title: [Erysipelas without fever or biologic inflammation during tocilizumab therapy].
abstract: BACKGROUND
  Tocilizumab (TCZ) is a monoclonal antibody that inhibits the interleukin 6 (IL-6) signalling pathway. This treatment is extremely effective in rheumatoid arthritis (RA), which may well be accompanied by serious infections presenting misleading clinical pictures. Herein we report a case of a typical bacterial dermo-hypodermitis in a female patient treated with TCZ.
  
  
  METHODS
  An 80-year-old woman treated with methotrexate (MTX) and TCZ for RA presented dermo-hypodermitis on her left leg 8 days after receiving her 13th infusion of TCZ. She exhibited neither fever nor biological inflammatory syndrome. Oral amoxicillin (3g/d) was initiated on an outpatient basis. Two weeks later, the patient was apyretic and her laboratory results were normal, although local inflammatory signs persisted. TCZ infusion was postponed and she was given intravenous amoxicillin (4g/d) for 2days, followed by oral amoxicillin, resulting in rapid recovery. Subsequent courses of TCZ were administered without incident.
  
  
  CONCLUSIONS
  During the course of treatment with TCZ, this patient presented delineated bacterial cellulitis in the form of erysipelas, which was noteworthy on account of the absence of fever and of biological inflammatory syndrome. While there have been reports of severe cases of cellulitis during TCZ treatment, to our knowledge, there have been none of erysipelas. Attenuation of local and systemic inflammatory symptoms is widely reported, and is directly associated with the anti-IL-6 action of TCZ. Patients with RA are especially susceptible to opportunistic or severe infections as a result of the disease itself and of associated treatments, and increased vigilance is called for with regard to infections that may be transformed and potentially more severe as a result of TCZ.
authors.affiliation: Hôpital central, centre régional de pharmacovigilance, CHRU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy, France.
authors.forename: M
authors.initials: M
authors.lastname: Yéléhé-Okouma
authors.affiliation: Département de dermatologie et allergologie, CHRU de Nancy, rue du Morvan, bâtiment des spécialités médicales, site de Brabois, 545011 Vandœuvre-lès-Nancy, France.
authors.forename: J
authors.initials: J
authors.lastname: Henry
authors.affiliation: Hôpital central, centre régional de pharmacovigilance, CHRU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy, France.
authors.forename: N
authors.initials: N
authors.lastname: Petitpain
authors.affiliation: Département de dermatologie et allergologie, CHRU de Nancy, rue du Morvan, bâtiment des spécialités médicales, site de Brabois, 545011 Vandœuvre-lès-Nancy, France.
authors.forename: J-L
authors.initials: JL
authors.lastname: Schmutz
authors.affiliation: Hôpital central, centre régional de pharmacovigilance, CHRU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy, France. Electronic address: p.gillet@chru-nancy.fr.
authors.forename: P
authors.initials: P
authors.lastname: Gillet
mesh_terms: D000369:Aged, 80 and over; D000658:Amoxicillin / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000009:adverse effects*; D018501:Antirheumatic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy; D003937:Diagnosis, Differential; D004359:Drug Therapy, Combination; D004886:Erysipelas / Q000139:chemically induced* / Q000175:diagnosis / Q000188:drug therapy; D005260:Female; D005334:Fever; D006801:Humans; D007249:Inflammation; D007260:Infusion Pumps / Q000009:adverse effects; D007866:Leg / Q000473:pathology; D008727:Methotrexate / Q000008:administration & dosage; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D000658:Amoxicillin; C502936:tocilizumab; D008727:Methotrexate
keywords: Cellulite; Cellulitis; Erysipelas; Interleukin-6; Interleukine-6; Polyarthrite rhumatoïde; Rheumatoid arthritis; Tocilizumab; Érysipèle