“My foot hurts”: a flare of rheumatoid arthritis?

A 56-year-old man with a history of rheumatoid arthritis presented with a 2-day history of worsening pain in his left foot. Treatment with high-dose steroids was of no benefit, hence a diagnosis of septic arthritis was considered. However, the patient’s condition deteriorated despite empirical antibiotic therapy. Following persistent investigation, the cause was identified as a fastidious Legionella longbeachae infection, and appropriate antibiotic therapy led to complete resolution of the sepsis. This emphasises the importance of considering infections with atypical organisms in patients on immunosuppressive therapy.

In July 2008, a 56-year-old retired man presented with a 2-day history of worsening pain in his left foot. His medical history included seropositive active rheumatoid arthritis (RA), type 2 diabetes mellitus with microvascular complications, and idiopathic dilated cardiomyopathy managed with an implantable cardioverter-defibrillator and permanent pacemaker (left ventricular ejection fraction: 12% in 2006, 42% in 2008). His RA had been difficult to control — intermittent flares, usually involving his feet, were managed with high-dose steroids. Before presentation, the patient was taking weekly oral methotrexate (20 mg) and daily prednisolone (7.5 mg). Leflunomide, hydroxychloroquine and sulfasalazine therapy had failed to control his RA in the past and were withdrawn because of adverse reactions. Treatment with rituximab, an anti-CD20 monoclonal antibody, in September 2007 (two 1000 mg infusions, administered 2 weeks apart) had also failed to control his RA, and tumour necrosis factor-α (TNF-α) inhibitors were contraindicated owing to his cardiac disease.1