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 )
