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Scientific letters
Mediterranean spotted fever in a patient with Crohn's disease under adalimumab: First case report and review of the literature
Fiebre botonosa en un paciente con enfermedad de Crohn con tratamiento de adalimumab: Observación clínica y revisión de la literatura
João Santos-Antunesa,b, Amadeu C.R. Nunesa, Guilherme Macedoa
a Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto, Portugal
b Department of Biochemistry (U38-FCT), Faculty of Medicine, University of Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 49 years old man with Crohn&#39;s disease and ankylosing spondylitis had been treated with adalimumab 40<span class="elsevierStyleHsp" style=""></span>mg every other week&#44; with clinical remission&#46; After 18 months of starting adalimumab and only three days after last subcutaneous injection&#44; a diffuse pruriginous maculopapular rash was elicited in the abdomen&#44; chest and upper and lower limbs &#40;including palms and soles&#41;&#46; He simultaneously had headache&#44; malaise&#44; myalgia and high-grade fever &#40;39&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#46; He came on to our Emergency Department five days after the first symptoms&#46; Upon admission&#44; he was febrile &#40;39&#46;2<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; with no other findings on physical evaluation besides the rash and the presence of a small raspberry lesion on the left shoulder&#46; Blood analysis showed elevated C-reactive protein &#40;60&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#44; without leucopenia or thrombocytopenia&#46; Abdominal ultrasound was unremarkable&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient lived in an urban apartment&#44; but he had recently spent two weeks in a rural area&#44; with contact with several farm animals &#40;chickens&#44; dogs and horses&#41;&#44; until three days before admission&#46; The lesion on the left shoulder was consistent with a tick bite &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; He was treated with doxycycline &#40;100<span class="elsevierStyleHsp" style=""></span>mg bid&#41; for spotted fever&#44; with an excellent clinical and analytical response&#46; He was discharged on the fifth day without fever and with no rash&#44; and the lesion on the left shoulder was almost completely resolved&#59; blood inflammatory markers returned to normal&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Mediterranean spotted fever &#40;MSF&#41; is a tick-borne disease caused by <span class="elsevierStyleItalic">Rickettsia conorii</span>&#46; Although mortality rates for MSF are low and generally range from 0&#37; to 3&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> a delay in the diagnosis or inadequate treatment can increase the rates of morbidity and mortality&#46; Serology for <span class="elsevierStyleItalic">Rickettsia</span> is frequently negative at presentation&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but in our case IgM for this agent was positive&#46; Additionally&#44; given the epidemiological context and the anamnesis &#40;namely the classic triad of rash involving palms and soles&#44; eschar and fever&#41; the diagnosis of MSF&#44; an infection endemic in European southern countries like Portugal&#44; must be assumed promptly&#44; especially in the summer when tick bites are much more common&#46; It is important to notice that the triad is not always present&#44; and the eschar may not be observed in up to 40&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Blood analysis is unspecific&#59; usually inflammatory markers are elevated&#44; and leucopenia or thrombocytopenia may occur in nearly 20&#37; of the patients&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Little is known concerning this type of infections&#44; namely regarding more serious outcomes and treatment implications&#44; in patients with inflammatory bowel disease &#40;IBD&#41;&#44; since there are no reported cases&#46; Furthermore&#44; the clinical course and outcome of MSF &#40;and other tick-borne illnesses&#41; in patients under anti-TNF agents is unknown&#46; TNF is a key cytokine in the defense against intracellular pathogens&#44; as <span class="elsevierStyleItalic">Rickettsia conorii</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> so one could anticipate a more serious disease&#46; The only reported case of a rickettsiosis in this context is a Rocky Mountain spotted fever &#40;by <span class="elsevierStyleItalic">Rickettsia ricketsii</span>&#41; in a patient with rheumatoid arthritis under adalimumab &#40;with prior exposure to etanercept&#41;&#44; with good outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Crohn&#39;s disease and the immunosuppressive treatments that are commonly applied in these patients raise the risk for opportunistic infections and can contribute to a poorer outcome of infectious diseases in general&#46; The authors present a very unusual case of a zoonosis in a context of anti-TNF-alpha therapy for Crohn&#39;s disease&#46; This is the first report of a MSF in a patient under adalimumab&#46; In an era in which immunosuppressants and biologics are the mainstay of Crohn&#39;s disease therapy&#44; it is expected that this type of drugs will been increasingly applied in patients living in rural areas&#46; Therefore&#44; zoonotic illnesses in patients under anti-TNF therapies may become more frequent&#44; and it is very important to know how to manage them&#46; The clinical challenge is to know whether these patients could have a worse outcome than general population&#44; requiring different therapeutic strategies&#46; It is unknown if adalimumab must be stopped and for how long&#44; since there are no guidelines for this kind of infections in the context of IBD&#46; We think that anti-TNF agents must be temporarily suspended because TNF is important in the defense from these intracellular organisms&#46; In our case&#44; we chose to prescribe standard antibiotic treatment and stop adalimumab until one week after concluding the antibiotic regimen&#46; Promptly recognition and treatment without delays was decisive for this excellent outcome&#46;</p></span>"
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Article information
ISSN: 02105705
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos