2020 Volume 32 Issue 4 Pages 275-281
A 64 year-old, female was diagnosed as rheumatoid arthritis（RA）in x-28 year. Administration of methotrexate（MTX）was started However, she developed immunodeficiency-associated lymphoproliferative disorders associated with MTX. MTX was stopped, and she received rituximab-CHOP chemotherapy, and the lymphoproliferative disorder attained remission. RA disease activity was stabilized after tocilizumab was started in x-9 year. After 8 days since the last tocilizumab administration, pain and swelling of the left thigh developed. She was hospitalized, and was suspected to have necrotizing fasciitis. However, necrotizing fasciitis was not confirmed because the Laboratory Risk Indicator for Necrotizing Fasciitis score（LRINEC score）was 3 points. She died due to multiple organ failure on the same day in spite of collective treatment. Blood culture revealed positive for streptococcus pyogenes infection. Finally, she was diagnosed as toxic shock syndrome complicated with necrotizing fasciitis caused by streptococcus pyogenes infection. In RA patients treated with biologics such as tocilizumab, the diagnosis of necrotizing fasciitis could be difficult due to the strong immunosuppressive effect of IL-6 inhibition.
