Trials and tribulations in managing a complex case of psoriatic arthritis—a success story in the real world
Abstract
DEAR EDITOR, PsA has a plethora of treatment options, with newer biologic showing promising patient-reported outcomes. However, these agents require a pre-screen for infections, including tuberculosis (TB). We share our success story in managing a difficult case with therapeutic challenges. In 2017, a 27-year-old Caucasian male relocated from Ireland and was referred to us for the ongoing care of his well-controlled polyarticular PsA. He had psoriasis since the age of 5 years and was diagnosed with PsA in 2014. In Ireland, he developed pneumonia necessitating early discontinuation of MTX. Work-up for adalimumab identified pulmonary TB. After 6 months of standard TB treatment, he started adalimumab and by 2015 achieved tight control of both PsA and psoriasis. Within 2 months of relocating to Nottingham, he was admitted with community-acquired pneumonia. Over the subsequent 3 months, he had multiple infections (skin, chest and urine) requiring antibiotics that led to interrupted administration of adalimumab. He then developed a temperature of 40 C, paralytic ileus and left upper quadrant pain, requiring an extensive infection screen and necessitating 31 days in the hospital. CT scan demonstrated ascites, thickened mesentery, intraabdominal lymphadenopathy and features of widespread intra-abdominal tuberculosis. We put his adalimumab on hold and advised symptom control with nonsteroidal and topical creams for his arthritis and psoriasis whilst he was an in-patient under…
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