Disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection in a patient with infliximab and methotrexate.
METHODS
Despite chemoprophylaxis with isoniazid a 58-year-old Creole patient with mild rheumatoid arthritis developed disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection during treatment with infliximab and methotrexate.


METHODS
The patient received antituberculous drugs (ethambutol, isoniazid, pyrazinamide, rifampicin), amphotericin B, flucytosine, and valaciclovir, along with prolonged intensive care treatment and mechanical ventilation.


CONCLUSIONS
The present case confirms that isoniazid prophylaxis (300 mg once daily, during 6 months) does not protect against the reactivation and dissemination of latent tuberculosis. It also shows that combined treatment with infliximab and methotrexate may induce severe immunosuppression with prolonged leukocytopenia and depressed cellular immunity, leading to multiple opportunistic infections. Extensive diagnostic testing, early start of antimicrobial therapy and enteral immunonutrition, and further infection prevention with selective decontamination of the digestive tract may have been the key to a good clinical outcome.
Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM, Amsterdam, The Netherlands. jm.vd.klooster@ikazia.nl.|Ikazia Ziekenhuis, Montessoriweg 1, 3083 AN, Rotterdam, The Netherlands. jm.vd.klooster@ikazia.nl.
J M
JM
van der Klooster
Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM, Amsterdam, The Netherlands.
R J
RJ
Bosman
Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM, Amsterdam, The Netherlands.
H M
HM
Oudemans-van Straaten
Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM, Amsterdam, The Netherlands.
J I
JI
van der Spoel
Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM, Amsterdam, The Netherlands.
J P J
JPJ
Wester
Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM, Amsterdam, The Netherlands.
D F
DF
Zandstra
D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000150:complications* / Q000188:drug therapy; D001229:Aspergillosis, Allergic Bronchopulmonary / Q000150:complications*; D005260:Female; D006561:Herpes Simplex / Q000150:complications*; D006801:Humans; D000069285:Infliximab; D008727:Methotrexate / Q000627:therapeutic use; D008875:Middle Aged; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy
D000911:Antibodies, Monoclonal; D018501:Antirheumatic Agents; D000995:Antitubercular Agents; D000069285:Infliximab; D008727:Methotrexate