RESUMEN
This case report describes a 61-year-old rheumatoid arthritis patient with an atypical clinical presentation of a sore throat. Because of rheumatoid arthritis refractory to conventional disease-modifying antirheumatic drug therapy, anti-TNFalpha was felt to be indicated, and a screening for tuberculosis was carried out. As the screening for tuberculosis (PPD) was positive, isoniazid was prescribed prophylactically for six months. After eight months of anti-TNFalpha (adalimumab) treatment, he developed tonsillar enlargement and nodular pulmonary lesions. Histopathological and microbial investigations established the diagnosis of tonsillar tuberculosis.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Tonsila Palatina/microbiología , Tuberculosis Laríngea/microbiología , Tuberculosis Pulmonar/microbiología , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Adalimumab , Antibacterianos , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales Humanizados , Antituberculosos/uso terapéutico , Artritis Reumatoide/sangre , ADN Bacteriano/análisis , Diagnóstico Diferencial , Quimioterapia Combinada/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Mycobacterium tuberculosis/genética , Mycobacterium tuberculosis/aislamiento & purificación , Tonsila Palatina/patología , Reacción en Cadena de la Polimerasa , Factores de Riesgo , Tuberculosis Laríngea/diagnóstico , Tuberculosis Laríngea/tratamiento farmacológico , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/tratamiento farmacológico , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
BACKGROUND: Leflunomide is the prodrug of the disease modifying antirheumatic metabolite A77 1726. More than 50% of patients withdraw from leflunomide treatment within one year, mainly because of adverse drug reactions. Therapeutic drug monitoring of A77 1726 may be useful in predicting the efficacy of leflunomide treatment. OBJECTIVE: To study the relation between A77 1726 steady state serum concentrations and disease activity using the 28 joint (DAS28) response. METHODS: Outpatients with rheumatoid arthritis on a stable leflunomide dose for >4 months were included. DAS28 score and adverse drug reactions were recorded. Blood samples were taken for determination of A77 1726 concentrations. The primary end point was the relation of serum A77 1726 concentrations with DAS28 response category. RESULTS: Serum A77 1726 concentrations were determined in 52 patients. A receiver operating characteristic (ROC) curve showed an area under the curve (AUC) of 0.73 (95% confidence interval, 0.54 to 0.93) (p<0.05). The sensitivity exceeded 99% at concentrations below 16 mg/l. DAS28 values at the point of sampling showed no relation with A77 1726 concentrations (AUC of the ROC curve = 0.50 (0.33 to 0.67) (NS)). CONCLUSIONS: A77 1726 steady state serum concentrations show a relation with DAS28 response. Determination of serum A77 1726 concentrations in patients with insufficient response to treatment may help when decisions have to be made about continuation of treatment or dose adjustment.
