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Managing Rheumatoid Arthritis in Patients with Pulmonary Tuberculosis and Lymphoma

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This case study outlines three patients diagnosed with Rheumatoid Arthritis (RA) and their treatment journeys involving tumor necrosis factor inhibitors like Humira and Enbrel. The first patient, a 55-year-old male, faced complications with pulmonary tuberculosis, leading to the cessation of RA treatment and subsequent anti-TB therapy. The second patient, a 52-year-old female with a history of hepatitis B, navigated liver function abnormalities during RA treatment. The third patient, a 69-year-old male, encountered lymphoma after prolonged RA therapy. Each case exemplifies the complexities of RA management in the presence of other significant health issues.

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Managing Rheumatoid Arthritis in Patients with Pulmonary Tuberculosis and Lymphoma

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  1. Case 1 • Chart number:20139683 • name: 林XX • Occupation: 水電工 • Age:55 years old • Sex: male

  2. 2009/5/26 Start Humira 2010/6/01 Stop Humira Major event 2010/5/4 OPD :QFT (+) 2010/5/10 Open TB 2010/10/19 Shift Rituximab 2008/9/2 Diagnosed RA

  3. 2008/9/2: diagnosed RA with DAS-28:8.3 • Start MTX 10mg QW ,HCQ 200mg QD( from 9/2) ,Leflunomide 20mg QD and prednisolone 5mg QD (from 11/11) back

  4. DAS 28 Humira Rituximab DC Humira due to TB

  5. back • 2009/5/26 • PPD negative • Quantiferon test negative • CXR no active lesion • Start Adalimumab due to high RA disease activity under DMARDs(DAS 28:5.53)

  6. DAS 28 Humira Rituximab DC Humira due to TB

  7. Return rheuma OPD on 5/4 • QFT follow-up (+) • Lack of AFB result due to no productive cough • CXR suspected pulmonary TB • Start INH 300mg QD

  8. 2010/5/10: admitted to chest ward due to prolonged fever one week and productive cough • Sputum AFB positive • Diagnosed : pulmonary miliary TB • Stop Humira • Treated with Rifater + EMB back

  9. DAS 28 back Humira Rituximab DC Humira due to TB

  10. DAS 28 Humira Rituximab DC Humira due to TB

  11. Return chest OPD 2010/7/27 • Sputum culture :M. tuberculosis complex sensitive to all anti-TB medications • Discontinue EMB since 2010/9/21 • Complete 9 months TB treatment on 2011/2/15

  12. Case 2 • Chart number:2453132 • name: 陳XX • Occupation: housekeeper • Age:52 • Sex: female

  13. 2008 /3 Enbrel 2000-2006 treat with DMARs 2006/10 Add Leflunomide 2009/10 Abnormal LFT Stop Enbrel Start ETV 2007/12 Change ETV Major event 2006/12 Abnormal LFT 2007/3 DC MTX and Leflunomide Start LMV 2010/9 Resume Enbrel 2008/8 Stop ETV 2000 diagnosed RA

  14. Present illness • Past history with hepatitis B carrier • Diagnosed with rheumatoid arthritis from 2000 • 2000-2004 • Treated with NSAID ,HCQ and prednisolone 5mg QD • Added MTX (15mg QW) from 2004/11/3 • Add Leflunomide 10mg QD from 2006/10/7 back

  15. ALT and total bilirubin DC Enbrel Add ETV Complete ETV Enbrel 2007/2 HBV-DNA 5.61 Mcps 2007/8 HBV-DNA <0.00035Mcps 2008/7 HBV-DNA Non-detectable 2009/3 HBV-DNA 0.119Mcps

  16. DAS 28 DC Enbrel Enbrel Resume Enbrel

  17. Case 3 • Chart number:20020457 • name: 林XX • Occupation: 機車修理退休 • Age:69 • Sex: male

  18. 2004/8/29 Start Enbrel 2011/1/13 lymphoma Major event 2006/9/19 Stop Enbrel 2000/7/17 Diagnosed RA

  19. 2000/7/17 : diagnosed with Rheumatoid arthritis • Start MTX 7.5 mg QW and Sulfasalazine 500mg BID back

  20. back DAS 28 DC Enbrel

  21. 2006/9/9 admission • Stop Enbrel and MTX on due to pancytopenia • 2006/9/7 Abdominal echo • Fatty liver and splenomegaly • Consider Felty’s syndrome

  22. back DAS 28 DC Enbrel

  23. 2011/1/13 : Prolonged fever for one month • Right neck lymph node biopsy • Nodular sclerosis classical Hodgkin lymphoma • DAS28:2.79 • Treat lymphoma with 8 cycles ABVD on 2011/3/10 - 2011/10/20 (Doxorubicine ,Bleomycin, Vinblastin, and Dacarbazine)

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