Paul Vishesh, Kuhlenschmidt Michael S
Pulmonary and Critical Care Medicine, Carle Foundation Hospital, Urbana, Illinois, USA.
Internal Medicine, University of Illinois College of Medicine, Urbana, Illinois, USA.
BMJ Case Rep. 2018 Dec 14;11(1):e226621. doi: 10.1136/bcr-2018-226621.
A 63-year-old white man with a history of rheumatoid arthritis on adalimumab was admitted to the hospital for left arm swelling and erythema. On physical examination, the patient was afebrile and non-toxic appearing and there was tense oedema of the left forearm. Initial laboratory work was unremarkable except for elevated inflammatory markers. MRI of the arm showed non-specific findings of inflammation. The patient was started on empiric antibiotics but did not improve. Given the patient's immunosuppression, early consideration was given to fungal or mycobacterial causes. Initial serum fungal studies were negative and the patient was taken for diagnostic local incision and biopsy of the left volar forearm. Grocott's methenamine silver and periodic acid-Schiff staining revealed fungal organisms resembling and intraoperative fungal cultures grew confirming the diagnosis. The patient was treated with a 6-month course of itraconazole with improvement in his condition and eventual complete resolution.
一名63岁有类风湿关节炎病史且正在使用阿达木单抗治疗的白人男性因左臂肿胀和红斑入院。体格检查时，患者无发热，外观无中毒表现，左前臂有紧张性水肿。初始实验室检查除炎症标志物升高外无异常。手臂的MRI显示有非特异性炎症表现。患者开始接受经验性抗生素治疗，但病情未改善。鉴于患者存在免疫抑制，早期考虑了真菌或分枝杆菌感染原因。初始血清真菌学检查为阴性，患者接受了左掌侧前臂的诊断性局部切开活检。格罗科特六胺银染色和过碘酸希夫染色显示有类似真菌的生物体，术中真菌培养生长出 ，确诊。患者接受了6个月的伊曲康唑治疗，病情改善，最终完全缓解。
