ABSTRACT
Infections of the soft tissues due to atypical mycobacteria are relatively uncommon. We describe two cases. A 61-year-old woman with rheumatoid arthritis (RA) who was treated with the combination of the TNF inhibitor etanercept (Enbrel) and leflunomide (Arava), developed paronychia and cellulitis of the index finger due to Mycobacterium chelonae/abscessus complex. The patient was successfully treated with clarithromycin and surgical debridement. A second case describes a 50-year-old man with ankylosing spondylitis, receiving infliximab (Remicade) and low dose corticosteroids, who developed a granulomatous infection of the right thumb and forearm due to Mycobacterium marinum.The patient was successfully treated with clarithromycin and ethambutol. The increased risk for subcutaneous mycobacterial infections in these cases are probably related to the DMARD treatment with a TNF-inhibitor and leflunomide.
Subject(s)
Adrenal Cortex Hormones , Antirheumatic Agents , Clarithromycin , Ethambutol , Isoxazoles/administration & dosage , Mycobacterium Infections, Nontuberculous , Mycobacterium chelonae , Mycobacterium marinum , Tumor Necrosis Factors , Adrenal Cortex Hormones/administration & dosage , Adrenal Cortex Hormones/adverse effects , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/adverse effects , Antirheumatic Agents/administration & dosage , Antirheumatic Agents/adverse effects , Arthritis, Rheumatoid/drug therapy , Clarithromycin/administration & dosage , Clarithromycin/adverse effects , Ethambutol/administration & dosage , Ethambutol/adverse effects , Female , Humans , Isoxazoles/adverse effects , Leflunomide , Male , Microbial Sensitivity Tests , Middle Aged , Mycobacterium Infections, Nontuberculous/drug therapy , Mycobacterium Infections, Nontuberculous/etiology , Mycobacterium Infections, Nontuberculous/microbiology , Mycobacterium Infections, Nontuberculous/pathology , Mycobacterium Infections, Nontuberculous/physiopathology , Mycobacterium chelonae/drug effects , Mycobacterium chelonae/isolation & purification , Mycobacterium marinum/drug effects , Mycobacterium marinum/isolation & purification , Risk Factors , Skin/pathology , Soft Tissue Infections/drug therapy , Soft Tissue Infections/etiology , Soft Tissue Infections/microbiology , Soft Tissue Infections/pathology , Soft Tissue Infections/physiopathology , Spondylitis, Ankylosing/drug therapy , Tumor Necrosis Factor InhibitorsABSTRACT
We report on one patient with Wegener's granulomatosis (WG) and two patients with microscopic polyangiitis (MPA). The patient with WG had signs of a respiratory infection and showed a c-ANCA pattern with proteinase 3 (PR3) specificity. The patients with MPA presented with pulmonary haemorrhage and signs of renal damage and showed a p-ANCA pattern with myeloperoxidase (MPO) specificity. In the three patients histopathological findings confirmed the diagnosis. We discuss the clinical indications of ANCA testing and the current terminology for reporting ANCA results (c-ANCA, p-ANCA, c-ANCA (atypical) and atypical ANCA). The target antigens and diseases associated with these different patterns are considered. Finally we focus on the value of ANCA and more specific PR3-ANCA and MPO-ANCA in the diagnosis of WG and MPA. The new application domain of ANCA in Crohn's disease and ulcerative colitis is also discussed.
