Sasaki Tsuyoshi, Okamura Koichi, Yonemoto Yukio, Okura Chisa, Takagishi Kenji
Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22, Showamachi, Maebashi, Gunma 371-8511 Japan.
Springerplus. 2014 Sep 29;3:567. doi: 10.1186/2193-1801-3-567. eCollection 2014.
Infections are recognized as major complications during therapy with biologics and other immunosuppressant drugs. The respiratory tract, bone, joint, skin, and soft tissues are well known sites of infection in patients with rheumatoid arthritis (RA) treated by biologics or other immunosuppressants. It is known that patients with intra-abdominal infections may develop tuberculous peritonitis during biologic therapy. However, non-tuberculous pelvic peritonitis is rare.
A case of a 46-year-old patient with RA developed pelvic peritonitis during therapy with MTX, tacrolimus (TAC), and golimumab (GLM). The patient visited our hospital due to a fever and general malaise. Physical findings included lower abdominal tenderness and rebound tenderness. Abdominal computed tomography (CT) images showed an intrauterine foreign body and ascites. The contraceptive ring was removed. Streptococcus agalactiae and Streptococcus constellatus were cultured from the removed contraceptive ring. She was started on an antimicrobial agent, flomoxef (FMOX), at 2 g/day. The FMOX dosage was increased to 3 g/day from the 3rd day of disease and continued for 10 days. Her fever disappeared from the 4th disease day, and her inflammatory response then gradually decreased. No exacerbation of symptoms occurred even after the FMOX treatment was stopped, and the patient was discharged on the 14th disease day.
MTX and biologics were being administered at the time of onset of peritonitis. The peritonitis was diagnosed on the basis of the gynecological evaluation and CT imaging findings that were typical of peritonitis. The patient was in an immunosuppressed state during administration of anti-rheumatic drugs, and the peritonitis was thought to have developed due to an ascending infection via the long-term presence of the intrauterine contraceptive ring which had an attached string.
Before starting biological agents, patients must be questioned regarding the presence of an intrauterine foreign body.
感染被认为是使用生物制剂和其他免疫抑制药物治疗期间的主要并发症。呼吸道、骨骼、关节、皮肤和软组织是接受生物制剂或其他免疫抑制剂治疗的类风湿关节炎（RA）患者中众所周知的感染部位。已知腹腔内感染患者在生物治疗期间可能会发生结核性腹膜炎。然而，非结核性盆腔腹膜炎很少见。
一名46岁的RA患者在接受甲氨蝶呤（MTX）、他克莫司（TAC）和戈利木单抗（GLM）治疗期间发生盆腔腹膜炎。患者因发热和全身不适前来我院就诊。体格检查发现下腹部压痛和反跳痛。腹部计算机断层扫描（CT）图像显示宫内异物和腹水。取出了避孕环。从取出的避孕环中培养出无乳链球菌和星座链球菌。开始给予抗菌药物氟氧头孢（FMOX），剂量为每日2g。从疾病第3天起，FMOX剂量增加至每日3g，并持续10天。患者从疾病第4天起发热消失，炎症反应随后逐渐减轻。即使在停止FMOX治疗后症状也未加重，患者于疾病第14天出院。
腹膜炎发作时正在使用MTX和生物制剂。根据妇科评估和典型腹膜炎的CT影像学表现诊断为腹膜炎。患者在服用抗风湿药物期间处于免疫抑制状态，腹膜炎被认为是由于带有尾丝的宫内避孕环长期存在导致上行感染而发生的。
在开始使用生物制剂之前，必须询问患者是否存在宫内异物。
