Risk factors of severe infections in patients with rheumatoid arthritis treated with leflunomide

Possible environmental exposure-associated pulmonary cryptococcosis in a patient with rheumatoid arthritis: a case report and literature review

Patients with rheumatoid arthritis (RA) taking long-term immunosuppressive drugs are more susceptible to opportunistic infections, such as cryptococcosis. A 65-year-old woman was transferred to our hospital for rapidly progressing pulmonary lesions identified by lung computed tomography. She had a 7-year history of RA and had been prescribed methotrexate and glucocorticoids for 10 months. Additionally, our patient had a history of environmental exposure to house renovation lasting approximately 1 week before onset. Her serological test results and histopathological examination confirmed the diagnosis of pulmonary cryptococcosis (PC). The patient recovered well after 6 months of fluconazole treatment. In addition, we summarized 28 reported cases of RA patients with PC and found that older age might be a risk factor for cryptococcal infection in RA patients. The most common location for pulmonary lesions was the lower lobe, and the most common radiologic manifestations were nodules. Detection of cryptococcal capsular polysaccharide antigen was important for diagnosis. Patients undergoing antirheumatic therapy should avoid exposure to Cryptococcus.

Acute respiratory viral adverse events during use of antirheumatic disease therapies: A scoping review

INTRODUCTION

COVID-19 is an acute respiratory viral infection that threatens people worldwide, including people with rheumatic disease, although it remains unclear to what extent various antirheumatic disease therapies increase susceptibility to complications of viral respiratory infections.

OBJECTIVE

The present study undertakes a scoping review of available evidence regarding the frequency and severity of acute respiratory viral adverse events related to antirheumatic disease therapies.

METHODS

Online databases were used to identify, since database inception, studies reporting primary data on acute respiratory viral infections in patients utilizing antirheumatic disease therapies. Independent reviewer pairs charted data from eligible studies using a standardized data abstraction tool.

RESULTS

A total of 180 studies were eligible for qualitative analysis. While acknowledging that the extant literature has a lack of specificity in reporting of acute viral infections or complications thereof, the data suggest that use of glucocorticoids, JAK inhibitors (especially high-dose), TNF inhibitors, and anti-IL-17 agents may be associated with an increased frequency of respiratory viral events. Available data suggest no increased frequency or risk of respiratory viral events with NSAIDs, hydroxychloroquine, sulfasalazine, methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide, or apremilast. One large cohort study demonstrated an association with leflunomide use and increased risk of acute viral respiratory events compared to non-use.

CONCLUSION

This scoping review identified that some medication classes may confer increased risk of acute respiratory viral infections. However, definitive data are lacking and future studies should address this knowledge gap.

Non-healing tongue ulcer in a rheumatoid arthritis patient medicated with leflunomide. An adverse drug event?

Leflunomide is a member of the disease modifying anti-rheumatic drugs group used as a treatment modality in active rheumatoid and psoriatic arthritis. “Oral ulcers” are reported in 3-5% of leflunomide medicated rheumatoid arthritis patients with adverse events, but they are not described in detail in the literature. We present a case of an ulcer in the tongue of a rheumatoid arthritis patient managed with leflunomide and contemplate on its pathogenesis.

Key words:Leflunomide, oral ulcer, DHODH.

Pulmonary cryptococcosis that mimicked rheumatoid nodule in rheumatoid arthritis lesion

Recently, the incidence of pulmonary cryptococcosis is gradually increasing in rheumatoid arthritis (RA) patients. Pulmonary rheumatoid nodules (PRN) are rare manifestations of RA. Eighteen months ago, a 65-year old woman was admitted to hospital due to multiple nodules (2.5×2.1×2 cm) with cavitations in the right lower lobe. She was diagnosed with RA three year ago. She had been taking methotrexate, leflunomide, and triamcinolone. A video-assisted thoracoscopic surgery biopsy was performed and PRN was diagnosed. However, a newly growing huge opacity with cavitation was detected in the same site. Pulmonary cryptococcal infection was diagnosed through a transthoracic computed tomograpy guided needle biopsy. Cryptococcus antigen was detected in serum but not in cerebrospinal fluid. The patient was treated with oral fluconazole which resulted clinical improvement and regression of the nodule on a series of radiography. Herein, we report the case of pulmonary cryptococcosis occurring in the same location as that of the PRN.