title: Disseminated Histoplasma capsulatum infection presenting with panniculitis and focal myositis in rheumatoid arthritis treated with etanercept.
abstract: We report the case of a patient with rheumatoid arthritis (RA) on etanercept who presented with panniculitis and focal myositis as manifestations of disseminated histoplasmosis. Systematic search of the literature showed 11 additional case reports of disseminated histoplasmosis with tumour necrosis factor-alpha (TNFalpha) blockade therapy (infliximab, n = 8; etanercept, n = 3). Although disseminated histoplasmosis may manifest with classical symptoms of fever and respiratory complaints, it may also present atypically, such as with panniculitis and focal myositis. This review illustrates and emphasizes the importance of being highly suspicious for infection, including by opportunistic organisms, and to exclude such process in patients treated with a TNFalpha inhibitor when faced with unusual complications, even when an alternative aetiology appears plausible.
authors.affiliation: Division of Rheumatology, Department of Medicine, Notre-Dame Hospital, Centre Hospitalier de l'Université de Montréal, and Université de Montréal, Montreal, Quebec, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Bourré-Tessier
authors.forename: C
authors.initials: C
authors.lastname: Fortin
authors.forename: A
authors.initials: A
authors.lastname: Belisle
authors.forename: E
authors.initials: E
authors.lastname: Desmarais
authors.forename: D
authors.initials: D
authors.lastname: Choquette
authors.forename: J-L
authors.initials: JL
authors.lastname: Senécal
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology; D001707:Biopsy, Needle; D003937:Diagnosis, Differential; D004359:Drug Therapy, Combination; D000068800:Etanercept; D005500:Follow-Up Studies; D016469:Fungemia / Q000175:diagnosis* / Q000188:drug therapy; D006658:Histoplasma / Q000302:isolation & purification; D006660:Histoplasmosis / Q000175:diagnosis* / Q000473:pathology; D006801:Humans; D016867:Immunocompromised Host / Q000276:immunology; D007074:Immunoglobulin G / Q000627:therapeutic use*; D007150:Immunohistochemistry; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D017964:Itraconazole / Q000627:therapeutic use; D008297:Male; D009220:Myositis / Q000175:diagnosis* / Q000188:drug therapy / Q000276:immunology; D009894:Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy; D015434:Panniculitis / Q000175:diagnosis* / Q000188:drug therapy / Q000276:immunology; D018124:Receptors, Tumor Necrosis Factor / Q000627:therapeutic use*; D018570:Risk Assessment
chemical_list: D000900:Anti-Bacterial Agents; D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D018124:Receptors, Tumor Necrosis Factor; D017964:Itraconazole; D000068800:Etanercept