Letter to the Editor
Adverse Effects of Immunosuppressive Therapy in Rheumatic Patients: Non-tuberculous Mycobacterial Infection
Efectos adversos de terapia inmunosupresora en paciente reumatológico: infección por micobacterias no tuberculosas
Jean Sebastian Hurtado Hurtado
Internist, Salucoop, Cali, Colombia
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At the time of writing, she was being treated with rituximab (she had received 2 cycles of 1<span class="elsevierStyleHsp" style=""></span>g each), azathioprine 100<span class="elsevierStyleHsp" style=""></span>mg/day, methylprednisolone 16<span class="elsevierStyleHsp" style=""></span>mg/day and hydroxyurea 1<span class="elsevierStyleHsp" style=""></span>g/day. She was admitted to a quaternary care center with a 3-month history of pain in her right hip. Drug treatment with a variety of analgesics and multiple local injections in right hip and gluteus resulted in a partial improvement of her symptoms. One month later, the clinical symptoms returned and she presented with an abscess in right gluteus, with local inflammatory changes. Physical examination revealed the presence of a painful nodule. She underwent surgical drainage of the abscess, and cultures for the usual bacteria, fungi and mycobacteria (auramine–rhodamine stain and culture in Löwenstein–Jensen solid medium) were negative. Antibiotic therapy was initiated with ceftriaxone<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>vancomycin and ampicillin/sulbactam, with no improvement whatsoever. A biopsy was performed with the drained material, and the latter was analyzed by polymerase chain reaction (PCR) for the detection of mycobacteria, in which <span class="elsevierStyleItalic">M. chelonae</span> DNA was isolated. The patient began treatment with clarithromycin 1<span class="elsevierStyleHsp" style=""></span>g/day and moxifloxacin 400<span class="elsevierStyleHsp" style=""></span>mg/day in May 2014, with which she continued at the time of writing, with resolution of the clinical condition.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nontuberculous mycobacteria constitute a group of species that includes <span class="elsevierStyleItalic">Mycobacterium abscessus</span> (with 3 subspecies), <span class="elsevierStyleItalic">M. chelonae</span> and <span class="elsevierStyleItalic">Mycobacterium fortuitum</span>, which are widely distributed in nature.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As a pathogen in humans, <span class="elsevierStyleItalic">M. chelonae</span> has a number of clinical forms, the severity of which ranges from frequent mild skin and soft tissue infections to potentially fatal systemic infections.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Skin infection is the most common clinical condition in immunocompetent individuals, and is usually preceded by an injury, open fracture, wound from a sharp, cutting weapon, or a surgical procedure (especially plastic surgery).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In immunocompromised individuals, this pathogen causes disseminated skin infections, and the entry route or route of transmission is generally unidentified. The clinical manifestations consist of infections in organs and skin abscesses that generally affect the lower extremities. Localized injuries can also cause infections (cellulitis, abscesses and osteomyelitis), as can surgical wounds and catheters, although to a lesser degree.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is important that general practitioners, when treating patients with autoimmune diseases and using biologic therapies, have a high index of suspicion of infection by <span class="elsevierStyleItalic">M. chelonae</span>, founded on 3 criteria: (a) a previous skin lesion, mainly from cosmetic or surgical procedures; (b) the presence of painful subcutaneous nodules and abscesses at the site of the lesion; and (c) a poor or inadequate response to the antibiotic therapy received.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis starts with the direct observation of mycobacteria in the aspirate of secretions or in the tissue obtained, using Ziehl–Neelsen or auramine–rhodamine stain, plus the performance of special cultures for the diagnosis. The classical Ziehl–Neelsen technique and the fluorescence technique with auramine–rhodamine are equally effective for the diagnosis, but around 30% of the rapidly growing mycobacteria can exhibit negative fluorescence with the auramine-rhodamine technique. Thus, when infection by rapidly growing mycobacteria is suspected, the procedure of choice is the Ziehl–Neelsen stain.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Bacteriological culture enables us to enhance the sensitivity of the diagnosis; even if the result of direct observation is negative, the disease is not ruled out. Therefore, sampling should be carried out for DNA amplification using the PCR technique, to obtain the patterns of sensitivity to first-line and second-line drugs that serve as a guide to the most adequate and effective treatment.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they had no source of funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hurtado Hurtado JS. Efectos adversos de terapia inmunosupresora en paciente reumatológico: infección por micobacterias no tuberculosas. Reumatol Clin. 2016;12:118–119.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Mycobacterium chelonae</span> cutaneous infection in a patient with mixed connective tissue disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Lage" 1 => "D.G. Biccigo" 2 => "F.B. Santos" 3 => "E. Chimara" 4 => "E.S. Pereira" 5 => "A.D. Costa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1590/abd1806-4841.20153545" "Revista" => array:6 [ "tituloSerie" => "An Bras Dermatol" "fecha" => "2015" "volumen" => "90" "paginaInicial" => "104" "paginaFinal" => "110" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26312688" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "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" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Infectious Diseases Society of America Emerging Infections Network" "etal" => false "autores" => array:4 [ 0 => "K.L. Winthrop" 1 => "S. Yamashita" 2 => "S.E. Beekmann" 3 => "P.M. 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Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12275-015-4495-8" "Revista" => array:6 [ "tituloSerie" => "J Microbiol" "fecha" => "2015" "volumen" => "53" "paginaInicial" => "38" "paginaFinal" => "46" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25557479" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001200000002/v1_201604080059/S2173574316000186/v1_201604080059/en/main.assets" "Apartado" => array:4 [ "identificador" => "8400" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001200000002/v1_201604080059/S2173574316000186/v1_201604080059/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574316000186?idApp=UINPBA00004M" ]
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| 2023 October | 40 | 36 | 76 |
| 2023 September | 41 | 41 | 82 |
| 2023 August | 34 | 13 | 47 |
| 2023 July | 47 | 31 | 78 |
| 2023 June | 33 | 23 | 56 |
| 2023 May | 35 | 26 | 61 |
| 2023 April | 18 | 15 | 33 |
| 2023 March | 39 | 40 | 79 |
| 2023 February | 37 | 37 | 74 |
| 2023 January | 26 | 12 | 38 |
| 2022 December | 41 | 48 | 89 |
| 2022 November | 41 | 39 | 80 |
| 2022 October | 44 | 38 | 82 |
| 2022 September | 30 | 33 | 63 |
| 2022 August | 36 | 40 | 76 |
| 2022 July | 35 | 50 | 85 |
| 2022 June | 39 | 42 | 81 |
| 2022 May | 40 | 52 | 92 |
| 2022 April | 39 | 49 | 88 |
| 2022 March | 39 | 56 | 95 |
| 2022 February | 33 | 31 | 64 |
| 2022 January | 29 | 49 | 78 |
| 2021 December | 32 | 52 | 84 |
| 2021 November | 46 | 52 | 98 |
| 2021 October | 42 | 65 | 107 |
| 2021 September | 35 | 42 | 77 |
| 2021 August | 26 | 29 | 55 |
| 2021 July | 23 | 32 | 55 |
| 2021 June | 20 | 20 | 40 |
| 2021 May | 41 | 48 | 89 |
| 2021 April | 69 | 101 | 170 |
| 2021 March | 41 | 34 | 75 |
| 2021 February | 35 | 16 | 51 |
| 2021 January | 18 | 21 | 39 |
| 2020 December | 29 | 16 | 45 |
| 2020 November | 30 | 23 | 53 |
| 2020 October | 10 | 14 | 24 |
| 2020 September | 41 | 26 | 67 |
| 2020 August | 21 | 12 | 33 |
| 2020 July | 14 | 15 | 29 |
| 2020 June | 29 | 16 | 45 |
| 2020 May | 24 | 9 | 33 |
| 2020 April | 31 | 9 | 40 |
| 2020 March | 14 | 8 | 22 |
| 2019 February | 2 | 0 | 2 |
| 2018 May | 5 | 1 | 6 |
| 2018 April | 41 | 9 | 50 |
| 2018 March | 53 | 8 | 61 |
| 2018 February | 17 | 1 | 18 |
| 2018 January | 28 | 4 | 32 |
| 2017 December | 24 | 8 | 32 |
| 2017 November | 14 | 3 | 17 |
| 2017 October | 22 | 7 | 29 |
| 2017 September | 26 | 7 | 33 |
| 2017 August | 23 | 7 | 30 |
| 2017 July | 23 | 13 | 36 |
| 2017 June | 40 | 14 | 54 |
| 2017 May | 45 | 14 | 59 |
| 2017 April | 24 | 4 | 28 |
| 2017 March | 13 | 15 | 28 |
| 2017 February | 10 | 18 | 28 |
| 2017 January | 11 | 5 | 16 |
| 2016 December | 47 | 15 | 62 |
| 2016 November | 37 | 18 | 55 |
| 2016 October | 48 | 9 | 57 |
| 2016 September | 48 | 3 | 51 |
| 2016 August | 42 | 10 | 52 |
| 2016 July | 21 | 7 | 28 |
| 2016 April | 3 | 18 | 21 |
Show all
