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Borrás-Blasco J, Nuñez-Cornejo C, Gracia-Perez A, Rosique-Robles JD, Casterá MDE, Viosca E, Abad FJ. Parapharyngeal Abscess in a Patient Receiving Etanercept. Ann Pharmacother 2016; 41:341-4. [PMID: 17227824 DOI: 10.1345/aph.1h407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To report a case of parapharyngeal abscess associated with Streptococcus viridans in a patient with rheumatoid arthritis receiving treatment with etanercept. Case Summary: A 40-year-old man diagnosed with rheumatoid arthritis had received treatment with nonsteroidal antiinflammatory drugs, methotrexate, and deflazacort. Six months prior to admission, the patient had a Disease Activity Score of 3.4; clinicians decided to start treatment with etanercept. Chest X-rays were normal and the tuberculin skin test was negative. Treatment with etanercept plus methotrexate was started. Three months later, methotrexate was discontinued. Six months after etanercept therapy was started, the patient presented to our emergency department with a swelling of his neck, odynophagia, otalgia, and trismus. The clinical course was consistent with parapharyngeal abscess. Etanercept treatment was suspended. The parapharyngeal abscess was drained and intravenous methylprednisolone, amoxicillin/clavulanic acid, and clindamycin were administered. The parapharyngeal abscess secretion culture was positive for S. viridans and Bacteroides spp. The patient's condition improved with antibiotic therapy; he was discharged 5 days after admission. Discussion: Tumor necrosis factor-α plays an essential role in the immune-mediated response to infection. In our patient, the most possible cause of parapharyngeal abscess was considered to be etanercept because of the temporal relationship between exposure to the drug and onset of symptoms. Etanercept was the only drug administered before the abscess developed. Based on the Naranjo probability scale, an association between etanercept and the adverse reaction could be considered possible. Conclusions: Patients initiated on etanercept therapy should be closely monitored for the development of tuberculosis and other infections. During treatment, all febrile or novel illnesses should be evaluated promptly. If clinical evaluation leads to the suspicion of tuberculosis and other infections associated with etanercept, it should be discontinued immediately.
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Downey C. Serious infection during etanercept, infliximab and adalimumab therapy for rheumatoid arthritis: A literature review. Int J Rheum Dis 2015. [DOI: 10.1111/1756-185x.12659] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Colum Downey
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
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Kang SJ, Kim HY, Kim YS, Lee HN, Kim HT, Kim SH. Intractable pneumococcal meningoencephalitis associated with a TNF-α antagonist. J Neurol Sci 2014; 344:215-8. [PMID: 24998513 DOI: 10.1016/j.jns.2014.05.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 04/15/2014] [Accepted: 05/16/2014] [Indexed: 01/10/2023]
Abstract
A 34-year-old man was treated with a TNF-α antagonist for ankylosing spondylitis, and this subsequently developed a CNS infection. Magnetic resonance imaging showed diffuse subcortical white matter lesions. Streptococcus pneumoniae was cultured from the cerebrospinal fluid and blood. The patient died of multifocal widespread brain damage and subarachnoid hemorrhage, despite intensive antibacterial medication. Pneumococcal meningoencephalitis can occur in association with TNF-α antagonists. Clinicians should be aware of both the risk of fatal bacterial meningoencephalitis associated with TNF-α antagonists and the possibility of an unusual presentation of bacterial meningitis.
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Affiliation(s)
- Seok-Jae Kang
- Departments of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea.
| | - Hyun Young Kim
- Departments of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea.
| | - Young Seo Kim
- Departments of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea.
| | - Ha Neul Lee
- Departments of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea.
| | - Hee Tae Kim
- Departments of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea.
| | - Seung H Kim
- Departments of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea.
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Autoimmune diseases in the intensive care unit. An update. Autoimmun Rev 2013; 12:380-95. [DOI: 10.1016/j.autrev.2012.06.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 06/12/2012] [Indexed: 12/18/2022]
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Kasirye Y, Epperla N, Manne JR, Bapani S, Garcia-Montilla RJ. Brain abscesses complicating acute pneumococcal meningitis during etanercept therapy. Clin Med Res 2012; 10:230-5. [PMID: 22634540 PMCID: PMC3494549 DOI: 10.3121/cmr.2012.1049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Brain abscess formation as a sequelae of community-acquired pneumococcal meningitis is extremely rare, accounting for less than 1% of all meningitis complications. Although metastatic seeding from a distal peripheral septic focus has been observed, this phenomenon most commonly occurs in the context of ear, nose and throat infections, post-cranial neurosurgical procedures, traumatic open cranial injury, or immunosuppression. We present the case of a man, 61 years old, on etanercept therapy for ankylosing spondylitis who developed multiple brain abscesses as a complication of pneumococcal meningitis. We believe that the predisposition to this extremely rare complication of a particularly aggressive pneumococcal meningitis was most likely due to the underlying immunosuppression resulting from etanercept therapy. As far as we know, this case is the first report linking multiple brain abscess formation in a patient with community-acquired pneumococcal meningitis with etanercept therapy.
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Affiliation(s)
- Yusuf Kasirye
- Department of Internal Medicine, Marshfield Clinic-Park Falls Center, Park Falls, WI 54552, USA.
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Renaud C, Ovetchkine P, Bortolozzi P, Saint-Cyr C, Tapiero B. Fatal group A Streptococcus purpura fulminans in a child receiving TNF-α blocker. Eur J Pediatr 2011; 170:657-60. [PMID: 21063727 DOI: 10.1007/s00431-010-1341-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 10/20/2010] [Indexed: 12/13/2022]
Abstract
Inhibition of tumor necrosis factor alpha (TNF-α) is effective in the treatment of many pediatric autoimmune diseases and inflammatory conditions. Commonly available biologic agents blocking TNF-α are infliximab, etanercept, and adalimumab. These agents have changed the management of rheumatic diseases in the adult population and are being used more and more in pediatric patients as safety and efficacy have been demonstrated. Infections have been the most commonly reported adverse effects of TNF-α inhibition. Granulomatous infections such as tuberculosis are well-known complications, but serious bacterial infections are also reported. We describe a fatal case of purpura fulminans caused by group A Streptococcus in an 8-year-old child with systemic juvenile idiopathic arthritis treated with etanercept. This case highlights the clinical association of severe bacterial infection and TNF-α inhibition in children. Pediatricians should educate their patients who are treated with TNF-α blockers regarding early warning symptoms and should also have a lower threshold for initiating antibiotic therapy in case of fever.
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Affiliation(s)
- Christian Renaud
- Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, 3175 côte Sainte-Catherine (Québec), Montreal, Québec, Canada H3T 1C5
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Meyer-Olson D, Hoeper K, Schmidt RE. [Infectious complications of biologic therapy in patients with rheumatoid arthritis]. Z Rheumatol 2010; 69:879-88. [PMID: 21128049 DOI: 10.1007/s00393-010-0677-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The introduction of biological disease-modifying drugs (DMARDs) has substantially improved the treatment options for patients with rheumatoid arthritis. However, infectious complications represent the most common side effects of these drugs, including severe infections as well as rare opportunistic infections. Treating patients on biological DMARDs is therefore one of the biggest challenges in rheumatology care. The present review describes the current state of knowledge regarding frequency and type of infectious complications associated with biological DMARDs. The article focuses mainly on risk management, in particular on diagnosis and recurrence prevention of tuberculosis and reactivation of hepatitis B virus infection. Furthermore, we discuss the importance of vaccinations in primary disease prevention in patients with rheumatoid arthritis.
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Affiliation(s)
- D Meyer-Olson
- Klinik für Immunologie und Rheumatologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, Hannover, Germany.
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Choueiter NF, Olson AK, Shen DD, Portman MA. Prospective open-label trial of etanercept as adjunctive therapy for kawasaki disease. J Pediatr 2010; 157:960-966.e1. [PMID: 20667551 PMCID: PMC2970727 DOI: 10.1016/j.jpeds.2010.06.014] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Revised: 05/04/2010] [Accepted: 06/08/2010] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine the safety and pharmacokinetics of etanercept (Amgen, Thousand Oaks, California) a tumor necrosis factor-α receptor blocker, in children with acute Kawasaki disease (KD). Standard therapy of acute KD includes intravenous immunoglobulin (IVIG) and high-dose aspirin, but a substantial number of patients are refractory and require additional treatment. Tumor necrosis factor-α levels are elevated in children with KD, suggesting a role for etanercept in treatment. STUDY DESIGN We performed a prospective open-label trial of etanercept in patients with KD (age range, 6 months-5 years; n = 17) meeting clinical criteria and with fever ≤ 10 days. All received IVIG and high-dose aspirin. They received etanercept immediately after IVIG infusion and then weekly two times. For the initial safety evaluation, the first 5 patients received 0.4 mg/kg/dose. Subsequent subjects received 0.8 mg/kg/dose. RESULTS Fifteen patients completed the study. The pharmacokinetics were similar to that in older children in published series. No serious adverse events related to etanercept occurred. No patient demonstrated prolonged or recrudescent fever requiring re-treatment with IVIG. No patient showed an increase in coronary artery diameter or new coronary artery dilation/cardiac dysfunction. CONCLUSION Etanercept appears to be safe and well tolerated in children with KD. The data support performance of a placebo-controlled trial.
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Affiliation(s)
- Nadine F. Choueiter
- Division of Cardiology, Department of Pediatrics, University of Washington and Center for Developmental Therapeutics, Seattle Children’s Hospital and Research Institute, School of Pharmacy, UW, Seattle WA
| | - Aaron K. Olson
- Division of Cardiology, Department of Pediatrics, University of Washington and Center for Developmental Therapeutics, Seattle Children’s Hospital and Research Institute, School of Pharmacy, UW, Seattle WA
| | - Danny D. Shen
- Department of Pharmacy and Pharmaceutics, School of Pharmacy, UW, Seattle WA
| | - Michael A. Portman
- Division of Cardiology, Department of Pediatrics, University of Washington and Center for Developmental Therapeutics, Seattle Children’s Hospital and Research Institute, School of Pharmacy, UW, Seattle WA
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Zulaica A, Pérez-Pérez L, Allegue F. Eficacia y seguridad a corto plazo de etanercept en la psoriasis. ACTAS DERMO-SIFILIOGRAFICAS 2010; 101 Suppl 1:5-11. [DOI: 10.1016/s0001-7310(10)70002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Furst DE. The risk of infections with biologic therapies for rheumatoid arthritis. Semin Arthritis Rheum 2008; 39:327-46. [PMID: 19117595 DOI: 10.1016/j.semarthrit.2008.10.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2008] [Revised: 09/09/2008] [Accepted: 10/01/2008] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To assess the risk of serious and nonserious bacterial and viral infections associated with the use of biologic therapy (abatacept, adalimumab, anakinra, etanercept, infliximab, and rituximab) in patients with rheumatoid arthritis (RA). METHODS Information was derived from PubMed, EMBASE, and the Cochrane clinical trials register and database of systematic reviews and relevant congress abstracts up to and including February 2008. RESULTS Compared with the general population, patients with RA have a heightened risk of infection, including tuberculosis. Long-term clinical trials and postmarketing studies indicate that anakinra and the tumor necrosis factor (TNF) inhibitors are associated with an increased risk of infections versus conventional disease-modifying antirheumatic drugs (DMARDs), especially early in the course of treatment. The most common sites of infection are the respiratory tract (including pneumonia), skin and soft tissue, and the urinary tract. The risk of tuberculosis also appears higher with TNF inhibitors (in particular, infliximab) versus DMARDs, although this can be reduced by screening and prophylaxis. TNF inhibitors do not appear to significantly increase the risk of reactivating chronic viral infections. Influenza and pneumococcal vaccinations are generally effective in the face of TNF inhibitors or abatacept. Available data suggest that the risk of infections and serious infections with abatacept and rituximab may be similar to that of the TNF inhibitors. To date, there have been no reports from clinical trials of increased tuberculosis or opportunistic infections with abatacept or rituximab. CONCLUSIONS All marketed TNF inhibitors for compared to control RA appear to increase the risk of serious and nonserious infections compared with DMARDs. Although suggestive, data for abatacept and rituximab are less definitive and longer periods of patient exposure to these agents are needed before an assessment of their risks can be made.
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Affiliation(s)
- Daniel E Furst
- University of California Los Angeles, Los Angeles, CA 90095-1670, USA.
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Booker MJ, Flint J, Saravana S. Aseptic meningitis in a patient taking etanercept for rheumatoid arthritis: a case report. CASES JOURNAL 2008; 1:364. [PMID: 19046446 PMCID: PMC2612655 DOI: 10.1186/1757-1626-1-364] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Accepted: 12/01/2008] [Indexed: 11/10/2022]
Abstract
Background We report a case of a 53 year old lady recently commenced on etanercept, an anti-TNF (tumour necrosis factor) therapy for rheumatoid arthritis presenting with confusion, pyrexia and an erythematous rash. Case presentation A lumbar puncture was highly suggestive of bacterial meningitis, but CSF cultures produced no growth, and polymerase chain reactions (PCR) for all previously reported bacterial, fungal and viral causes of meningitis were negative. Conclusion This case report describes aseptic meningitis as a previously unreported complication of etanercept therapy, and serves as a reminder of the rare but potentially life-threatening risk of serious infections in patients taking anti-TNF therapy for a variety of conditions.
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Severe Ehrlichia chaffeensis Infection in a Patient Receiving Etanercept, a Tumor Necrosis Factor Inhibitor. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2008. [DOI: 10.1097/ipc.0b013e3181151217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Until recently, inflammatory diseases, collagen vascular diseases, inflammatory bowel diseases, and multiple sclerosis were met with a limited offering for treatment. The introduction of biologic agents has revolutionized the approach to these diseases, offering many patients freedom from disease activity staving off resultant destruction to organs and joints with marked improvement in quality of life and disability. This article focuses on the development of serious infections associated with the use of biologic agents. Presented is a synthesis of case series, reports, and systematic reviews to elucidate implicated pathogens and clinical presentations in patients being treated with biologic agents and to form a cursory backbone for prevention and treatment strategies to which clinicians prescribing these agents or encountering patients already on these agents can readily refer. Maintenance of a high index of suspicion is imperative for the prevention and appropriate treatment of serious life-threatening infections in these patients.
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Affiliation(s)
- Lesley Ann Saketkoo
- Division of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA 70115, USA.
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