meropenem and Arthritis--Rheumatoid

Hemophagocytic lymphohistiocytosis (HLH) is a rare condition with high mortality. We report a case of a 74-year-old woman with rheumatoid arthritis who developed HLH secondary to pyelonephritis due to Escherichia coli infection following infliximab treatment. Bone marrow aspiration showed proliferation of histiocytes with hemophagocytosis. The patient died despite treatment with intravenous antibiotics intravenous methylprednisolone and intravenous immunoglobulin. Cytokine levels were measured and are discussed.

Topics: Aged; Anti-Bacterial Agents; Antibodies, Monoclonal; Antirheumatic Agents; Arthritis, Rheumatoid; Bone Marrow; Escherichia coli Infections; Fatal Outcome; Female; Histiocytes; Humans; Immunocompromised Host; Immunoglobulins, Intravenous; Immunosuppressive Agents; Infliximab; Lymphohistiocytosis, Hemophagocytic; Meropenem; Methylprednisolone; Pyelonephritis; Thienamycins

We report a case of a frail 82-year-old man with seronegative rheumatoid arthritis and a recent pacemaker insertion, admitted with pulmonary oedema and a symptomatic pericardial effusion. He was treated with diuretics and an urgent pericardiocentesis, a sample from which cultured Enterobacter cloacae. A subsequent abdominal CT scan revealed faecal loading, an abnormal anorectal canal and sigmoid colon and a bowel perforation. Endoscopy, biopsies and histopathology confirmed a diagnosis of cytomegalovirus (CMV) colitis with coexistent fungal infection. The E. cloacae infection was successfully treated with 6 weeks of intravenous meropenem, while the CMV and fungal infections were treated with a combination of valganciclovir and fluconazole. We postulate that the bowel perforation resulted from a combination of CMV colitis, faecal loading and steroid therapy and led to bacterial translocation of E. cloacae and the development of the pericardial effusion. This case represents an unusual pathophysiology for the development of an E. cloacae pericardial effusion.

Topics: Aged, 80 and over; Anti-Bacterial Agents; Arthritis, Rheumatoid; Colitis; Colon, Sigmoid; Cytomegalovirus Infections; Diuretics; Drug Therapy, Combination; Enterobacter cloacae; Enterobacteriaceae Infections; Frail Elderly; Humans; Intestinal Perforation; Male; Meropenem; Pacemaker, Artificial; Pericardial Effusion; Pericardiocentesis; Pulmonary Edema; Radiography; Rectum; Risk Factors; Thienamycins; Treatment Outcome

The patient presented with increasing fatigue and dyspnoea. The patient had medical history of rheumatoid arthritis for which she had been taking methotrexate for the past 15 years and etanercept for the past 6 years. Initial diagnosis was cardiac failure but further investigation by echocardiogram revealed a large pericardial effusion. Empirical piperacillin-tazobactam was started due to moderately raised inflammatory markers. Four hundred millilitre of frank pus was aspirated from the pericardial sac and antimicrobial treatment was changed to meropenem. Gram positive cocci were seen in the initial Gram stain, but conventional cultures remained negative. However, 16S ribosomal RNA gene sequencing of the pus sample detected the presence of Parvimonas micra genome. Reaccumulation of the effusion required further drainage where again P micra was detected by 16S ribosomal RNA gene sequencing. Two weeks of meropenem was completed followed by treatment with benzylpenicillin and metronidazole.

Topics: Aged; Anti-Bacterial Agents; Antirheumatic Agents; Arthritis, Rheumatoid; Drug Therapy, Combination; Etanercept; Female; Gram-Positive Bacteria; Humans; Immunoglobulin G; Meropenem; Metronidazole; Opportunistic Infections; Penicillin G; Pericarditis; Receptors, Tumor Necrosis Factor; Risk Factors; Thienamycins