LETTER TO THE EDITOR

Spinal Epidural Abscess Following Minimally Invasive Dental Examination in a Rheumatoid Arthritis Patient Receiving Methotrexate, Glucocorticoids, and Anti–Tumor Necrosis Factor Therapy To the Editor: n September 2011, Antonelli and Magrey1 reported a case of spinal epidural abscess in a patient on rituximab published in the Journal of Clinical Rheumatology. We present a similar case in a gentleman on adalimumab who developed an anaerobic epidural spinal abscess shortly after undergoing a dental examination. A 64-year-old man with a history of seropositive rheumatoid arthritis was transferred to our tertiary care center after presenting to a community emergency department with acute back pain for the preceding 3 days and progressive weakness in the lower extremities. Magnetic resonance imaging revealed a spinal epidural fluid collection at the level of L3–L4 (Figure). Prior to transfer, he was treated empirically with intravenous vancomycin and ceftriaxone. His regimen for rheumatoid arthritis included adalimumab, methotrexate, and prednisone 10 mg daily. He had undergone a dental examination 2 days before the onset of symptoms for a research study that involved periodontal probing.2 At that time, he was noted to have chronic periodontitis, multiple decayed or missing teeth, and extensive caries. Other medical comorbidities included hypertension, well-controlled diabetes mellitus, osteopenia, and chronic low back pain with osteoarthritis involving the lumbar spine. He was a smoker. His physical examination was remarkable for diminished strength in the lower extremities and absent rectal sphincter tone with saddle anesthesia. He was diagnosed with cauda equina syndrome due to spinal epidural abscess and underwent emergent laminectomy with abscess evacuation. Bacterial cultures were obtained from the involved disk, abscess fluid, and blood. Anaerobic wound culture grew out Finegoldia magna. The patient went to inpatient rehabilitation with a 12-week course of antibiotics. Follow-up reports indicated persistent lower-extremity weakness and urinary retention.

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This patient had potential risk factors for serious infection, including anti–tumor necrosis factor therapy3 and use of prednisone.4,5 To our knowledge, this is the first reported case of a spinal epidural abscess in a patient taking adalimumab, although this complication has been reported with inflixamab,6,7 etanercept,8 and rituximab.1 Furthermore, symptoms started following dental examination without an alternative source of infection. Cases of spinal epidural abscess following dental extraction have been reported with a similar time course.9,10 Admittedly, poor dentition, an anaerobic organism found in the oral cavity,11 and consistent time course are supportive but not definitive evidence of a dental source of infection. This case raises the question: Is there an increased risk of infection following dental procedures in the broader rheumatoid arthritis population on potentially immunosuppressive therapies? A large registry study examining possible associations between increased rates of infection and dental procedures in rheumatoid arthritis patients may be a reasonable initial approach to addressing this question. As of this writing, there are no specific recommendations regarding prevention of infections

following dental procedures in the general rheumatoid arthritis population. On a related note, in a study comparing rheumatoid arthritis patients who held versus continued therapy before nondental surgery, there was no difference in infection rates.12 This report emphasizes the importance of clinician and patient awareness with regard to infection risk in patients with rheumatoid arthritis and its associated therapies. Michael D. Darley, MD Department of Internal Medicine University of Utah Salt Lake City, UT

Dany Saad, MD Division of Rheumatology University of Utah Salt Lake City, UT

Souha Haydoura, MD Division of Infectious Diseases University of Utah Salt Lake City, UT

David McGowan, DDS, M. Dent. Sc Dental Service George Wahlen Veterans Affairs Medical Center Salt Lake City, UT

FIGURE. Sagittal T1 sequence magnetic resonance imaging of the lumbar spine demonstrating areas of enhancement and no enhancement within the anterior epidural space posterior to L3 and L4 consistent with spinal epidural abscess. JCR: Journal of Clinical Rheumatology • Volume 21, Number 1, January 2015

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.

JCR: Journal of Clinical Rheumatology • Volume 21, Number 1, January 2015

Jeffrey B. Payne, DDS, M. Dent. Sc Division of Periodontics Department of Surgical Specialties College of Dentistry University of Nebraska Medical Center Lincoln and Department of Internal Medicine College of Medicine University of Nebraska Medical Center Omaha, NE

Grant W. Cannon, MD, MACP, FACR George Wahlen Veterans Affairs Medical Center and Division of Rheumatology Affairs Medical Center Salt Lake City, UT

Ted R. Mikuls, MD, MSPH Division of Rheumatology Omaha VAMC and Nebraska Arthritis Outcomes Research Center University of Nebraska Medical Center, Omaha, NE

The authors declare no conflict of interest. REFERENCES 1. Antonelli M, Magrey M. Spinal epidural abscess on rituximab. J Clin Rheumatol. 2011; 17:348.

2. Mikuls TR, Payne JB, Yu F, et al. Periodontitis and Porphyromonas gingivalis in patients with rheumatoid arthritis. Arthritis Rheum. 2014. 3. Bongartz T, Sutton AJ, Sweeting MJ, et al. Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials. JAMA. 2006;295: 2275–2285. 4. Smitten AL, Choi HK, Hochberg MC, et al. The risk of hospitalized infection in patients with rheumatoid arthritis. J Rheumatol. 2008;35: 387–393. 5. Dixon WG, Suissa S, Hudson M. The association between systemic glucocorticoid therapy and the risk of infection in patients with rheumatoid arthritis: systematic review and meta-analyses. Arthritis Res Ther. 2011;13:R139. 6. Vasoo S, Gurnani P, Agustin T, et al. Chest pain as presenting symptom of Staphyloccocus aureus epidural abscess associated with anti-tumor necrosis factor and methotrexate therapy. J Clin Rheumatol. 2009;15:396–398. 7. Smith AP, Musacchio MJ, O'Toole JE. Spinal epidural abscess associated with infliximab

Letter to the Editor

treatment for psoriatic arthritis. Case report. J Neurosurg Spine. 2008;9:261–264. 8. Darabi K, Jaiswal R, Hostetler S, et al. Infectious complications in patients with psoriasis and rheumatoid arthritis treated with antitumor necrosis factor agents and methotrexate. J Drugs Dermatol. 2009;8: 175–178. 9. Burgess BJ. Epidural abscess after dental extraction. Emerg Med J. 2001;18:231. 10. Walters HL, Measley R. Two cases of Pseudomonas aeruginosa epidural abscesses and cervical osteomyelitis after dental extractions. Spine. 2008;33: E293–E296. 11. Rosenthal ME, Rojtman AD, Frank E. Finegoldia magna (formerly Peptostreptococcus magnus): an overlooked etiology for toxic shock syndrome? Med Hypotheses. 2012;79:138–140. 12. Abou Zahr Z, Spiegelman A, Cantu M, et al. Perioperative use of anti-rheumatic agents does not increase early postoperative infection risks: a Veteran Affairs' administrative database study. Rheumatol Int. 2014. [Epub ahead of print].

© 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.

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Spinal epidural abscess following minimally invasive dental examination in a rheumatoid arthritis patient receiving methotrexate, glucocorticoids, and anti-tumor necrosis factor therapy.

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