IMAGES
Cat-Scratch Fever and Lymphadenopathy in a Rheumatoid Arthritis Patient on Tocilizumab Namrata Singh, MD, Lori L. Sinclair, MD, and Jacob IJdo, MD, PhD
A
29-year-old man had been followed up in rheumatology clinic since 2004 for seronegative rheumatoid arthritis affecting primarily bilateral wrists, hips, and the knees. He had been tried on multiple disease-modifying medications including methotrexate, leflunomide, hydroxychloroquine, tumor necrosis factor inhibitors, abatacept, and cyclosporine, but all were ineffective in controlling his disease. Only prednisone doses greater than 20 mg controlled his inflammation. Subsequently, he became wheelchair bound because of developing severe uniform joint space narrowing of both hips requiring bilateral hip arthroplasty in 2009. He regained ambulatory function despite ongoing active knee inflammation. In 2011, tocilizumab infusions (8 mg/kg) were started that resulted in a remarkable clinical response, allowing him to taper off his prednisone. He continued tocilizumab for about 2 years when he presented with sudden onset of right arm redness, pain, and swelling (Fig. 1). On examination, he had a suppurative epitrochlear lymph node and an enlarged right axillary node. Broad differential was considered given his immunosuppressed condition including bacterial or fungal infection, reactivation tuberculosis, and less likely malignancy. Bartonella henselae immunoglobulin G was positive with titer of 1:2048, and a right epitrochlear lymph node biopsy showed Bartonella organisms
FIGURE 2. Right epitrochlear lymph node biopsy showing Bartonella organisms (arrows) on the Warthin-Starry stain.
(arrows) on the Warthin-Starry stain (Fig. 2), stain that is used to identify the bacteria on histopathology sections.1 He was treated with azithromycin with good response. On further questioning, he did report acquiring a new pet cat few weeks earlier. His tocilizumab infusions were resumed after the infection was completely resolved 2 months later. To our best knowledge, this is the second case reported in the literature of cat-scratch disease developing in a patient receiving tocilizumab infusions.2 Rheumatologists should consider cat-scratch disease or infection with B. henselae in the differential diagnosis for lymphadenopathy when caring for immunosuppressed patients. REFERENCES 1. Miller-Catchpole R, Variakojis D, Vardiman JW, et al. Cat scratch disease. Identification of bacteria in seven cases of lymphadenitis. Am J Surg Pathol. 1986;10:276–81. 2. Milin M, Acquitter M, Le Berre R, et al. Bartonella henselae infection during tocilizumab therapy. Joint Bone Spine. 2013;80:221.
FIGURE 1. Redness and swelling of the right arm.
From the University of Iowa Hospitals and Clinics, Iowa City, IA. Correspondence: Namrata Singh, MD, Division of Immunology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, C42 E10 Iowa City, IA 52242. Email: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1076-1608/15/2101–0040 DOI: 10.1097/RHU.0000000000000203
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www.jclinrheum.com
JCR: Journal of Clinical Rheumatology • Volume 21, Number 1, January 2015
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
Cat-Scratch Fever and Lymphadenopathy in a Rheumatoid Arthritis Patient on Tocilizumab Namrata Singh, MD, Lori L. Sinclair, MD, and Jacob IJdo, MD, PhD
A
29-year-old man had been followed up in rheumatology clinic since 2004 for seronegative rheumatoid arthritis affecting primarily bilateral wrists, hips, and the knees. He had been tried on multiple disease-modifying medications including methotrexate, leflunomide, hydroxychloroquine, tumor necrosis factor inhibitors, abatacept, and cyclosporine, but all were ineffective in controlling his disease. Only prednisone doses greater than 20 mg controlled his inflammation. Subsequently, he became wheelchair bound because of developing severe uniform joint space narrowing of both hips requiring bilateral hip arthroplasty in 2009. He regained ambulatory function despite ongoing active knee inflammation. In 2011, tocilizumab infusions (8 mg/kg) were started that resulted in a remarkable clinical response, allowing him to taper off his prednisone. He continued tocilizumab for about 2 years when he presented with sudden onset of right arm redness, pain, and swelling (Fig. 1). On examination, he had a suppurative epitrochlear lymph node and an enlarged right axillary node. Broad differential was considered given his immunosuppressed condition including bacterial or fungal infection, reactivation tuberculosis, and less likely malignancy. Bartonella henselae immunoglobulin G was positive with titer of 1:2048, and a right epitrochlear lymph node biopsy showed Bartonella organisms
FIGURE 2. Right epitrochlear lymph node biopsy showing Bartonella organisms (arrows) on the Warthin-Starry stain.
(arrows) on the Warthin-Starry stain (Fig. 2), stain that is used to identify the bacteria on histopathology sections.1 He was treated with azithromycin with good response. On further questioning, he did report acquiring a new pet cat few weeks earlier. His tocilizumab infusions were resumed after the infection was completely resolved 2 months later. To our best knowledge, this is the second case reported in the literature of cat-scratch disease developing in a patient receiving tocilizumab infusions.2 Rheumatologists should consider cat-scratch disease or infection with B. henselae in the differential diagnosis for lymphadenopathy when caring for immunosuppressed patients. REFERENCES 1. Miller-Catchpole R, Variakojis D, Vardiman JW, et al. Cat scratch disease. Identification of bacteria in seven cases of lymphadenitis. Am J Surg Pathol. 1986;10:276–81. 2. Milin M, Acquitter M, Le Berre R, et al. Bartonella henselae infection during tocilizumab therapy. Joint Bone Spine. 2013;80:221.
FIGURE 1. Redness and swelling of the right arm.
From the University of Iowa Hospitals and Clinics, Iowa City, IA. Correspondence: Namrata Singh, MD, Division of Immunology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, C42 E10 Iowa City, IA 52242. Email: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1076-1608/15/2101–0040 DOI: 10.1097/RHU.0000000000000203
40
www.jclinrheum.com
JCR: Journal of Clinical Rheumatology • Volume 21, Number 1, January 2015
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
