POS1464 TOXOPLASMOTIC CHORIORETINITIS IN A PATIENT WITH RHEUMATOID ARTHRITIS

Abstract

Background: Biological disease-modifying antirheumatic drugs (bDMARD) are one of the most effective in the treatment of rheumatoid arthritis. Infectious complications are one of the most common complications of this type of therapy. Before the therapy is started, patients are examined for tuberculosis, human immunodefciency virus and hepatitis B and C, but the spectrum of chronic infections is much wider, for example toxoplasmosis infection is widespread. Toxoplasma gondii mainly affects the brain, lungs, liver and organ of vision. Objective(s): To present a clinical case of toxoplasma chorioretinitis in a patient with rheumatoid arthritis. Method(s): Case report. The patient was treated and examined based on real clinical practice. Result(s): A 59-year-old woman was admitted to the rheumatology department with symmetric arthritis of the hand joints, long morning stiffness duration (up to 4 hours). The diagnosis of rheumatoid arthritis was previously verified according to the ACR/EULAR 2010 criteria (three years ago). She received treatment in accordance with the clinical guidelines of the Ministry of Health of the Russian Federation: methotrexate 12.5 mg per week with a subsequent increase in dosage to 20 mg per week. Due to the increase in transaminases, the dosage of methotrexate was reduced to 17.5 mg per week, the daily intake of glucocorticosteroids (prednisone 7. 5 mg per day). Nevertheless she had high disease activity (Disease Activity Score (DAS28) 5.54, Clinical Disease Activity Index (CDAI) 26.6, Simplied Disease Activity Index (SDAI) 30.12). Considering the continued high activity of the disease against the background of ongoing therapy lasting more than 6 months, infliximab was added to the treatment at a dose of 3 mg per kg of body weight. A good clinical response was achieved (DAS28 2.67, CDAI 4.0, SDAI 9.4, prednisone canceled). After 4 months, there were complaints of acute decrease in vision in the right eye. Referred to an ophthalmologist. Visual Acuity: best corrected visual acuity (BCVA) on right eye is 0.4 (Snellen Chart), BCVA on left eye is 0.9 (Snellen Chart), intraocular pressure: right eye-18 mmHg (non-contact), left eye-19 mmHg (non-contact). Right eye: palpation is painful; cornea and anterior chamber humor are transparent; mild cataract in lens; inflammation cells in vitreous body (3+). Fundus (right eye): disc of optic nerve is normal; edema along upper-temporal vessels in macular region, exudates with pigmentation; periphery is normal. Left eye: findings are not clinical significant. Optical coherence tomography of retina (OCT): macular depression is normal; in paramacular region is epiretinal membrane, no traction; along upper-temporal vessels in macular region is chorioretinal focus with retina layer disorganization and tractions. Laboratory: Diaskintest is negative; Toxoplasma IgG = 170 ME/ml (positive is> 8 ME/ml). Diagnosis: Toxoplasma chorioretinitis, infiltration phase of right eye. Topical therapy: dexamethasone 0.1%-1 x 6 times/day-20 days, nepafenac 0.1%-1 x 3 TID-20 days. Oral: rovamycine 3 mil. ME-2 TID-20 days. Infliximab and methotrexate were canceled for the entire period of toxoplasma chorioretinitis treatment. Ophthalmologist's follow-up after 20 days: no complaints on visual acuity, BCVA on right eye is 1.0 (Snellen Chart). No cells in vitreous body. Fundus: decrease evidence of edema. OCT: decrease evidence of edema. Taking into account the presence of chronic toxoplasmosis infection, the patient was prescribed sulfasalazine 3 g per day as a basic therapy. Conclusion(s): In this clinical case we demonstrated the possibility of activating chronic infections such as toxoplasmosis during therapy with bDMARD infixi-mab. To avoid risk of activating toxoplasmosis patients with rheumatoid arthritis should be screened for this infection before start bDMARD therapy.