Fatal fulminant legionnaires' disease in a patient with severe erythodermic psoriasis treated with infliximab after long-term steroid therapy

Legionnaire's Disease and Immunosuppressive Drugs

Immunosuppressive agents predispose patients to legionnaire's disease. Patients receiving tumor necrosis factor antagonists are generally not severely immunocompromised by the underlying disease. In patients with malignancy receiving immunosuppressive therapies, it is difficult to balance the underlying disease versus the therapy used. Transplant recipients are often on multiple drugs, including immunosuppressants. It seems that immunosuppressive drugs add to the risk for legionella infection. The index of suspicion should be high for legionella infection early during a compatible clinical syndrome. The control of Legionella species and prevention of transmission should be the foremost goal in protecting susceptible populations from Legionnaire's disease.

Environmental factors associated with nosocomial legionellosis after anti-tumor necrosis factor therapy: case study

In response to 2 reported cases of nosocomial legionellosis after anti-tumor necrosis factor (TNF) treatment, the environmental controls and testing facilities in a 221-bed acute care hospital were investigated. This investigation led to the implementation of a series of specific preventive measures adapted from protocols used to protect immunosuppressed patients. These 2 cases of legionellosis might be related to 2 concurrent events: treatment of hospitalized patients with anti-TNF drugs and secondary environmental changes related to major construction work. Patients undergoing anti-TNF treatment may be at increased risk for developing opportunistic infections during construction work, renovations, or water supply perturbations and require specific preventive measures.

[Non tuberculous anti-TNF associated opportunistic infections]

Anti-TNFalpha agents have revolutionized the treatment of patients with rheumatoid arthritis, spondylarthropathies and Crohn's disease. However, their use is associated with an increased risk of infections. Pyogenic infections (involving the lungs, skin and urinary tract) and tuberculosis are the more commonly observed infectious complications in patients receiving anti-TNFalpha agents. However, opportunistic infections have been increasingly reported in anti-TNFalpha-treated patients, and include non tuberculous mycobacteria, fungi (Pneumocystis jiroveci, Candida sp, Aspergillus, Cryptococcus, Histoplasma), opportunistic bacterial (Nocardia), parasitic (Leishmania) and viral (e.g. Cytomegalovirus, human herpes virus 8 [HHV 8]) infections. These infectious complications usually occur within the first months of therapy and are important causes of morbidity and mortality in anti-TNFalpha-treated patients. It is recommended to rule out infections, especially latent or active tuberculosis, before the initiation of anti-TNFalpha therapy. However, it is necessary to follow-up closely these patients to detect the possible occurrence of opportunistic infections.

Fulminant legionellosis in two patients treated with infliximab for Crohn's disease: case series and literature review

Two cases of fulminant pulmonary legionellosis, complicated by prolonged intensive care unit stays and acute respiratory distress syndrome, and who were recently treated with infliximab for Crohn's disease, are described. A review of the literature revealed three additional cases in patients with inflammatory bowel disease, and a total of 22 cases of Legionella pneumophila pneumonia in the context of treatment with antitumour necrosis (TNF)-alpha medications. The median age of the patients was 49 years, and men and women were affected equally. The case fatality rate was 14% (three of 22). Early recognition and treatment of this anti-TNF-alpha-related complication would likely result in reduced mortality and morbidity. Physicians prescribing anti-TNF-alpha drugs should be aware of this association.

Epidemiological investigation on a suggestive case of Legionella pneumonia and public health implications

We report a case of Legionella pneumonia in a patient with psoriasis. The clinical strain had an identical PFGE pattern of 1 subtype of L. pneumophila serogroup 1 isolated at low concentration in a sporting club bath. Diagnostic, clinical and epidemiological aspects are discussed for their relevant public health implications.

Infliximab in severe ulcerative colitis: short-term results of different infusion regimens and long-term follow-up

BACKGROUND

Severe ulcerative colitis is a life-threatening disorder, despite i.v. glucocorticoids treatment. Infliximab has been proposed as a safe rescue therapy.

AIM

To evaluate short- and long-term effectiveness and safety of infliximab in severe refractory ulcerative colitis.

METHODS

Eighty-three patients with severe ulcerative colitis (i.v. glucocorticoids treatment-refractory) were treated with infliximab in 10 Italian Gastroenterology Units. Patients underwent one or more infusions according to the choice of treating physicians. Short-term outcome was colectomy/death 2 months after the first infusion. Long-term outcome was survival free from colectomy. Safety data were recorded.

RESULTS

Twelve patients (15%) underwent colectomy within 2 months. One died of Legionella pneumophila infection 12 days after infliximab. Early colectomy rates were higher in patients receiving one infusion (9/26), compared with those receiving two/more infusions (3/57, P = 0.001, OR = 9.53). Seventy patients who survived colectomy and did not experience any fatal complications were followed-up for a median time of 23 months; 58 patients avoided colectomy during the follow-up. Forty-two patients were maintained on immunosuppressive drugs. No clinical features were associated with outcomes.

CONCLUSIONS

Infliximab is an effective and relatively safe therapy to avoid colectomy and maintain long-term remission for patients with severe refractory ulcerative colitis. In the short term, two or more infusions seem to be more effective than one single infusion.

Emergence of Legionella pneumophila Pneumonia in Patients Receiving Tumor Necrosis Factor- Antagonists

BACKGROUND

Patients treated with tumor necrosis factor-alpha (TNF-alpha) antagonists have an increased risk of infection, but infection due to Legionella pneumophila has rarely been described in patients receiving such therapy.

METHODS

A registry involving 486 clinical departments in France was designed by a multidisciplinary group (Recherche Axée sur la Tolérance des Biothérapies [RATIO]) to collect data on opportunistic and severe infections occurring in patients treated with TNF-alpha antagonists. All cases are reported to RATIO in accordance with national health authorities and validated by infectious disease experts. The legionellosis rate among patients treated with TNF-alpha antagonists was compared with the rate in France overall.

RESULTS

We report a 1-year consecutive series of 10 cases of L. pneumophila pneumonia in France in 2004, including 6 cases treated with adalimumab, 2 treated with etanercept, and 2 treated with infliximab. The median patient age was 51 years (range, 40-69 years). Eight patients were treated for rheumatoid arthritis, 1 was treated for cutaneous psoriasis, and 1 was treated for pyoderma gangrenosum. The median duration of TNF-alpha antagonist treatment at onset of infection was 38.5 weeks (range, 3-73 weeks). Eight patients were receiving concomitant treatment with corticosteroids, and 6 were receiving treatment with methotrexate. The relative risk of legionellosis when receiving treatment with a TNF-alpha antagonist, compared with the relative risk in France overall, was estimated to be between 16.5 and 21.0. We also report a second episode of confirmed legionellosis following the reintroduction of infliximab therapy.

CONCLUSIONS

L. pneumophila pneumonia is a potentially severe but curable infection that might complicate anti-TNF-alpha therapy. In patients receiving anti-TNF-alpha who develop pneumonia, legionellosis should be systematically investigated, and first-line antibiotic therapy should be efficient against L. pneumophila.