J Korean Rheum Assoc.  2008 Jun;15(2):175-179. 10.4078/jkra.2008.15.2.175.

A Case of Candida Bursitis Associated with Etanercept Treatment in a Patient with Rheumatoid Arthritis

• Lee KS
• Lee HY
• Lee SW
• Jung HJ
• Song JS

• KMID: 1270236
• DOI: http://doi.org/10.4078/jkra.2008.15.2.175

Abstract

Tumor necrosis factor (TNF)-alpha blockade has been well proved to significantly improve the disease course of rheumatoid arthritis. However, since TNF-alpha plays an important role in the immune system against external infectious organisms, it was reported that TNF-alpha blockade could increase the frequency of serious opportunistic infections such as tuberculosis. Fungal bursitis is a rare infectious disease following sever infections, malignancies and immune deficiencies. Moreover, there was no report on fungal bursitis occurring after administration of TNF-alpha blockade in Korea to date. Recently we experienced a 58-year-old female patient with rheumatoid arthritis who presented soft buttock mass after treatment with etanercept and was finally diagnosed as fungal bursitis by Candida parapsilosis.

Keyword

Etanercept; Candida parapsilosis; Bursitis; Rheumatoid arthritis

MeSH Terms

Female
Humans
Tumor Necrosis Factor-alpha

Figure

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  Fig. 1. non-tender 6×5 cm left buttock soft tissue mass was found.

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  Fig. 2. Left ischial bursal mass (arrow) was detected on T2 weighted image of enhanced pelvis MRI (A) and capsular enhancement was showed on T1 weighted image (B).

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  Fig. 3. Left ischial bursal biopsy shows degeneration of synovium (A) (H&E, ×100) and chronic inflammation with fibrosis (B) (H&E, ×400).

Reference

References

1. Moreland LW, Baumgartner SW, Schiff MH, Tindall EA, Fleischmann RM, Weaver AL, et al. Treatment of rheumatoid arthritis with a recombinant human tumor necrosis factor receptor (p75)-Fc fusion protein. N Engl J Med. 1997; 337:141–7.

2. Wallis RS, Broder MS, Wong JY, Hanson ME, Beenhouwer DO. Granulomatous infectious diseases associated with tumor necrosis factor antagonists. Clin Infect Dis. 2004; 38:1261–5.

3. Hamilton CD. Infectious complications of treatment with biologic agents. Curr Opin Rheumatol. 2004; 16:393–8.

4. Zimmermann B 3rd, Mikolich DJ, Ho G Jr. Septic bursitis. Semin Arthritis Rheum. 1995; 24:391–410.

5. Canoso JJ, Yood RA. Reaction of superficial bursae in response to specific disease stimuli. Arthritis Rheum. 1979; 22:1361–4.

6. Ho G Jr, Tice AD, Kaplan SR. Septic bursitis in the prepatellar and olecranon bursae: an analysis of 25 cases. Ann Intern Med. 1978; 89:21–7.

7. Roach DR, Bean AG, Demangel C, France MP, Briscoe H, Britton WJ. TNF regulates chemokine induction essential for cell recruitment, granuloma formation, and clearance of mycobacterial infection. J Immunol. 2002; 168:4620–7.

8. Allendoerfer R, Deepe GS Jr. Blockade of endogenous TNF-alpha exacerbates primary and secondary pulmonary histoplasmosis by differential mechanisms. J Immunol. 1998; 160:6072–82.

9. Flynn JL, Goldstein MM, Chan J, Triebold KJ, Pfeffer K, Lowenstein CJ, et al. Tumor necrosis factor-alpha is required in the protective immune response against Mycobacterium tuberculosis in mice. Immunity. 1995; 2:561–72.

10. Huffnagle GB, Toews GB, Burdick MD, Boyd MB, McAllister KS, McDonald RA, et al. Afferent phase production of TNF-alpha is required for the development of protective T cell immunity to Cryptococcus neoformans. J Immunol. 1996; 157:4529–36.

11. Mehrad B, Strieter RM, Standiford TJ. Role of TNF-alpha in pulmonary host defense in murine invasive aspergillosis. J Immunol. 1999; 162:1633–40.

12. Giles JT, Bathon JM. Serious infections associated with anticytokine therapies in the rheumatic diseases. J Intensive Care Med. 2004; 19:320–34.

13. Kang MJ, Kim MS, Choi EH, Lee KE, Kim YK, Choi HJ. Adenoviral pneumonia during etanercept treatment in a patient with rheumatoid arthritis. Korean J Intern Med. 2007; 22:63–6.

14. Kim YH, Lee BJ, Park JJ, Lee WW, Han WS, Oh SN, et al. Tuberculous meningitis in a patient with Crohn's disease, which was treated with infliximab. Korean J Gastrointest Endosc. 2007; 34:339–42.