J Rheum Dis.  2011 Sep;18(3):212-215. 10.4078/jrd.2011.18.3.212.

A Case of Invasive Pulmonary Aspergillosis in a Patient with Rheumatoid Arthritis Treated with Adalimumab

• Kim JH
• Bae JK
• Jun JW
• Lee HS
• Ju HW
• Oh JS
• Choi SW

• KMID: 2223153
• DOI: http://doi.org/10.4078/jrd.2011.18.3.212

Abstract

We describe a fatal case of invasive pulmonary aspergillosis in a patient with rheumatoid arthritis receiving the TNF-alpha inhibitor, adalimumab. The use of TNF-alpha inhibitor has been associated with an increased risk of infections, including tuberculosis and other opportunistic infections. Physicians should have a high index of suspicion for opportunistic infection that can develop during TNF-alpha inhibitor treatment.

Keyword

Invasive aspergillosis; Rheumatoid arthritis; Tumor necrosis factor-alpha

MeSH Terms

Antibodies, Monoclonal, Humanized
Arthritis, Rheumatoid
Humans
Invasive Pulmonary Aspergillosis
Opportunistic Infections
Tuberculosis
Tumor Necrosis Factor-alpha
Adalimumab
Antibodies, Monoclonal, Humanized
Tumor Necrosis Factor-alpha

Figure

• 

  Figure 1. Chest radiograph shows no parenchymal lung lesion before the treatment of adalimumab.

• 

  Figure 2. On admission, chest X-ray shows nodular shadow on the left lower lung field (A). Chest CT reveals a 3×3 cm sized nodule in the left lower lobe of the lung with underlying bronchiectasis (B).

• 

  Figure 3. Microscopic examination of lung nodule aspirates shows thin septate hyphae branching at acute angles (H&E, ×400).

• 

  Figure 4. On the 12th day of ad-mission, chest X-ray shows bilateral massive infiltrates (A). Chest CT shows diffuse ground-glass opacifi-cations (B).

Reference

References

1. Crum NF, Lederman ER, Wallace MR. Infections associated with tumor necrosis factor-alpha antagonists. Medicine (Baltimore). 2005; 84:291–302.

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

3. Rychly DJ, DiPiro JT. Infections associated with tumor necrosis factor-alpha antagonists. Pharmacotherapy. 2005; 25:1181–92.

4. Tsiodras S, Samonis G, Boumpas DT, Kontoyiannis DP. Fungal infections complicating tumor necrosis factor alpha blockade therapy. Mayo Clin Proc. 2008; 83:181–94.

5. Bakleh M, Tleyjeh I, Matteson EL, Osmon DR, Berbari EF. Infectious complications of tumor necrosis factor-alpha antagonists. Int J Dermatol. 2005; 44:443–8.

6. Yi SM, Lim MJ, Kwon SR, Jeong JC, Lee JS, Kwon SH, et al. A case of cryptococcal pneumonia in a rheumatoid arthritis patient after tumor necrosis factor-alpha antagonist therapy. J Korean Rheum Assoc. 2007; 14:412–6.

7. Lee KS, Lee HY, Lee SW, Jung HJ, Song JS. A case of candida bursitis associated with etanercept treatment in a patient with rheumatoid arthritis. J Korean Rheum Assoc. 2008; 15:175–9.

8. Lee EJ, Song R, Park JN, Lee YA, Son JS, Hong SJ, et al. Chronic necrotizing pulmonary aspergillosis in a patient treated with a tumor necrosis factor-alpha inhibitor. Int J Rheum Dis. 2010; 13:e16–9.

9. Listing J, Strangfeld A, Kary S, Rau R, von Hinueber U, Stoyanova-Scholz M, et al. Infections in patients with rheumatoid arthritis treated with biologic agents. Arthritis Rheum. 2005; 52:3403–12.

10. Burmester GR, Mariette X, Montecucco C, Monteagudo-Sáez I, Malaise M, Tzioufas AG, et al. Adalimumab alone and in combination with disease-modifying antirheumatic drugs for the treatment of rheumatoid arthritis in clinical practice: the Research in Active Rheumatoid Arthritis (ReAct) trial. Ann Rheum Dis. 2007; 66:732–9.

11. Kim HO, Kang KY, Ju JH, Kim HY, Park SH. The incidence of serious infection among rheumatoid arthritis patients exposed to tumor necrosis factor antagonists. J Korean Rheum Assoc. 2010; 17:246–53.

12. Soubani AO, Chandrasekar PH. The clinical spectrum of pulmonary aspergillosis. Chest. 2002; 121:1988–99.

13. Warris A, Bj⊘rneklett A, Gaustad P. Invasive pulmonary aspergillosis associated with infliximab therapy. N Engl J Med. 2001; 344:1099–100.

14. Winthrop KL. Risk and prevention of tuberculosis and other serious opportunistic infections associated with the inhibition of tumor necrosis factor. Nat Clin Pract Rheumatol. 2006; 2:602–10.