复旦大学：《传染病学 Infectious Disease》课程教学资源（MBBS）教案案例（英文）Tuberculous periprostheticinfection precipitated by infliximab therapy

BMJ Case Reports Tuberculous periprosthetic infection precipitated by infliximab therapy CASE REPORT Tuberculous periprosthetic infection precipitated by infliximab therapy

Tuberculous periprosthetic infection precipitated by infliximab therapy

Part 1 Part 2 Part 3 Part 4 Part 5 Part 6 Part 7 Symptoms &Signs Male. 45 severe pain in his left this g h for 2 weeks symptoms evening rise of temperature for inability to bear weight the past I month no associated anorexia or ankylosing spondylitis Sequential revision total hip weight lOSS 强直性脊柱炎 arthroplasty Physical examination 20 years old 7 years before a tender swelling on the anterior aspect of the thigh with a discharging sinus 22 years old 2 months before bilateral total hip arthroplasty short intravenous course of infliximab because of acute polyarthralgia(多关节痛)

Part 1 Part 2 2 Part 3 Part 4 Part 5 Part 6 Part 7 Symptoms &Signs Male, 45 severe pain in his left thigh for 2 weeks, inability to bear weight 20 years old ankylosing spondylitis 强直性脊柱炎 22 years old bilateral total hip arthroplasty Symptoms: evening rise of temperature for the past 1 month; no associated anorexia or weight loss Physical examination: a tender swelling on the anterior aspect of the thigh with a discharging sinus 7 years before Sequential revision total hip arthroplasty short intravenous course of infliximab, because of acute polyarthralgia (多关节痛) 2 months before

Part 1 Part 2 Part 3 Part 4 Part 5 Part 6 Part7 Investigations Variable On Presentation Erythrocyte sedimentation rates ( ESr) 149 mm/hour C reactive peptide(CRP) 21 mg/L

Part 2 Part 1 3 Part 3 Part 4 Part 5 Part 6 Part 7 Inves0ga0ons Variable On Presenta0on Erythrocyte sedimenta0on rates (ESR) 149 mm/ hour C reac0ve pep0de (CRP) 21 mg/L

Part 1 Part 2 Part 3 Part 4 Part 5 Part 6 Part7 Investigations osteolysis of proximal femur, without loosening or subsidence of implant Immediate postoperative 7 years follow-up X-ray X-ray

Part 2 Part 1 4 Part 3 Part 4 Part 5 Part 6 Part 7 Inves0ga0ons Immediate postoperative X-ray 7 years follow-up X-ray Ø osteolysis of proximal femur, without loosening or subsidence of implant

Part 1 Part 2 Part 3 Part 4 Part 5 Part 6 Part7 Investigations B multifocal cortical breach with a discharging sinus no obvious effusion Coronal section Axial section, showing a draining sinus

Part 2 Part 1 5 Part 3 Part 4 Part 5 Part 6 Part 7 Inves0ga0ons Coronal section Axial section, showing a draining sinus Ø mul0focal cor0cal breach, with a discharging sinus, no obvious effusion

Part 1 Part 2 Part 3 Part 4 Part 5 Part 6 Part7 Investigations Culture: sterile including for fungi and mycobacterium tuberculosis Histopathology: non-specific chronic inflammation Aspiration: under ultrasound guidance > sterile cultures and negative reports for acid-fast bacilli staining PCR: positive for Mycobacterium tuberculosis

Part 2 Part 1 6 Part 3 Part 4 Part 5 Part 6 Part 7 Inves0ga0ons Ø Culture: sterile, including for fungi and Mycobacterium tuberculosis. Ø Histopathology: non-specific chronic inflamma0on. Ø Aspira0on: under ultrasound guidance >> sterile cultures and nega0ve reports for acid-fast bacilli staining Ø PCR: posi0ve for Mycobacterium tuberculosis

Part 1 Part 2 Part 3 Part 4 Part 5 Part 6 Part7 Treatment Antitubercular therapy hrZE 6 weeks later: symptomatic relief, the size of collection decreased CRP 4 months: the withdrawal of pyrazinamide and ethambutol >18 months: stop aTt

Part 3 Part 1 7 Part 2 Part 4 Part 5 Part 6 Part 7 Treatment Ø An0tubercular therapy: HRZE Ø 6 weeks later: symptoma0c relief, the size of collec0on decreased, CRP↘ Ø 4 months: the withdrawal of pyrazinamide and ethambutol Ø 18 months: stop ATT

Part1 Part 3 Part 4 5 Part 6 Part7 Follow-up tom B C Coronal section: resolution of the Axial section improved bone a healed sinus density abscess no draining sinus

Part 4 Part 1 8 Part 2 Part 3 Part 5 Part 6 Part 7 Follow-up Coronal section: resolution of the abscess Axial section: no draining sinus A healed sinus improved bone density

Part1 Part 2 Part 3 Part 4 Part 5 Part 6 Part7 Discussion TNF-a antagonist Tumour necrosis factor-a(TNF-a) is a pleiotropic cytokine that plays a central role in the pathogenesis of rheumatoid arthritis (ra) inflammatory bowel disease(iBD), ankylosing spondylitis (as) and other immune-mediated or inflammation -related diseases The most frequent serious adr was infection The most prevalent infectious disease was pneumonia and higher irs of tuberculosis and pneumocystis jiroveci pneumonia(PCp

Part 5 Part 1 9 Part 2 Part 3 Part 4 Part 6 Part 7 Discussion Ø Tumour necrosis factor-α (TNF-α) is a pleiotropic cytokine that plays a central role in the pathogenesis of rheumatoid arthri0s (RA), inflammatory bowel disease (IBD), ankylosing spondyli0s (AS) and other immune-mediated or inflamma0on-related diseases. Ø The most frequent serious ADR was infec0on. Ø The most prevalent infec0ous disease was pneumonia, and higher IRs of tuberculosis and Pneumocys0s jiroveci pneumonia (PCP)

Part1 Part 2 Part 3 Part 4 Part 5 Part 6 Part7 Discussion TNF-a antagonist An increased risk of tuberculosis(Tb) has been reported in patients treated with tNF-a antagonists an issue that has been highlighted in a WHo black box warning The association between TNF-a antagonists and an increased risk of TB remains uncertain atypical clinical presentation (extrapulmonary in >50%, disseminated in 25%of cases

Part 5 Part 1 10 Part 2 Part 3 Part 4 Part 6 Part 7 Discussion Ø An increased risk of tuberculosis (TB) has been reported in pa0ents treated with TNF-α antagonists, an issue that has been highlighted in a WHO black box warning Ø The associa0on between TNF-α antagonists and an increased risk of TB remains uncertain. Ø atypical clinical presenta0on (extrapulmonary in > 50%, disseminated in 25% of cases )