A case of elderly rheumatoid arthritis with undeniable complication of fungal infection

Abstract

Here we report a case of elderly rheumatoid arthritis（RA）complicated by an aspergillus infection treated with an abatacept（ABT）infusion. A 74-year-old woman with RA who had been treated with methotrexate（MTX）for 12 years was referred to our hospital with left ankle joint pain. Her RA was moderately active, but swelling and tenderness were observed in the left talocrural articulation, an indication for biologic disease-modifying antirheumatic drugs（bDMARDs）. In the screening test for infection, β-d-glucan was positive at 38.3pg/mL and aspergillus antigen positive at 0.5, but computed tomography showed no consolidation or ground glass opacity in the lung field, but fluid accumulation was present in the left maxillary sinus. She had a history of sinusitis for which antifungal agents were administered before the bDMARDs. She continued to receive MTX 8mg/week, and an ABT 750mg infusion was introduced. The RA activity decreased 3 months later. The fluid accumulation in the left maxillary sinus also disappeared with continuation of the antifungal medication. In RA complicated by infection, treatment should be intensified based on the risk–benefit ratio; however, in the elderly case, further safety considerations are also necessary. In this case, the RA activity promptly decreased after introduction of the ABT, and the patientʼs clinical course showed no exacerbation of the left maxillary sinusitis, suggesting that ABT can be safely used in combination with antifungal agents.