valacyclovir 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

A 72-year-old woman with rheumatoid arthritis was treated with methotrexate (MTX) and iguratimod. Upon examination of a liver tumor, blisters due to varicella-zoster virus (VZV) infection were observed. Despite oral administration of valacyclovir, she developed varicella pneumonia and meningoencephalitis. A VZV antibody test revealed reinfection. The liver tumor shrank after discontinuance of MTX, and polymerase chain reaction revealed the reactivation of the Epstein-Barr virus (EBV). Therefore, we were unable to deny MTX-associated lymphoproliferative disorder (MTX-LPD). This is the first case of a complication of pneumonia and meningoencephalitis due to VZV reinfection and EBV reactivation.

Topics: Aged; Arthritis, Rheumatoid; Epstein-Barr Virus Infections; Female; Herpesvirus 3, Human; Herpesvirus 4, Human; Humans; Liver Neoplasms; Lymphoproliferative Disorders; Meningoencephalitis; Methotrexate; Pneumonia; Reinfection; Valacyclovir

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

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; 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