Rev. Bras. Reumatol. vol.54 número6

r e v b r a s r e u m a t o l . 2014;54(6):483–485

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

ww w . r e u m a t o l o g i a . c o m . b r

Case

report

Colonic

perforation

due

to

invasive

amebic

colitis

during

anti-TNF

therapy

for

spondyloarthritis

夽

Juan

Pablo

Restrepo

,

María

del

Pilar

Molina

b_{UniversidadLibre,Quindío,Colombia}

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o

Articlehistory:

Received7July2013 Accepted27September2013 Availableonline23October2014

Keywords:

Anti-TNFInhibitors ColonicPerforation AmebicColitis

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b

s

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c

t

TNFblockadehasbeensuccessfulinthetreatmentofsomerheumaticdiseasessuchas spondyloarthritis.Manyinfectiouscomplicationshavebeenreportedwithanti-TNFtherapy, mainlybacterial,mycobacterial,viralandfungalinfections.Entamoebahistolyticaisan extra-cellularprotozoanparasitethatmainlycausescolitisandhepaticabscess;bowelperforation isanuncommoncomplicationwithhighmortality.TNFisconsideredtheprincipalmediator ofcellimmunityagainstamebiasis.Initially,itischemotactictoE.histolytica,enhancingits adherencetoenterocyteviagalactoseinhibitablelectin,andthenactivatingmacrophages tokillamebathoughthereleaseofNO,sothatTNFblockingcouldbeharmful,increasing amebicvirulence.Wedescribethecaseofa46-year-oldwomanwithspondyloarthritiswho presentedacolonicperforationduetoinvasiveamebiccolitisduringanti-TNFuse.

©2014ElsevierEditoraLtda.Allrightsreserved.

Perfurac¸ão

do

colo

por

colite

amebiana

invasiva

durante

terapia

anti-TNF

para

espondiloartrite

Palavraschave:

InibidoresAnti-TNF,Perfurac¸ãodo colo,Coliteamebiana

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ObloqueiodoTNFtemtidosucessonotratamentodealgumasdoenc¸asreumáticas,comoa espondiloartrite.Relatam-semuitascomplicac¸õesinfecciosascomaterapiaanti-TNF, prin-cipalmenteinfecc¸õesbacterianas,micobacterianas,viraisefúngicas.AEntamoebahistolytica

éumprotozoárioextracelularquecausaprincipalmentecoliteeabscessohepático,sendo queaperfurac¸ãointestinaléumacomplicac¸ãorara,comaltamortalidade.OTNFé con-siderado oprincipal mediadorda imunidadecelularcontra aamebíase.Inicialmente, é quimiotático paraaE.histolytica,potencializandosuaadesãoaoenterócitopormeioda lectina galactose-inibível,edepoisativandoosmacrófagosparamataremaamebapela

DOIoforiginalarticle:http://dx.doi.org/10.1016/j.rbr.2013.09.004.

夽

ThecasewasoriginatedinServicioOccidentaldeSalud,Rheumatologysection,Cali,Colombia.

∗ _{Correspondingauthor.}

E-mail:jprestrep@lycos.com(J.P.Restrepo).

http://dx.doi.org/10.1016/j.rbre.2013.09.004

484

liberac¸ãodeNO;assim,obloqueiodoTNFpoderiaserprejudicial,aumentandoa virulên-ciaamebiana.Descreve-seocasodeumamulherde46 anoscomespondiloartriteque apresentouumaperfurac¸ãodocoloporcoliteamebianainvasivaduranteusodeanti-TNF. ©2014ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

TNF(tumoralnecrosisfactor)isamajorcytokineinvolvedin thepathogenesisofrheumatoidarthritisand spondyloarthri-tis.TNFinhibitorshavebeen showedtobeeffectiveinthe treatment ofaxial and peripheralspondyloarthritis and in someextraarticularmanifestations,howeversomeinfectious complicationshavebeenreported.Theseincludedbacterial, mycobacterial, viraland fungal infection. Amebic infection hasnotbeendescribedduringanti-TNFinhibitor.Wedescribe a46-year-oldwomanwithspondyloarthritiswhopresenteda colonicperforationduetoinvasiveamebiccolitisduring anti-TNFuse.

Case

report

A46-year-old female witha previous diagnosis of spondy-loarthritis based on ASAS criteria,1 _{who was been treated}

withsubcutaneousadalimumab40mgeveryotherweek dur-ing4monthsandgooddiseasecontrolactivity.Shepresented diffuseabdominal pain and mucous diarrheafor 2 weeks. Physical exam revealed distended abdomen without bowel sounds and diffuserebound tenderness, so a diagnosis of acuteperitonitiswasdone.Laboratorytestsgavethefollowing results:leucocytecount:11.980/mm3_{with73%ofneutrophils,}

hemoglobin:9.6gr/dL,CRP:55mgr/L.Emergencylaparotomy showedmultipleandsmall colonicperforationsandsevere peritonitis; right hemicolectomy, mucous fistula of ileon andintraperitonealdrainagewereperformed.Metronidazole, ertapenem,teclozanwereadministeredduringher hospital-izationinintensivecareunit.Histopathologicalexamination oftheresectedgutrevealedextensiveareasofulcerationwith abundanttrophozoites ofE histolytica (Figs. 1and 2). One monthlaterthepatientwasdischargedwithoutother com-plication.Atthis timethe patient isbeingmedicated with naproxen250mgrBIDwithpartialresponse,whileileostomy closureisdonetoresumeadalimumab.

Discussion

Entamoeba histolytica is an extracellular protozoan para-sitethatcausesmainlycolitisandhepaticabscessanditis responsibleof100.000deathsworldwideeveryyear.Bowel per-forationoccursbetween1%-6%ofthepatientswithamebiasis butitsmortalityisextremelyhighrangingfrom55%to100%.2

TNF plays an important role in the pathogenesis of parasiticinfection3,4_{anditisconsideredtheprincipal}

medi-atorofcellimmunityagainstamebiasis.Gammainterferon, colony-stimulating factor 1 actsynergistically with TNF in

Figure1–Histologicalexaminationoftheresectedcolon demonstratedextensivemucosalulceration.

macrophageactivationusingamurinemode.5_TNFproduced

bymacrophagescankillEhistolyticainvitro.6

Oppositely, Blasquez et al demonstrated that TNF can enhance amebic virulence and is chemotactic for E histolytica.7 _{Amebic adherence tocolonic mucosais}

medi-ated by galactose inhibitable lectin8 _{which is a potent}

stimulant of TNF production. Nitric oxid (NO) is a major effector molecule produced by activated macrophages for in vitro toxicity against E histolytica trophozoites and its productionisincreasedbyTNF.9_{Macrophagesisolatedfrom}

amoebiclivergranulomasaredefectivefortheproductionof

rev bras reumatol.2014;54(6):483–485

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TNF,10_NO,11_H

2O2.12Finallyanti-TNFantibodiesinhibitTNF

release,NO production, and amebicidal activity byactived murinemacrophages.13

InconclusionTNFhasadualrole,initiallyis chemotac-tictoEhistolytica,enhancingitsadherencetoenterocytevia galactoseinhibitablelectinandthenactivatingmacrophages to kill ameba though the release NO so that TNF block-ingcouldbeharmfulincreasingamebicvirulence.Fromour knowledgethisisthefirstcaseofcolonicperforationdueto invasiveamebiccolitisduringanti-TNFtherapy.We recom-menddewormingagainstEhistolyticainendemicareasprior thebeginningofanti-TNFtherapyandregularlyduringitsuse.

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2009;68:777–83.

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