Necrotising soft tissue infection without systemic toxicity in a patient with rheumatoid arthritis treated with tocilizumab

Manabe, Saki; Yanagi, Hidetaka; Ozawa, Hideki; Takagi, Atsushi

doi:10.1136/bcr-2017-222826

Cited by 7 publications

(4 citation statements)

References 16 publications

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“…In the particular case of our patient both minor local trauma and pharmacological immunosuppression could be identified as known risk factors for NSTI. Patient treatment consisted in a combination of Methotrexate and Tocilizumab which have been previously individually described as risk factors for NSTI [8,9]. In our case we speculate that this combination of two immune system suppressants, could be the favoring factor for the fulminant evolution leading to death.…”

Section: Discussionmentioning

confidence: 55%

Fulminant necrotizing streptococcal myositis with dramatic outcome – a rare case report

Morar

Pîrlog

Vlaicu

et al. 2021

Medicine and Pharmacy Reports

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Necrotizing myositis represents a rare, aggressive form of bacterial-induced soft tissue necrotizing infection. We present a fulminant case of a 44-year-old patient with a necrotizing soft tissue infection and a history of rheumatoid arthritis transferred to our service, Cluj-Napoca Emergency County Hospital, from a local hospital where he had been admitted two days before with chills and light-headedness after an accidental minor blunt trauma in the right thigh region. After admission to our hospital and first assessment, broad spectrum antibiotherapy was started with Meropenem, Vancomycin and Metronidazole along with surgical debridement. The evolution was fulminant with rapid development of multiple organ dysfunction syndrome, therefore he was transferred to the intensive care unit, intubated, and started the volemic resuscitation and vasopressor therapy. The blood culture was positive for group A beta-hemolytic streptococcus (GAS) and high dose Penicillin G was added to the therapeutic scheme. Despite all efforts, the patient developed disseminated intravascular coagulation syndrome and died in the next hours. The clinical picture together with the findings from the autopsy were suggestive for a streptococcal toxic shock syndrome developed as a complication of GAS induced necrotizing myositis.

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Section: Discussionmentioning

confidence: 55%

Fulminant necrotizing streptococcal myositis with dramatic outcome – a rare case report

Morar

Pîrlog

Vlaicu

et al. 2021

Medicine and Pharmacy Reports

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“…Our literature search in PubMed using “tocilizumab” with special attention to cases of infectious diseases during TCZ therapy and reported CRP levels at the time of diagnosis yielded a total of 28 case reports on this specific issue ( Table 2 ) [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. In 15 out of 28 reported cases, CRP was normal or only slightly elevated.…”

Section: Discussionmentioning

confidence: 99%

The Effect of Tocilizumab on Inflammatory Markers in Patients Hospitalized with Serious Infections. Case Series and Review of Literature

Berman

Ben‐Ami

Berliner

et al. 2021

Life

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Background: The human anti-IL-6 receptor antibody tocilizumab (TCZ) has been approved for the treatment of rheumatoid arthritis (RA) and giant cell arteritis (GCA). It is observed that CRP levels drop quickly after starting TCZ treatment. This may lead to misinterpretation of laboratory results when accessing the patient with infectious disease while on TCZ. We conducted this study to report cases treated with tocilizumab who developed serious infections with special reference to levels of CRP and to review the literature on the effect of tocilizumab on acute phase response (APR) during infections. Methods: The files of RA and GCA patients hospitalized in the Tel Aviv medical center between 2009–2019 were reviewed. Cases of patients with RA and GCA treated with tocilizumab who were hospitalized due to severe infections were reviewed with special emphasis on the duration of treatment, type of infection, and APR. Results: We identified nine admissions. Seven patients were treated with tocilizumab for RA, two for GCA. The diagnosis was pneumonia in three cases, osteomyelitis in one, cellulitis in one, endocarditis due to Whipple disease in one, abscess of cervix uteri in one, meningitis in one, and perforated diverticulitis in one. The mean CRP levels on admission were 4.75 mg/L (normal range, up to 5 mg/L). All cases were diagnosed correctly on admission. Conclusions: CRP levels may not correctly reflect the severity of infectious diseases during tocilizumab treatment. Increased awareness of the masking effect of tocilizumab on the APR during infection is needed in order to avoid a delay in the diagnosis.

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“…blockade [24]. Tocilizumab is known to reduce the production of acute-phase reactants by its mechanism of action and thus the detection of infection may be delayed [25].…”

Section: Discussionmentioning

confidence: 99%

“…Manabe et al presented a case of a patient with necrotizing soft tissue infection emphasizing the importance of recognizing infections in patients treated with tocilizumab in whom the symptoms of toxemia are masked by IL-6 blockade [ 24 ]. Tocilizumab is known to reduce the production of acute-phase reactants by its mechanism of action and thus the detection of infection may be delayed [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

Psoas abscess during treatment with intravenous tocilizumab in a patient with rheumatoid arthritis: a case-based review

Vajdić

Štimac²,

Pezelj³

et al. 2021

Rheumatol Int

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Interleukin-6 receptor antagonist tocilizumab is a biologic drug used for treating patients with active rheumatoid arthritis (RA) who failed to respond to synthetic or other biologic disease-modifying antirheumatic drugs or where they were contraindicated. Interleukin-6 receptor blockade results in a decrease of disease activity but has some potential adverse effects, the most common being infections. We present a case of a 75-year-old female patient with long-lasting RA, several comorbidities and multiple prior therapies, who developed back pain and general malaise during tocilizumab intravenous treatment. The laboratory findings were typical of toxemia, and the imaging findings revealed large psoas muscle abscess. Surgical and antibiotic treatment was performed with a good outcome. To our knowledge, this has been the first case of a psoas abscess in a patient with RA treated with tocilizumab described in the literature so far. We also present a review of the literature regarding infection, and particularly abscess formation in patients treated with biological disease-modifying antirheumatic drugs, tocilizumab included.

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Necrotising soft tissue infection without systemic toxicity in a patient with rheumatoid arthritis treated with tocilizumab

Cited by 7 publications

References 16 publications

Fulminant necrotizing streptococcal myositis with dramatic outcome – a rare case report

Fulminant necrotizing streptococcal myositis with dramatic outcome – a rare case report

The Effect of Tocilizumab on Inflammatory Markers in Patients Hospitalized with Serious Infections. Case Series and Review of Literature

Psoas abscess during treatment with intravenous tocilizumab in a patient with rheumatoid arthritis: a case-based review

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