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anterior uveitis&#44; enthesitis&#44; bilateral sacroiliitis and positive HLA-B27&#46; He was first treated with infliximab &#40;2004&#8211;2009&#41; and was after changed to adalimumab because of recurrent uveitis&#46; Before infliximab&#44; he had been treated with isoniazid for latent tuberculosis&#44; following a positive tuberculin skin test&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On December 2013&#44; he referred asthenia and new onset of left axillar nodules lasting for two weeks without fever or other complaints&#46; He had nodules around 30<span class="elsevierStyleHsp" style=""></span>mm limited to left axillar region&#44; without skin lesions&#46; The cardiopulmonary&#44; abdominal and neurological examinations were unremarkable&#46; He denied known contacts with tuberculosis patients&#46; He was owner of a cat which frequently scratched him but he did not recall any special lesion&#46; Adalimumab treatment was stopped and diagnostic workup was performed&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Except for Erythrocyte sedimentation rate &#40;38<span class="elsevierStyleHsp" style=""></span>mm&#47;1st hour&#41; and C Reactive Protein &#40;9&#46;0<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#44; no others relevant analytical findings were found&#46; Quantiferon&#8211;Gold in Tube was negative and thoracic X-ray was normal&#46; Axillar ultrasound examination revealed multiple hypoechoic nodules sized between 20&#8211;30<span class="elsevierStyleHsp" style=""></span>mm&#46; After fine needle aspiration procedure&#44; the cytology revealed granulomatous inflammation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; being Ziehl Neelsen stain&#44; culture for mycobacteria and PCR for&#58; <span class="elsevierStyleItalic">Mycobacterium &#40;tuberculosis&#44; avium and intracellulare</span>&#41;&#44; <span class="elsevierStyleItalic">Borrelia Burgdorferi</span> and <span class="elsevierStyleItalic">Nocardia</span> all negative&#46; The PCR for <span class="elsevierStyleItalic">Bartonella</span> spp&#46; was positive as were blood antibodies for <span class="elsevierStyleItalic">Bartonella henselae</span> &#40;IgG titer 1&#58;256&#59; 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to our knowledge&#44; the second case of CSD on adalimumab treatment&#46; Splenic nodules raised the concern of splenic dissemination of the disease that we cannot certainly attribute to <span class="elsevierStyleItalic">Bartonella</span> infection since biopsy was not undertaken&#46; Tuberculosis&#44; being our first concern&#44; was completely excluded&#46; In a retrospective study of adverse event reports on TNF&#945; blockers users&#44; an increased risk of granulomatous infections&#44; particularly tuberculosis&#44; was documented&#44; but only one case was caused by <span class="elsevierStyleItalic">Bartonella</span> infection&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Later on&#44; 10 CSD reports were described&#58; seven patients were under TNF&#945; blockers &#40;one case on adalimumab&#41;&#44; one case on abatacept and two on tocilizumab&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#8211;11</span></a> The majority presented regional lymphadenopathy and had good therapeutic response&#44; restarting biologics 2&#8211;3 months after&#46; However&#44; in three published cases&#44; visceral infection presenting with mesenteric panniculitis&#44; splenic nodules and&#44; one of those&#44; with liver granulomatosis&#44; were documented&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;8&#44;11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">It should be stressed that new onset lymphadenopathy and granulomatosis in patients under biological therapies should raise the suspicion of CSD&#44; particularly in the field of epidemiologic risk&#46; The possibility of systemic dissemination should be kept in mind due to underlying immunosuppression&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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Vol. 15. Núm. 5.
Páginas 309-310 (septiembre - octubre 2019)
Letter to the Editor
Cat Scratch Disease During Adalimumab Therapy: A Case Report
Enfermedad por arañazo de gato durante el tratamiento con adalimumab: a propósito de un caso
Teresa Martins-Rochaa,
Autor para correspondencia
teresa.asmr@gmail.com

Corresponding author.
, Cândida Abreub, Alexandra Bernardoa, Miguel Bernardesa,c, Joanne Lopesd
a Rheumatology Department, Centro Hospitalar de São João, Porto, Portugal
b Infectious Diseases Department, Centro Hospitalar de São João, Porto, Portugal
c Rheumatology Department, Faculty of Medicine of the University of Porto, Portugal
d Department of Anatomic Pathology, Centro Hospitalar de São João, Porto, Portugal

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Letter to the Editor
Cat Scratch Disease During Adalimumab Therapy: A Case Report
Enfermedad por arañazo de gato durante el tratamiento con adalimumab: a propósito de un caso
Teresa Martins-Rochaa,
Autor para correspondencia
teresa.asmr@gmail.com

Corresponding author.
, Cândida Abreub, Alexandra Bernardoa, Miguel Bernardesa,c, Joanne Lopesd
a Rheumatology Department, Centro Hospitalar de São João, Porto, Portugal
b Infectious Diseases Department, Centro Hospitalar de São João, Porto, Portugal
c Rheumatology Department, Faculty of Medicine of the University of Porto, Portugal
d Department of Anatomic Pathology, Centro Hospitalar de São João, Porto, Portugal
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anterior uveitis&#44; enthesitis&#44; bilateral sacroiliitis and positive HLA-B27&#46; He was first treated with infliximab &#40;2004&#8211;2009&#41; and was after changed to adalimumab because of recurrent uveitis&#46; Before infliximab&#44; he had been treated with isoniazid for latent tuberculosis&#44; following a positive tuberculin skin test&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On December 2013&#44; he referred asthenia and new onset of left axillar nodules lasting for two weeks without fever or other complaints&#46; He had nodules around 30<span class="elsevierStyleHsp" style=""></span>mm limited to left axillar region&#44; without skin lesions&#46; The cardiopulmonary&#44; abdominal and neurological examinations were unremarkable&#46; He denied known contacts with tuberculosis patients&#46; He was owner of a cat which frequently scratched him but he did not recall any special lesion&#46; Adalimumab treatment was stopped and diagnostic workup was performed&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Except for Erythrocyte sedimentation rate &#40;38<span class="elsevierStyleHsp" style=""></span>mm&#47;1st hour&#41; and C Reactive Protein &#40;9&#46;0<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#44; no others relevant analytical findings were found&#46; Quantiferon&#8211;Gold in Tube was negative and thoracic X-ray was normal&#46; Axillar ultrasound examination revealed multiple hypoechoic nodules sized between 20&#8211;30<span class="elsevierStyleHsp" style=""></span>mm&#46; After fine needle aspiration procedure&#44; the cytology revealed granulomatous inflammation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; being Ziehl Neelsen stain&#44; culture for mycobacteria and PCR for&#58; <span class="elsevierStyleItalic">Mycobacterium &#40;tuberculosis&#44; avium and intracellulare</span>&#41;&#44; <span class="elsevierStyleItalic">Borrelia Burgdorferi</span> and <span class="elsevierStyleItalic">Nocardia</span> all negative&#46; The PCR for <span class="elsevierStyleItalic">Bartonella</span> spp&#46; was positive as were blood antibodies for <span class="elsevierStyleItalic">Bartonella henselae</span> &#40;IgG titer 1&#58;256&#59; IgM &#60;1&#58;32&#41;&#46; Due to CSD diagnosis&#44; azithromycin was prescribed for 5 days&#46; After one month&#44; he presented complete regression of lymphadenopathies&#46; Abdominal CT revealed splenic hypodense millimetric nodules and abdominal ultrasound showed two splenic nodules &#40;11 and 8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#59; there was no previous exam to compare &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Regarding procedure risks&#44; it was decided by a multidisciplinary team to avoid splenic biopsy and ciprofloxacin during 3 weeks was prescribed&#46; Regular ultrasound examinations revealed stability of the splenic lesions&#46; Adalimumab was re-started on September 2014 because of exacerbation of AS activity&#46; After more than three years&#44; he remains asymptomatic and abdominal ultrasound revealed slight reduction of splenic nodules &#40;8 and 5<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We herein report&#44; to our knowledge&#44; the second case of CSD on adalimumab treatment&#46; Splenic nodules raised the concern of splenic dissemination of the disease that we cannot certainly attribute to <span class="elsevierStyleItalic">Bartonella</span> infection since biopsy was not undertaken&#46; Tuberculosis&#44; being our first concern&#44; was completely excluded&#46; In a retrospective study of adverse event reports on TNF&#945; blockers users&#44; an increased risk of granulomatous infections&#44; particularly tuberculosis&#44; was documented&#44; but only one case was caused by <span class="elsevierStyleItalic">Bartonella</span> infection&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Later on&#44; 10 CSD reports were described&#58; seven patients were under TNF&#945; blockers &#40;one case on adalimumab&#41;&#44; one case on abatacept and two on tocilizumab&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#8211;11</span></a> The majority presented regional lymphadenopathy and had good therapeutic response&#44; restarting biologics 2&#8211;3 months after&#46; However&#44; in three published cases&#44; visceral infection presenting with mesenteric panniculitis&#44; splenic nodules and&#44; one of those&#44; with liver granulomatosis&#44; were documented&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;8&#44;11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">It should be stressed that new onset lymphadenopathy and granulomatosis in patients under biological therapies should raise the suspicion of CSD&#44; particularly in the field of epidemiologic risk&#46; The possibility of systemic dissemination should be kept in mind due to underlying immunosuppression&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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Información del artículo
ISSN: 1699258X
Idioma original: Inglés
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