Affected by Listeia meningoencephalitis during Remicade treatment for steroid-dependent Still's disease

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A case in which the subject was affected by Listeia meningoencephalitis

during administration of infliximab for steroid-dependent adult onset

Still's disease.

Yamamoto M, Takahashi H, Miyamoto C, Ohara M, Suzuki C, Naishiro Y, Yamamoto

H, Shinomura Y, Nonaka M, Imai K.

First Department of Internal Medicine, Sapporo Medical University School of

Medicine. http://www.docguide.com/news/

The subject was a 22-year-old woman who developed high fever and arthralgias

and eruptions in the extremities around June 2005. She sought medical advice

at a nearby dermatology clinic, where hepatic dysfunction was noted on blood

testing. The patient was thus hospitalized the next day. Although CRP levels

were significantly high, no sign of infection was observed and bone marrow

cell differentiation was normal.

Adult onset Still's disease was diagnosed based on the observation of

persistent high fever >39 degrees C, eruptions, increased leukocytes,

pharyngeal pain, splenomegaly, hepatic dysfunction, negative autoantibody

results from blood testing, and high serum ferritin levels.

Administration of prednisolone 30 mg/day was initiated, but proved

ineffective. Steroid pulse therapy was conducted, and the subject was

transferred to our medical facility for continued treatment. Attempts were

made to control the disease using combined steroid and cyclosporine

administration ; but exacerbation of high serum ferritin levels and hepatic

dysfunctions were observed, so a second course of steroid pulse therapy was

conducted.

Symptoms improved temporarily, but steroid levels were difficult to reduce.

Cyclosporine was therefore replaced by methotrexate, and administration of

infliximab was initiated. In the course of treatment, administration of a

sulfamethoxazole/trimethoprim combination was initiated, but was

discontinued due to suspicion of drug-induced hepatic injury.

A second administration of infliximab was conducted in late August, and

rapid improvements in clinical symptoms and abnormal test values was

observed. However, high fever and headache developed suddenly in early

September.

Based on the results of spinal fluid testing, blood and spinal fluid

cultures and MRI of the head, Listeria meningoencephalitis was diagnosed.

Diplopia and impaired consciousness occurred during the disease course, and

formation of a brain abscess was observed on imaging. However, symptoms were

controlled by long-term combination administration of ampicillin and

gentamicin.

Administration of infliximab was discontinued for treatment of adult onset

Still's disease, and steroid levels were reduced following double-membrane

filtration plasma exchange. On follow-up, no relapse of symptoms or

abnormalities in blood test values were observed, so the subject was

discharged from our medical facility in December 2005.

In treatment for rheumatic diseases, a dramatic improvement in treatment

results for pathologies displaying tolerance against conventional treatments

has been acquired with the development of biological drugs. However,

opportunistic infections represent a serious problem, and appropriate

preventative measures are required.

The present report describes a case in which the subject was affected by

Listeria meningoencephalitis during administration of infliximab for

steroid-dependent adult Still's disease. Since listeriosis is one of the

complications, along with tuberculosis, that warrants precautionary

measures, this case is reported and discussed.

Nihon Rinsho Meneki Gakkai Kaishi. 2006 Jun;29(3):160-8.

PMID: 16819265 [PubMed - in process]