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The day before, the patient had right otalgia (earache), for which she was prescribed amoxicillin/clavulanic acid. 24<span class="elsevierStyleHsp" style=""></span>h later she developed severe headache, vomiting and drowsiness, without fever. One month before the presentation, the patient had started treatment with CZP for psoriatic arthritis resistant to conventional treatments. No history of travel, contact with sick people or epidemiological exposures of interest.</p><p id="par0020" class="elsevierStylePara elsevierViewall">At admission, she presented with 37.3<span class="elsevierStyleHsp" style=""></span>°<span class="elsevierStyleSmallCaps">C</span> fever, a heart rate of 120<span class="elsevierStyleHsp" style=""></span>bpm and a blood pressure of 125/76<span class="elsevierStyleHsp" style=""></span>mmHg. Physical examination revealed nuchal rigidity without pupillary abnormalities or focal neurological deficits. Brain computed tomography showed an opaque left petrous apex, indicative of petrous apicitis. Cerebrospinal fluid (CSF) revealed a white blood cell count of 11,840<span class="elsevierStyleHsp" style=""></span>cel/mm<span class="elsevierStyleSup">3</span> with 85% granulocytes, 14<span class="elsevierStyleHsp" style=""></span>mg/dl glucose, 350<span class="elsevierStyleHsp" style=""></span>mg/dl proteins and Gram-negative staining. The patient was treated with dexamethasone, ceftriaxone, ampicillin and vancomycin.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Microbiological CSF cultures and blood cultures were negative. Adenosine deaminase was normal, and <span class="elsevierStyleItalic">polymerase chain reaction</span> (PCR) for meningococcus, pneumococcus and <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> was negative. The Ziehl–Neelsen staining was also negative. The lumbar puncture was repeated on the third day after admission: 295 white blood cells per field, 87% polymorphonuclear. A real-time PCR and subsequent sequencing was performed for the detection of 16S ribosomal RNA, which turn out positive for <span class="elsevierStyleItalic">Moraxella catarrhalis.</span> Two weeks of intravenous ceftriaxone and 4 weeks with oral moxifloxacin were completed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There are reports of a higher incidence of serious infections with the use of anti-TNF.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In a comprehensive systematic review which grouped together severe infections, the <span class="elsevierStyleItalic">odds ratio</span> was 2.0 (95% CI 1.3–3.1) over a treatment period of 3–12 months<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>; a significant proportion of these cases are granulomatous opportunistic infections.</p><p id="par0035" class="elsevierStylePara elsevierViewall">CZP binds to TNF-α through a selective neutralization. In 2013, the use of CZP was approved for active psoriatic arthritis. Just a few reports relate infectious and non-infectious complications during treatment<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>; in the case of serious infections such as meningitis, there is only one case report, of a 51-year-old female patient with Crohn's disease who, during treatment with CZP, developed meningococcal meningitis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Our patient was negative for CSF Gram staining and culture. We believe this was due to the previous use of antibiotics. Epidemiology in our area points to known pathogens, such as <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>, <span class="elsevierStyleItalic">Haemophilus influenzae</span> and <span class="elsevierStyleItalic">M. catarrhalis</span>, although this last microorganism is a rare cause in Spain.</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">M. catarrhalis</span> is a Gram-negative aerobic diplococcus, often isolated as commensal in the upper respiratory tract. There is very little medical literature on meningitis associated with <span class="elsevierStyleItalic">M. catarrhalis</span>, limited to a few case reports.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The application of conventional microbiological techniques requires the growth of microorganisms under optimum conditions and the absence of previous antibiotics, which sometimes is difficult to achieve. Since 1990, multiple protocols have been developed that allow the specific and rapid identification of bacteria of difficult diagnosis until now, as well as to detect the presence of clinically relevant genes, such as those that code for resistance to antibiotics or those that confer greater virulence to organisms. Once these individual applications of PCR have been optimized and their clinical usefulness proven, during the last few years the development of two types of techniques has been of great interest: on the one hand, the so-called multiple PCRs, reactions that manage to detect simultaneously and specifically several microorganisms; on the other hand, detection techniques of the 16S ribosomal RNA and its subsequent sequencing, that allow to identify any bacteria present in the sample.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, we consider it important to closely monitor the post-marketing effects of CZP and that physicians using this medication take into account the possible association with severe infections; also, clinical practice requires the optimization of early microbiological diagnosis, which will allow the implementation of prevention and treatment programs, improving survival. To achieve this, Molecular Biology techniques such as CRP are considered a great alternative, especially in patients with previous antibiotic treatment, which will allow the detection of bacteria from various fluids and clinical specimens.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Franco J, Ossenkopp J, Peñarroja G. Meningitis por <span class="elsevierStyleItalic">Moraxella catarrhalis</span> durante tratamiento con certolizumab. Med Clin (Barc). 2017;149:46.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The risk of tuberculosis related to tumour necrosis factor antagonist therapies: a TBNET consensus statement" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Solovic" 1 => "M. Sester" 2 => "J.J. Gomez-Reino" 3 => "H.L. Rieder" 4 => "S. Ehlers" 5 => "H.J. 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Kumar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.crohns.2012.06.012" "Revista" => array:5 [ "tituloSerie" => "J Crohns Colitis" "fecha" => "2013" "volumen" => "7" "paginaInicial" => "e19" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22742971" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Can broad-range 16S ribosomal ribonucleic acid gene polymerase chain reactions improve the diagnosis of bacterial meningitis? A systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L. Srinivasan" 1 => "J.M. Pisapia" 2 => "S.S. Shah" 3 => "C.H. Halpern" 4 => "M.C. 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Journal Information
Vol. 149. Issue 1.
Pages 46 (July 2017)
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Vol. 149. Issue 1.
Pages 46 (July 2017)
Letter to the Editor
Moraxella catarrhalis meningitis during certolizumab pegol treatment
Meningitis por Moraxella catarrhalis durante tratamiento con certolizumab
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Jonathan Franco
, Jhon Ossenkopp, Georgina Peñarroja
Corresponding author
Departamento de Medicina Interna, Hospital Universitario Quirón Dexeus, Barcelona, Spain
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