J Korean Rheum Assoc.  2007 Dec;14(4):412-416.

A Case of Cryptococcal Pneumonia in a Rheumatoid Arthritis Patient after Tumor Necrosis Factor-alpha Antagonist Therapy

• Yi SM
• Lim MJ
• Kwon SR
• Jeong JC
• Lee JS
• Kwon SH
• Kim L
• Park W

Abstract

Tumor necrosis factor-alpha (TNF-alpha) plays a important role in the pathogenesis of rheumatoid arthritis and Crohn's disease, TNF-alpha antagonist has been widely used for these disease, but it also plays a major role in cell mediated immunity. Cryptococcus neoformans, an encapsulated, ubiquitous environmental yeast, is pathogenic for humans, primarily those with compromised immune function. Cryptococcus neoformans is believed to be a facultative intracellular pathogen. We report a case of pulmonary cryptococcosis after chimeric anti-TNF monoclonal antibody therapy. No case has been reported in Korea for the best of our knowledge. A 66-year old woman was admitted because of severe cough. She was diagnosed to have rheumatoid arthritis 4 years ago and taken prednisolone and methotrexate. She was started on infliximab and received ten doses, the last dose being administered 6 weeks prior to above symptom. Chest PA and computed tomography of chest revealed multifocal consolidative lesions in both lungs. Pulmonary cryptococcosis confirmed by thoracoscopic lung biopsy tissue stained with Grocott-Gomori methenamine-silver (GMS). Initially the lung lesion responded to amphotericin B but leukopenia developed after 12 days of treatment. It was changed to fluconazole, then leukopenia and the pneumonia also improved. Physicians should remind pulmonary cryptococcosis in patients receiving TNF-alpha antagonist therapy.

Keyword

Rheumatoid arthritis; Cryptococcal pneumonia; TNF-alpha blocker

MeSH Terms

Aged
Amphotericin B
Arthritis, Rheumatoid*
Biopsy
Cough
Crohn Disease
Cryptococcosis
Cryptococcus neoformans
Female
Fluconazole
Humans
Immunity, Cellular
Infliximab
Korea
Leukopenia
Lung
Methotrexate
Pneumonia*
Prednisolone
Thorax
Tumor Necrosis Factor-alpha*
Yeasts
Amphotericin B
Fluconazole
Methotrexate
Prednisolone
Tumor Necrosis Factor-alpha

Figure

• 

  Fig. 1. (A) Multifocal nodular opacity with reticular opacity was noted in both lungs, especially both lower lobes at the time of admission. (B) The consolidative lesion in both lungs improved after antifungal therapy.

• 

  Fig. 2. Throcoscopic biopsy stained with (A) hematoxylin-eosin stain and (B) Grocott-Gomori methenamine-silver stain shows numerous encapsulated yeast-like organisms (∗400).

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