A 43 year old man with ankylosing spondylitis treated with infliximab, on the 6th dosese presented with severe proximaly myopathy and fever and drenching sweating.Ix reported myositis.with fequent neutrophilic lekocytosis last reading 31000.imaging CT scan of chest and abdomen Normal and blood culture normal. Virology screen nornal. tuberculin skin test negative and culture for fungal infection waiting. CPK >2000. What is the most likely diagnosis and hpw to investigate and treat?
looking like bacterial infection.. Please get bacterial blood culture done.. It can also be a case of pyomyositis. You can consider empirical therapy with Vancomycin .
Please rule out a bacterial infection, do blood cultures. Keep checking for milairy tuberculosis (X-ray, sputum culture|). Does he have mitral valve involvement? He might have endocarditis.
Bacterial Septicaemia most likely possibility. Further blood cultures required. Emperical treatment with broadspectrum antibiotics. Other opportunistic infections like Toxoplasmosis coccidiodocomycosis aldo considered. Rhabdomyolysis may be associated with some septicaemias. Urine should be checked for myoglobulins.
Thanks a lot Dr.Irene and Dr.Shakil.
Blood culture was done and result negative and the patient was put on Vancomycine and ceftriaxon but no response.
We added fluconazol also no response.
Tuberculin skin test negative. Chest xray ?? nodules.
ECHo normal
Blood culture for fungus was done and the first result was negative
His myositis better on steroids and CPK decreased from >4000 to 670.
But patients still develop attack of fever and drenching sweating.
last WBC 25 0000 neutrophilia.
BAL done for culuter and gram stain and AFB and for PCR
US abdomen last one hepatomegaly.
Still we do not reach a diagonsis.
What are other lines of treatment. Please inform me if you have an opinion
Small multiple Pulmonary nodules are suspiceous of Milliary Tuberculosis. I know that Tuberculin test is negative but as such has been described in milliary TB. So if a CT chest elaborates the nature of the pulmonary nodules then your most likely diagnosis would be miliary TB. I would still continue cover for a secondary bacterial infection.
Another culture for fungal and bacterial infection was negative also.
Drenching sweating occurs in brucellar infection. You may examine serology for Brucellosis.
Thanks a lot. Irene. I deeply appreciate your response. We did BAL and new bone marrow biopsy for the patient. . Best regards
The most probably diagnosis is Reactivation of latent TB .please ask for .Interferon-gamma release assays (IGRAs) as it has higher sensitivity of detection than Tuberculin Skin Test.
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