ABSTRACT
BACKGROUND: Tumor necrosis factor antagonist inhibitors have transformed the approach to patients with severe autoimmune conditions, such as rheumatoid arthritis. Although the therapy can be highly effective, TNF-α inhibitors are associated with an increased risk of opportunistic infections. CASE PRESENTATION: Here, we report a case of concomitant disseminated histoplasmosis and tuberculosis in a 65-year-old female with rheumatoid arthritis treated with TNF-α inhibitor. Both conditions can be found in disseminated form in immunosuppressed hosts, but co-infection is rare with only a few cases having been reported, to our knowledge, all in HIV patients. CONCLUSIONS: This case posed a considerable challenge for diagnosis and treatment due to the unusual disseminated co-infection, the overlapping symptoms, and the interactions between medications.
Subject(s)
Adalimumab/adverse effects , Antirheumatic Agents/adverse effects , Arthritis, Rheumatoid/drug therapy , Histoplasmosis/immunology , Immunocompromised Host , Opportunistic Infections/immunology , Tuberculosis/immunology , Aged , Antifungal Agents/therapeutic use , Antitubercular Agents/therapeutic use , Coinfection , Female , Histoplasmosis/diagnostic imaging , Histoplasmosis/drug therapy , Histoplasmosis/etiology , Humans , Opportunistic Infections/diagnostic imaging , Opportunistic Infections/drug therapy , Opportunistic Infections/etiology , Tomography, X-Ray Computed , Tuberculosis/diagnostic imaging , Tuberculosis/drug therapy , Tuberculosis/etiology , Tumor Necrosis Factor-alpha/antagonists & inhibitorsABSTRACT
OBJECTIVES: There is considerable discussion regarding "success" rates for laparoscopic antireflux surgery (LARS). We hypothesized that, in part, this was a reflection of the outcome variables used. We, therefore, defined 8 specific variables (within 3 categories) and assessed outcomes for each in a large cohort of patients. METHODS: Four hundred patients (208 women; median age 52 years old) who underwent LARS at the University of Washington from 1993 to 2008 were given a comprehensive questionnaire to assess various aspects of their outcomes from LARS. In addition, we analyzed all functional studies and all endoscopies performed in these patients in our institution, whether the patients had symptoms or not, and compared the findings to all available preoperative values. RESULTS: The median follow-up was 92 (6-175) months. CONCLUSIONS: The success or failure of LARS cannot be defined in a single domain. A comprehensive analysis of outcomes requires categorization that includes symptom response, side-effects, patient's perception and objective measurement of acid exposure, mucosal integrity, and the need for additional medical or surgical treatment. Only then can patients and physicians better understand the role of LARS and make informed decisions.
