Successful resumption of tocilizumab for rheumatoid arthritis after resection of a pulmonary Mycobacterium avium complex lesion: a case report.
BACKGROUND
Biological agents inhibiting TNF-α and other molecules involved in inflammatory cascade have been increasingly used to treat rheumatoid arthritis (RA). However, it remains controversial whether biological agents can be used safely in a patient with an underlying chronic infectious disease.


METHODS
A 63-year-old woman who had been treated with tocilizumab (TCZ), anti-interleukin-6 receptor antibody, for RA presented to our outpatient clinic due to hemoptysis. She was diagnosed with pulmonary Mycobacterium avium complex (MAC) infection, and high-resolution computed tomography (HRCT) showed a single cavitary lesion in the right upper lobe. After diagnosis of pulmonary MAC disease, TCZ was discontinued and combination chemotherapy with clarithromycin, rifampicin, ethambutol and amikacin was started for MAC pulmonary disease. Since the lesion was limited in the right upper lobe as a single cavity formation, she underwent right upper lobectomy. As her RA symptoms were deteriorated around the operation, TCZ was resumed. After resumption of TCZ, her RA symptoms improved and a recurrence of pulmonary MAC infection has not been observed for more than 1 year.


CONCLUSIONS
This case suggested that TCZ could be safely reintroduced after the resection of a pulmonary MAC lesion. Although the use of biological agents is generally contraindicated in patients with pulmonary MAC disease, especially in those with a fibrocavitary lesion, a multimodality intervention for MAC including both medical and surgical approaches may enable introduction or resumption of biological agents.
Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. hounamugun@gmail.com.
Ho
H
Namkoong
Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. tasaka@cpnet.med.keio.ac.jp.
Sadatomo
S
Tasaka
Division of Rheumatology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan. hhhirooo@hotmail.com.
Mitsuhiro
M
Akiyama
Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. kazumayagi1214@yahoo.co.jp.
Kazuma
K
Yagi
Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. ishii@z6.keio.jp.
Makoto
M
Ishii
Division of Rheumatology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan. katsuyas@ta2.so-net.ne.jp.
Katsuya
K
Suzuki
Division of General Thoracic Surgery, Keio University School of Medicine, Tokyo, Japan. kohno@a3.keio.jp.
Mitsutomo
M
Kohno
Center for Infectious Diseases and Infection Control, Keio University School of Medicine, Tokyo, Japan. n-hasegawa@z8.keio.jp.
Naoki
N
Hasegawa
Division of Rheumatology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan. tsutake@z5.keio.jp.
Tsutomu
T
Takeuchi
Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. tbetsuyaku@z5.keio.jp.
Tomoko
T
Betsuyaku
D000583:Amikacin / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized / Q000009:adverse effects* / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D017291:Clarithromycin / Q000627:therapeutic use; D004977:Ethambutol / Q000627:therapeutic use; D005260:Female; D006801:Humans; D016867:Immunocompromised Host; D008168:Lung / Q000000981:diagnostic imaging / Q000601:surgery*; D008875:Middle Aged; D015270:Mycobacterium avium-intracellulare Infection / Q000000981:diagnostic imaging / Q000276:immunology / Q000628:therapy*; D011013:Pneumonectomy; D012293:Rifampin / Q000627:therapeutic use; D014057:Tomography, X-Ray Computed
D000900:Anti-Bacterial Agents; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D000583:Amikacin; D004977:Ethambutol; D017291:Clarithromycin; C502936:tocilizumab; D012293:Rifampin