Cerebral Nocardiosis in a Patient With Rheumatoid Arthritis Under Treatment With Tocilizumab

Abstract

The use of biological therapy has revolutionized the treatment of various autoimmune diseases. Tocilizumab (TCZ) is a recombinant humanized antiinterleukin-6 (IL-6) receptor monoclonal antibody approved for the treatment of patients with rheumatoid arthritis, as monotherapy or in combination with other disease-modifying anti-rheumatic drugs (DMARDs). Clinical and post-marketing surveillance studies of TCZ indicate that infections are the most frequent adverse events. Most of the serious infections described are bacterial and viral, with no uncommon pathogens. The authors report a case of a patient with destructive rheumatoid arthritis under TCZ that presented with neurological symptoms and a right cerebellar lesion with marked diffusion restriction suggestive of cerebellar abscess. The microbiologic studies from aspirative cerebral biopsy revealed Nocardia farcinica . With adequate antibiotics, the patient evolved with resolution of all symptoms and brain abscess at 5 months of follow-up. According to published reports, this is the first case of nocardial infection in patients under TCZ. The case highlights the importance of being aware of risk infection in these patients and need of an early diagnosis allowing a prompt treatment. J Med Cases. 2018;9(2):68-72 doi: https://doi.org/10.14740/jmc2995w