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
Methicillin-resistant Staphylococcus aureus (MRSA) is a strain of S. aureus that shows resistance to multiple antibiotics. Up to 30% of S. aureus strains isolated from nosocomial infections are MRSA, and it has become a growing problem for public health. The cost of MRSA infection is also having a huge impact financially and results in considerable resource utilization. Puerto Rico's Legislature passed Law # 298 on October 19, 2012 for the control and prevention of MRSA infections in medical installations in Puerto Rico. In order to comply with the law we conducted a pilot study to identify possible setbacks of the implementation of the MRSA decolonization protocol as standard of care therapy in our institution while contributing to the process of quality improvement and patient safety. Nasal swabs were taken at the Pre-admission Department and processed through a PCR-based MRSA detection assay. A protocol of decolonization in patients with positive results was implemented. The study showed that patients without apparent risk factors could be colonized either with MRSA or Methicillin-sensitive S. aureus (MSSA). The time between pre- admission and surgery was less than the indicated for a proper decolonization procedure. Therefore, 50% of the scheduled surgeries could have been postponed in case of positive MRSA or MSSA. In our experience patient's education was crucial to guarantee compliance and adherence to treatment. In order to decrease risk of wound infection we recommend that both, screening process and decolonization if required, be performed before the preadmission appointment for elective surgery. This study provided a framework for MRSA pre-admission screening and decolonization in our Institution.
