Fulminant Necrotizing Fasciitis And Myositis With Streptococcal Toxic Shock Syndrome In A Patient With Rheumatoid Arthritis On Tocilizumab: A Case Report

IF 4.6 2区 教育学 Q1 EDUCATION & EDUCATIONAL RESEARCH Educational Technology & Society Pub Date : 2020-10-31 DOI:10.24966/ets-8798/100052
Oana Antal
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Abstract

Introduction: We present the case of a 44-year man with a fulminant necrotizing myositis and fasciitis and streptococcal toxic shock syndrome, the patient being under treatment with tocilizumab and methotrexate for rheumatoid arthritis. Case presentation: He presented to the emergency department with diarrhea, flu-like symptoms and intense progressive pain in the right thigh after having shoveled while doing building work at home. His condition deteriorated within hours, he developed severe rhabdomyolysis, multiple organ dysfunction syndrome, disseminated intravascular coagulopathy and died, despite early treatment. Discussion: A great index of suspicion for severe necrotizing soft tissue infections is necessary in patients on tocilizumab or other biologic immunosuppressive agents. The possible mechanisms in this setting include lowering CRP involved in innate immune responses, decrement of neutrophil count and function, increasing iron availability for infection, as well as high expression of vimentin, the streptococcal binding protein, by regenerating muscle fibers after trauma. Diarrhea due to endotoxins and flu-like symptoms may be early and sometimes they may be the only presenting signs of severe group A streptococcal infection in patients with blunt trauma on biologics. Low initial CRP and white blood cell count may be misleading. A rapid streptococcal strip test may help anticipate and possibly prevent a deleterious evolution in such patients. Conclusion: Biologics may modify the clinical presentation of NF, the LRINEC score, and the pathology decision algorithm. A great index of suspicion for severe soft tissue infections is required in patients on biologics with blunt trauma, especially when presenting with flu-like symptoms, diarrhea, or vomiting.
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Tocilizumab治疗类风湿性关节炎患者并发坏死性筋膜炎和肌炎伴链球菌毒性休克综合征一例报告
引言:我们报告一例44岁男性,患有暴发性坏死性肌炎、筋膜炎和链球菌中毒性休克综合征,该患者正在接受托西利珠单抗和甲氨蝶呤治疗类风湿性关节炎。病例介绍:他在家里做建筑工作时铲了铲,出现腹泻、流感样症状和右大腿剧烈进行性疼痛,随后去了急诊室。他的病情在数小时内恶化,出现严重的横纹肌溶解症、多器官功能障碍综合征、弥漫性血管内凝血病,尽管早期治疗,但仍死亡。讨论:对于使用托西利珠单抗或其他生物免疫抑制剂的患者,有必要对严重坏死性软组织感染进行高度怀疑。这种情况下的可能机制包括降低参与先天免疫反应的CRP,减少中性粒细胞计数和功能,增加感染的铁可利用性,以及通过创伤后再生肌肉纤维来高表达波形蛋白,即链球菌结合蛋白。内毒素和流感样症状引起的腹泻可能是早期的,有时它们可能是生物制品钝性创伤患者严重A组链球菌感染的唯一表现。低的初始CRP和白细胞计数可能会产生误导。快速链球菌条带检测可能有助于预测并可能预防此类患者的有害进化。结论:生物制品可以改变NF的临床表现、LRINEC评分和病理学决策算法。使用生物制剂治疗钝性创伤的患者,尤其是出现流感样症状、腹泻或呕吐时,需要对严重软组织感染进行高度怀疑。
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来源期刊
Educational Technology & Society
Educational Technology & Society EDUCATION & EDUCATIONAL RESEARCH-
CiteScore
9.10
自引率
2.50%
发文量
1
审稿时长
20 weeks
期刊最新文献
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