Secondary Failure of Tocilizumab in Treating Elderly-Onset Rheumatoid Arthritis With Systemic Symptoms Complicated by Diverticulum Perforation

Self Cite

Methotrexate (MTX), a cornerstone treatment for rheumatoid arthritis (RA), is associated with drug-induced hypersensitivity syndrome (DIHS), including rare instances of methotrexate-induced pneumonitis. We report a significant case of a 65-year-old woman with RA, treated with MTX for over two decades, who presented with fever, headache, nausea, and malaise and was later diagnosed with DIHS, manifesting as pneumonitis and hepatosplenomegaly. Despite initial suspicion of bacterial pneumonia, her condition deteriorated, leading to the consideration of DIHS. The diagnosis was confirmed through a drug lymphocyte stimulation test (DLST), and she responded well to prednisolone. This case underlines the complexity of long-term MTX therapy, emphasizing the need for vigilance towards DIHS even after years of treatment. The findings prompt a reconsideration of ongoing treatments for RA, particularly in settings where long-term MTX use is prevalent. Early intervention and diagnostic tests like the DLST are crucial for preventing severe outcomes. This case adds to the growing evidence of MTX's potential for causing DIHS even in long-term usage. It stresses the importance of balancing therapeutic benefits with the risks of significant adverse reactions in stable RA patients.

Section: Discussionmentioning

confidence: 99%

Drug-Induced Hypersensitivity Syndrome Due to Long-Term Usage of Methotrexate: A Case Report

Fujimori,

Sano,

Ohta

2024

Self Cite

“…Owing to the high incidence of elevated hepatobiliary enzymes and the absence of bile duct dilatation, various causes must be considered [ 11 ]. Clinical findings should be monitored over time to detect exacerbation of the condition or other symptoms, especially among older patients [ 12 ]. As invasive procedures are harmful and the benefit does not outweigh the risk of transient symptoms, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and liver biopsy were not performed in the current case, which may indicate a weak basis for the diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Gallstone Hepatitis Caused by Transient Common Bile Duct Obstruction in a Middle-Aged Woman

Murakami¹,

Tanaka²,

Mishiro³

et al. 2022

Self Cite

The interpretation of hepatocholangial laboratory test results is challenging. Possible liver biochemical tests include the evaluation of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, 5'-nucleotidase, lactate dehydrogenase, bilirubin, and albumin levels, as well as prothrombin time and international normalized ratio. When liver enzyme levels are elevated, R-values are generally used for diagnosis. A 62-year-old woman presented to our hospital with the chief complaint of abdominal pain and was consequently diagnosed with gallstone hepatitis based on her blood test results. Generally, gallstone hepatitis manifests as elevated liver enzyme levels showing a hepatocellular pattern, while common bile duct obstructions show a cholestatic pattern. Since gallstone hepatitis is indistinguishable from viral and ischemic hepatitis in the early stages of onset, it is vital to monitor changes in symptoms, biochemical tests, and imaging results over time to diagnose this disease.

“…With recent improvements in the treatment of RA, the progression of joint destruction and transformation to malignant RA is rare [4]. However, rural areas with inadequate autoimmune disease therapy may likely have more patients with RV complicating poorly controlled RA [5][6][7]. In this report, we describe a case in which a patient with poorly controlled RA developed RV complicated by skin ulcers and intestinal ischemia, and we discuss the future of autoimmune disease treatment in rural areas.…”

Section: Introductionmentioning

confidence: 96%

A Case of Capillary Leak Syndrome and Intestinal Ischemia Caused by Rheumatoid Vasculitis

Katsube¹,

Ohara²,

Horinishi³

et al. 2023

Self Cite

Rheumatoid vasculitis (RV) is a rare disease associated with rheumatoid arthritis (RA). The incidence of RV has decreased with the development of treatment for RA. However, some patients still develop RV in rural areas, where medical care for autoimmune diseases is inadequate. In this report, we describe a case of RV complicated by an acute exacerbation of generalized ulcerative lesions and capillary leak syndrome in an 86year-old woman with a severe joint deformity due to RA. RV is a systemic vasculitis characterized by various symptoms. When a patient with RA is diagnosed with poorly controlled joint deformities, general physicians should consider the possibility of RV. Urgent investigation and intensive treatment should be initiated for vasculitis to support the lives of older patients with advanced RA.