Antibodies, Monoclonal; Antirheumatic Agents; Arthritis, Rheumatoid; Colonic Diseases; Colonoscopy; Female; Follow-Up Studies; Fungemia; Histoplasmosis; Humans; Immunocompromised Host; Infliximab; Risk Assessment; Ulcer

A 58-year-old Japanese man was admitted with high fever, productive cough, marked leukocytosis, and chest X-ray findings of infiltration and fluid levels within lung cysts. He had been treated for pulmonary tuberculosis for 6 months. He was also receiving home oxygen therapy for chronic obstructive pulmonary disease and 10 mg prednisolone daily for rheumatoid arthritis. Aspergillus fumigatus was cultured from bronchial washing fluid and we diagnosed chronic necrotizing pulmonary aspergillosis (CNPA). Micafungin was initially effective but 9 weeks later the symptoms recurred. Micafungin was stopped and after combination therapy of intravenous liposomal amphotericin B and oral itraconazole capsule was started his symptoms and laboratory data markedly improved. Fifteen weeks later his medication was switched to oral voriconazole and he was discharged. CNPA is a chronic infectious disease with poor prognostic and no standard therapy has been confirmed. Each antifungal drug has different mechanisms and sites of action. In the case of treatment failure with several drugs, combination therapy to achieve drug interaction can be a treatment option.

Topics: Amphotericin B; Antifungal Agents; Arthritis, Rheumatoid; Aspergillosis; Aspergillus fumigatus; Chronic Disease; Drug Therapy, Combination; Humans; Itraconazole; Liposomes; Lung Diseases, Fungal; Male; Middle Aged; Pulmonary Disease, Chronic Obstructive; Treatment Outcome; Tuberculosis, Pulmonary

A 52-year-old woman with a seven-year history of rheumatoid arthritis (RA) was transferred to our department with chronic renal failure to undergo hemodialysis. She had been treated with prednisolone for a long time, and had renal amyloidosis secondary to RA. During her hospitalization, a left pleural effusion developed. Pleural fluid cultured positive for Cryptococcus neoformans (CN), and the CN antigen was detected in both pleural fluid and serum. Chest computerized tomography revealed an infiltrate shadow in the left lower lung field suggestive of CN infection. This was successfully treated with anti-fungal agents. Pleural effusion is an unusual manifestation of pulmonary cryptococcosis. We should consider a diagnosis of CN infection when pleural effusion is observed in compromised patients such as those receiving a long-term corticosteroid treatment.

Topics: Amphotericin B; Amyloidosis; Anti-Inflammatory Agents; Antifungal Agents; Arthritis, Rheumatoid; Cryptococcosis; Cryptococcus neoformans; Female; Humans; Kidney Failure, Chronic; Lung Diseases, Fungal; Middle Aged; Pleural Effusion; Prednisolone

Topics: Amphotericin B; Antirheumatic Agents; Arthritis, Rheumatoid; Female; Humans; Male; Tetracycline; Time Factors

Topics: Adrenal Cortex Hormones; Adult; Aged; Amphotericin B; Arthritis, Rheumatoid; Aspirin; Cryptococcosis; Cryptococcus; Female; Hematuria; Humans; Kidney Papillary Necrosis; Male; Meningitis; Middle Aged; Proteinuria; Pyelonephritis; Pyuria; Urea; Urinary Tract Infections