title: A life-threatening abscess in a patient treated with a tumour necrosis factor-alpha antagonist: a case report.
abstract: A 25-year-old man with a 3-year history of ankylosing spondylitis presented with a sudden onset of pain in his left thigh. His ankylosing spondylitis had been treated for 2 years with the tumour necrosis factor-alpha (TNF-alpha) antagonist infliximab. The initial diagnosis was a muscular tear, and non-steroidal anti-inflammatory drugs were prescribed. 40 days later, the patient had tender swelling with warmth and light redness on his left thigh. His knee function had decreased markedly. His C-reactive protein level was 320 mg/l and white cell count was 30.4 x10(9)/l, indicating severe infection. Magnetic resonance imaging revealed a loculated fluid collection in the quadriceps musculature measuring 30 cm. Hyperintensity seen on T1-weighted images was suggestive of infection. The infliximab therapy was stopped and repeated debridement and drainage performed, with about 2.5 litres of pus evacuated. Flucloxacillin was administered for 2 weeks. The wound was closed 9 days later. The patient was discharged 20 days after surgery. An alternative immunosuppressive therapy--abatacept--was introduced. At the 18-month follow-up, the patient reported only light discomfort in the thigh during exercise, with a mildly impaired range of knee movement. No infectious complications recurred.
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Royal Perth Hospital, Perth, Australia. dcadosch@anhb.uwa.edu.au
authors.forename: Dieter
authors.initials: D
authors.lastname: Cadosch
authors.forename: Lisa
authors.initials: L
authors.lastname: Neukom
authors.forename: Oliver P
authors.initials: OP
authors.lastname: Gautschi
authors.forename: Rene
authors.initials: R
authors.lastname: Zellweger
mesh_terms: D000069594:Abatacept; D000038:Abscess / Q000139:chemically induced* / Q000382:microbiology / Q000628:therapy*; D000893:Anti-Inflammatory Agents / Q000009:adverse effects*; D000911:Antibodies, Monoclonal / Q000009:adverse effects*; D003131:Combined Modality Therapy; D003646:Debridement; D003937:Diagnosis, Differential; D004322:Drainage; D006801:Humans; D018796:Immunoconjugates / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D000069285:Infliximab; D008279:Magnetic Resonance Imaging; D008297:Male; D013167:Spondylitis, Ankylosing / Q000188:drug therapy*; D013848:Thigh; D055815:Young Adult
chemical_list: D000893:Anti-Inflammatory Agents; D000911:Antibodies, Monoclonal; D018796:Immunoconjugates; D007166:Immunosuppressive Agents; D000069594:Abatacept; D000069285:Infliximab