Successful resumption of tocilizumab for rheumatoid arthritis after resection of a pulmonary Mycobacterium avium complex lesion: a case report

BMC Pulmonary Medicine

Tomoko Betsuyaku¹  Tsutomu Takeuchi³  Naoki Hasegawa⁴  Mitsutomo Kohno²  Katsuya Suzuki³  Makoto Ishii¹  Kazuma Yagi¹  Mitsuhiro Akiyama³  Sadatomo Tasaka¹  Ho Namkoong¹ 

[1]Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan

[2]Division of General Thoracic Surgery, Keio University School of Medicine, Tokyo, Japan

[3]Division of Rheumatology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan

[4]Center for Infectious Diseases and Infection Control, Keio University School of Medicine, Tokyo, Japan

关键词: Tocilizumab;    Rheumatoid arthritis;    Resection;    Mycobacterium avium complex (MAC);    Biological agents;   

Others  :  1231150
DOI  :  10.1186/s12890-015-0130-z

 received in 2015-07-19, accepted in 2015-10-15,  发布年份 2015

【 摘 要 】

Background

Biological agents inhibiting TNF-α and other molecules involved in inflammatory cascade have been increasingly used to treat rheumatoid arthritis (RA). However, it remains controversial whether biological agents can be used safely in a patient with an underlying chronic infectious disease.

Case presentation

A 63-year-old woman who had been treated with tocilizumab (TCZ), anti-interleukin-6 receptor antibody, for RA presented to our outpatient clinic due to hemoptysis. She was diagnosed with pulmonary Mycobacterium avium complex (MAC) infection, and high-resolution computed tomography (HRCT) showed a single cavitary lesion in the right upper lobe. After diagnosis of pulmonary MAC disease, TCZ was discontinued and combination chemotherapy with clarithromycin, rifampicin, ethambutol and amikacin was started for MAC pulmonary disease. Since the lesion was limited in the right upper lobe as a single cavity formation, she underwent right upper lobectomy. As her RA symptoms were deteriorated around the operation, TCZ was resumed. After resumption of TCZ, her RA symptoms improved and a recurrence of pulmonary MAC infection has not been observed for more than 1 year.

Conclusion

This case suggested that TCZ could be safely reintroduced after the resection of a pulmonary MAC lesion. Although the use of biological agents is generally contraindicated in patients with pulmonary MAC disease, especially in those with a fibrocavitary lesion, a multimodality intervention for MAC including both medical and surgical approaches may enable introduction or resumption of biological agents.

【 授权许可】

   
2015 Namkoong et al.

【 图 表 】

Fig. 1.

Fig. 2.

Fig. 3.

【 参考文献 】

• [1]Takeuchi T, Kameda H. The Japanese experience with biologic therapies for rheumatoid arthritis. Nat Rev Rheumatol. 2010; 6(11):644-652.
• [2]Woodrick RS, Ruderman EM. Safety of biologic therapy in rheumatoid arthritis. Nat Rev Rheumatol. 2011; 7(11):639-652.
• [3]Jani M, Hirani N, Matteson EL, Dixon WG. The safety of biologic therapies in RA-associated interstitial lung disease. Nat Rev Rheumatol. 2014; 10(5):284-294.
• [4]Furst DE. The risk of infections with biologic therapies for rheumatoid arthritis. Semin Arthritis Rheum. 2010; 39(5):327-346.
• [5]Singh JA, Cameron C, Noorbaloochi S, Cullis T, Tucker M, Christensen R, Ghogomu ET, Coyle D, Clifford T, Tugwell P et al.. Risk of serious infection in biological treatment of patients with rheumatoid arthritis: a systematic review and meta-analysis. Lancet. 2015; 386(9990):258-265.
• [6]Singh JA, Wells GA, Christensen R, Tanjong Ghogomu E, Maxwell L, Macdonald JK, Filippini G, Skoetz N, Francis D, Lopes LC et al.. Adverse effects of biologics: a network meta-analysis and Cochrane overview. Cochrane Database Syst Rev. 2011; 2:CD008794.
• [7]Kourbeti IS, Ziakas PD, Mylonakis E. Biologic therapies in rheumatoid arthritis and the risk of opportunistic infections: a meta-analysis. Clin Infect Dis. 2014; 58(12):1649-1657.
• [8]Winthrop KL, Yamashita S, Beekmann SE, Polgreen PM. Mycobacterial and other serious infections in patients receiving anti-tumor necrosis factor and other newly approved biologic therapies: case finding through the Emerging Infections Network. Clin Infect Dis. 2008; 46(11):1738-1740.
• [9]Namkoong H, Kurashima A, Morimoto K,·Hoshino Y, Hasegawa N, Manabu A,·Mitarai S: Nationwide Survey on the Epidemiology of Pulmonary Nontuberculous Mycobacterial in Japan. The annual meeting of American Thoracic Society 2015/05.
• [10]Henkle E, Winthrop KL. Nontuberculous mycobacteria infections in immunosuppressed hosts. Clin Chest Med. 2015; 36(1):91-99.
• [11]Winthrop KL, Iseman M. Bedfellows: mycobacteria and rheumatoid arthritis in the era of biologic therapy. Nat Rev Rheumatol. 2013; 9(9):524-531.
• [12]Yamamoto K, Goto H, Hirao K, Nakajima A, Origasa H, Tanaka K, Tomobe M, Totsuka K. Longterm Safety of Tocilizumab: Results from 3 Years of Followup Postmarketing Surveillance of 5573 Patients with Rheumatoid Arthritis in Japan. J Rheumatol. 2015; 42(8):1368-1375.
• [13]van Ingen J, Boeree MJ, Dekhuijzen PN, van Soolingen D. Mycobacterial disease in patients with rheumatic disease. Nat Clin Pract Rheumatol. 2008; 4(12):649-656.
• [14]Mori S, Tokuda H, Sakai F, Johkoh T, Mimori A, Nishimoto N, Tasaka S, Hatta K, Matsushima H, Kaise S et al.. Radiological features and therapeutic responses of pulmonary nontuberculous mycobacterial disease in rheumatoid arthritis patients receiving biological agents: a retrospective multicenter study in Japan. Mod Rheumatol. 2012; 22(5):727-737.
• [15]Nakahara H, Kamide Y, Hamano Y, Hosokawa T, Nishide M, Lin Y, Kawamoto K, Fusama M, Higa S, Kuroiwa T et al.. A case report of a patient with rheumatoid arthritis complicated with Mycobacterium avium during tocilizumab treatment. Mod Rheumatol. 2011; 21(6):655-659.
• [16]Biological agents and pulmonary diseases - the statement of the management - the Japanese Respiratory Society, the Japan college of Rheumatology and the Japanese Society for Tuberculosis. (in Japanese) 2014.
• [17]Griffith DE, Brown-Elliott BA, Langsjoen B, Zhang Y, Pan X, Girard W, Nelson K, Caccitolo J, Alvarez J, Shepherd S et al.. Clinical and molecular analysis of macrolide resistance in Mycobacterium avium complex lung disease. Am J Respir Crit Care Med. 2006; 174(8):928-934.
• [18]The statement of surgery against Mycobacterium avium comlex lung disease. Kekkaku. 2008; 83(12):527-528.
• [19]Yu JA, Weyant MJ, Mitchell JD. Surgical treatment of atypical mycobacterial infections. Thorac Surg Clin. 2012; 22(3):277-285.
• [20]Shiraishi Y, Katsuragi N, Kita H, Hyogotani A, Saito MH, Shimoda K. Adjuvant surgical treatment of nontuberculous mycobacterial lung disease. Ann Thorac Surg. 2013; 96(1):287-291.