LETTER TO THE EDITOR
Tuberculous Peritonitis in a Patient With Rheumatoid Arthritis To the Editor: e read with interest a report by Cooper et al1 (J Clin Rheumatol August 2009) on a case with tuberculous peritonitis whose first manifestation was abdominal pain.1 We would like to share our experience with a patient whose condition was similar to that reported by Cooper et al.1 A 52-year-old woman was admitted to our hospital because of 1-week history of abdominal pain. There was no chest symptom such as cough, sputum, and dyspnea on effort. She had a 12-year history of rheumatoid arthritis and, thereafter, was prescribed methotrexate (8 mg/wk) and prednisolone (10 mg/d) for 10 years. Her abdomen was not distended, but had diffuse dullness on percussion, without pathological masses. She had mild lower abdominal tenderness. Laboratory data showed a white blood cell count of 6400/ HL and C-reactive protein of 13.43 mg/dL.
W
Abdominal computed tomography (CT) scan showed ascites in perihepatic space and the rectouterine pouch (Douglas pouch) (Fig.). Chest CT scan revealed massive pleural fluid on the right, but neither infiltrate nor hilar lymph node swelling was found. Pleural fluid was aspirated, and analysis revealed it to be an exudate with predominant lymphocytes and an elevated adenosine deaminase level (131.5 IU/L). Culture for Mycobacterium tuberculosis was positive. Tuberculin skin test and quantiFERON-tuberculosis was positive. As ascites was high density but very small, abdominocentesis could not be performed. A standard antituberculosis regimen was initiated (isoniazid, rifampin, pyrazinamide, and ethambutol), and prednisolone and methotrexate were continued. Four months after the initiation of the therapy, ascites and pleural fluid disappeared, and abdominal pain completely resolved. Antituberculosis therapy was completed, and no relapse was observed after 12 months of follow-up after the end of treatment. We have described a patient suffering from rheumat oid arthritis who presented with
abdominal pain due to tuberculous peritonitis. The patient had been treated over 10 years with methotrexate and prednisolone. This was very similar to a patient with ankylosing spondylitis under treatment with the immunosuppressive drug, infliximab, reported by Cooper et al,1 whose first manifestation of tuberculous peritonitis was abdominal pain. There have been some reported cases with tuberculous peritonitis during immunosuppressive therapyfor collagen diseases.1Y7 The most deserving point is that some patients with collagen diseases, who are treated with any immunosuppressive drugs, might develop tuberculous peritonitis. Katsunori Kagohashi, Gen Ohara, Koichi Kurishima, Hiroaki Satoh,
MD MD MD MD
Division of Respiratory Medicine Mito Medical Center University of Tsukuba Mito, Ibaraki, Japan [email protected]
The authors declare no conflict of interest.
FIGURE. Abdominal CT scan showing ascites in the perihepatic space (arrowhead), adjacent to the colon (*), and in the rectouterine pouch (Douglas pouch) (arrow). JCR: Journal of Clinical Rheumatology
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Volume 20, Number 1, January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Letter to the Editor
REFERENCES 1. Cooper J, Flu¨ckiger B, Traichl B, et al. Abdominal pain in a patient with ankylosing spondylitis under treatment with infliximab. J Clin Rheumatol. 2009;15:244Y246. 2. Szerszen A, Gupta S, Seminara D, et al. Peritoneal tuberculosis complicated by immune reconstitution inflammatory syndrome in a patient treated with infliximab?: A case for adjuvant immunosuppressive therapy. J Clin Rheumatol. 2009;15:417Y418.
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3. Azuma N, Morimoto M, Tsubota N, et al. Tuberculous peritonitis during etanercept therapy for rheumatoid arthritis. Nihon Rinsho Meneki Gakkai Kaishi. 2011;34: 501Y509. 4. Huesler M, Ruef C, Pfyffer GE, et al. Peritoneal tuberculosis mimicking advanced ovarian cancer in a patient treated with methotrexate for chronic rheumatoid arthritis. J Obstet Gynaecol. 2003;23: 315Y316.
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Volume 20, Number 1, January 2014
5. Matsumoto T, Tanaka T, Kawase I. Infliximab for rheumatoid arthritis in a patient with tuberculosis. N Engl J Med. 2006;355:740Y741. 6. Verhave JC, van Altena R, Wijnands MJ, et al. Tuberculous peritonitis during infliximab therapy. Neth J Med. 2008;66:77Y80. 7. Yoo WH. Multiple organ tuberculosis of lung, pleura, and peritoneum in ankylosing spondylitis during adalimumab therapy. Rheumatol Int. 2012;32:787Y790.
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Tuberculous Peritonitis in a Patient With Rheumatoid Arthritis To the Editor: e read with interest a report by Cooper et al1 (J Clin Rheumatol August 2009) on a case with tuberculous peritonitis whose first manifestation was abdominal pain.1 We would like to share our experience with a patient whose condition was similar to that reported by Cooper et al.1 A 52-year-old woman was admitted to our hospital because of 1-week history of abdominal pain. There was no chest symptom such as cough, sputum, and dyspnea on effort. She had a 12-year history of rheumatoid arthritis and, thereafter, was prescribed methotrexate (8 mg/wk) and prednisolone (10 mg/d) for 10 years. Her abdomen was not distended, but had diffuse dullness on percussion, without pathological masses. She had mild lower abdominal tenderness. Laboratory data showed a white blood cell count of 6400/ HL and C-reactive protein of 13.43 mg/dL.
W
Abdominal computed tomography (CT) scan showed ascites in perihepatic space and the rectouterine pouch (Douglas pouch) (Fig.). Chest CT scan revealed massive pleural fluid on the right, but neither infiltrate nor hilar lymph node swelling was found. Pleural fluid was aspirated, and analysis revealed it to be an exudate with predominant lymphocytes and an elevated adenosine deaminase level (131.5 IU/L). Culture for Mycobacterium tuberculosis was positive. Tuberculin skin test and quantiFERON-tuberculosis was positive. As ascites was high density but very small, abdominocentesis could not be performed. A standard antituberculosis regimen was initiated (isoniazid, rifampin, pyrazinamide, and ethambutol), and prednisolone and methotrexate were continued. Four months after the initiation of the therapy, ascites and pleural fluid disappeared, and abdominal pain completely resolved. Antituberculosis therapy was completed, and no relapse was observed after 12 months of follow-up after the end of treatment. We have described a patient suffering from rheumat oid arthritis who presented with
abdominal pain due to tuberculous peritonitis. The patient had been treated over 10 years with methotrexate and prednisolone. This was very similar to a patient with ankylosing spondylitis under treatment with the immunosuppressive drug, infliximab, reported by Cooper et al,1 whose first manifestation of tuberculous peritonitis was abdominal pain. There have been some reported cases with tuberculous peritonitis during immunosuppressive therapyfor collagen diseases.1Y7 The most deserving point is that some patients with collagen diseases, who are treated with any immunosuppressive drugs, might develop tuberculous peritonitis. Katsunori Kagohashi, Gen Ohara, Koichi Kurishima, Hiroaki Satoh,
MD MD MD MD
Division of Respiratory Medicine Mito Medical Center University of Tsukuba Mito, Ibaraki, Japan [email protected]
The authors declare no conflict of interest.
FIGURE. Abdominal CT scan showing ascites in the perihepatic space (arrowhead), adjacent to the colon (*), and in the rectouterine pouch (Douglas pouch) (arrow). JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
57
Letter to the Editor
REFERENCES 1. Cooper J, Flu¨ckiger B, Traichl B, et al. Abdominal pain in a patient with ankylosing spondylitis under treatment with infliximab. J Clin Rheumatol. 2009;15:244Y246. 2. Szerszen A, Gupta S, Seminara D, et al. Peritoneal tuberculosis complicated by immune reconstitution inflammatory syndrome in a patient treated with infliximab?: A case for adjuvant immunosuppressive therapy. J Clin Rheumatol. 2009;15:417Y418.
58
JCR: Journal of Clinical Rheumatology
3. Azuma N, Morimoto M, Tsubota N, et al. Tuberculous peritonitis during etanercept therapy for rheumatoid arthritis. Nihon Rinsho Meneki Gakkai Kaishi. 2011;34: 501Y509. 4. Huesler M, Ruef C, Pfyffer GE, et al. Peritoneal tuberculosis mimicking advanced ovarian cancer in a patient treated with methotrexate for chronic rheumatoid arthritis. J Obstet Gynaecol. 2003;23: 315Y316.
&
Volume 20, Number 1, January 2014
5. Matsumoto T, Tanaka T, Kawase I. Infliximab for rheumatoid arthritis in a patient with tuberculosis. N Engl J Med. 2006;355:740Y741. 6. Verhave JC, van Altena R, Wijnands MJ, et al. Tuberculous peritonitis during infliximab therapy. Neth J Med. 2008;66:77Y80. 7. Yoo WH. Multiple organ tuberculosis of lung, pleura, and peritoneum in ankylosing spondylitis during adalimumab therapy. Rheumatol Int. 2012;32:787Y790.
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
