Rheumatology Advance Access originally published online on December 23, 2005
Rheumatology 2006 45(2):237-238; doi:10.1093/rheumatology/kei123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
LETTER TO THE EDITOR |
Two cases of serious food-borne infection in patients treated with anti-TNF-
. Are we doing enough to reduce the risk?
Departments of Rheumatology and 1 Microbiology, The Ipswich Hospital NHS Trust, Heath Road, Ipswich IP4 5PD, UK
Correspondence to: D. Makkuni. E-mail: damumak{at}yahoo.co.uk
SIR, We would like to report two cases of serious food-borne infection in patients receiving anti-TNF-
drugs, review previous case reports and suggest that the delivery of appropriate food hygiene advice to patients prescribed these drugs could be important.
Case 1 was a 65-yr-old man with ankylosing spondylitis and chronic renal failure (serum creatinine stable at 190 µmol/l) due to NSAID-induced interstitial nephritis. He had been receiving infliximab infusions at 5 mg/kg once every 8 weeks for the previous 11 months. Treatment had been successful in reducing symptoms, improving function and reducing his dependence on indomethacin. He presented with a 7-day history of fever and watery diarrhoea, which started a week after an infliximab infusion. On examination, temperature was 38.6°C, respiratory rate 24/min and blood pressure 110/70 mmHg. Blood tests showed a white cell count of 11.2 x 109/l, CRP 307 mg/l (normal 0–10), urea 6.7 mmol/l and creatinine 250 µmol/l. Stool cultures were negative for enteric pathogens but blood cultures grew Listeria monocytogenes. He was treated with amoxicillin 2 g intravenously 6-hourly for 10 days and supportive measures. On further questioning, the patient admitted to eating unpasteurized cheese purchased from a local farm prior to the onset of the symptoms. He was fond of soft cheeses and obtained them from this source regularly. Unfortunately, no sample of cheese was available for culture. He made a good clinical recovery and his renal function and electrolytes returned to baseline levels within a week. Treatment with etanercept was restarted 6 weeks after the end of the antibiotic course.
Case 2 was a 67-yr-old lady with rheumatoid arthritis (RA). She had received infliximab infusions 3 mg/kg once every 6 weeks for 6 months with prednisolone 7 mg daily and methotrexate 15 mg weekly. Her RA had been well controlled on this drug combination. She then presented with a very painful swollen left knee joint 2 weeks after an infliximab infusion. There was no history of fever, diarrhoea or pain and swelling in other joints. On examination her temperature was 37°C, pulse was 90 beats/min and blood pressure 154/90 mmHg. Her left knee was swollen, warm and markedly tender with gross limitation of movement. No synovitis was obvious in other joints. Blood tests showed a white cell count of 12.4 x 109/l with neutrophilia; ESR was 52 mm/h and CRP 153 mg/l. Initial analysis of joint fluid showed no evidence of organisms on Gram staining and culture. A second synovial fluid aspirate 1 week later grew Salmonella; however, blood and stool cultures were negative for Salmonella. Further questioning revealed that the patient regularly obtained hens eggs directly from a nearby farm and had recently eaten partly cooked eggs. Management consisted of initial bed rest, analgesia, arthroscopic joint lavage and oral ciprofloxacin for 4 weeks. The patient recovered completely from the infection and infliximab was recommenced 8 weeks after the end of the course of the antibiotics. She remains well, with no evidence of recrudescence of the joint sepsis 4 months later.
These two serious infections are likely to have been transferred from food sources. L. monocytogenes can be found in uncooked meat and vegetables, unpasteurized milk or foods prepared from raw milk [1]. Contamination of some food, such as hot dogs and delicatessen meats, can occur during packaging after the food has been processed [1]. The organisms are killed by cooking but can grow in refrigerated foods. The incidence of L. monocytogenes infection reported through the National Enhanced Listeria Surveillance System has increased since 2001 (146 and 139 cases reported in 2001 and 2002, respectively [2]). The incidence is higher in Yorkshire and Humberside, East Midlands and Wales compared with other regions [2]. L. monocytogenes infection has been reported in 15 patients receiving anti-TNF- drugs [3]. Notably, 14/15 patients were receiving infliximab. Six deaths were reported in this group, suggesting the potentially serious nature of this infection. Additionally, cases of Listeria meningitis have been reported in RA patients treated with anti-TNF- drugs [4, 5].
Salmonella can be spread through contaminated raw eggs, in unpasteurized milk and in under cooked meat. Two cases of Salmonella septic arthritis were reported to the BSR Biologic Register [6]. Both of these patients were receiving etanercept. Katsarolis et al. [7] have reported a case of septic arthritis caused by Salmonella enteritidis in a patient receiving infliximab for RA. Netea et al. [8] have also reported two cases of Salmonella septicaemia in RA patients during anti-TNF- therapy.
Food-borne infection from typical identifiable sources might be avoided with appropriate knowledge and advice. There are two main risk issues. The first is consumption of food that is typically known to have a high risk of specifically carrying and spreading potentially infectious organisms. This includes soft cheese contaminated with Listeria and eggs carrying Salmonella. The second issue—and a more general phenomenon—is transfer or spread of potentially infective organisms from poorly prepared foods. Listeria infection (1.5 cases per million/yr), though relatively rare in the general population, has clearly made an impact in patients treated with anti-TNF- drugs. Salmonella infection is more common than Listeria infection in the general population (11 cases/1000 people/yr in UK, European and North American populations [9]) and therefore potentially poses a greater risk burden.
In addition the potential risk of food-borne infection might be higher from foods obtained directly from farm producers—popular with consumers in rural areas—where food hygiene and preparation may not be reliable or monitored less stringently than by high-volume producers and retailers. Accordingly, it would be interesting to know whether there may be a relatively specific rural food-borne infection risk in anti-TNF--treated patients for which targeted advice can be given.
The ARC leaflets and the recent guidelines for anti-TNF- therapy do not carry food hygiene advice. To reduce the risk of Listeria and Salmonella infections specifically in patients taking anti-TNF- drugs, we propose that the following advice could be given [10].
Do not eat soft cheeses such as Feta, Brie, Camembert, blue-veined or Mexican-style cheeses, unless they have labels that clearly state they are made from pasteurized milk.
Do not eat refrigerated pâtés or meat spreads. Canned or shelf-stable pâtés and meat spreads may be eaten.
Avoid drinking unpasteurized milk and eating raw eggs, and cook the food to the proper temperatures.
Avoid eating hot dogs, luncheon meats or delicatessen meats, unless reheated until steaming hot.
In addition, patients being prescribed anti-TNF- therapy might be referred to general food hygiene advice carried by some popular cookery books, speciality publications and on the internet.
The authors have declared no conflicts of interest.
References
- Centres for Disease Control and Prevention. Multistate outbreak of listeriosis – United States 2000. Morbidity and Mortality Weekly. JAMA 2001;285:285–6.
[Free Full Text] - Listeria monocytogenes infections in England and Wales. CDR Weekly 2004;14:37.
- Slifman NR, Greshon SK, Lee J-H, Edwards ET, Braun MM. Listeria monocytogenes infection as a complication of treatment with tumour necrosis neutralisisng agents. Arthritis Rheum 2003;48:319–24.[CrossRef][Web of Science][Medline]
- Pagliano P, Attanasio V, Fusco U, Mohamed DA, Rossi M, Faella FS. Does etanercept monotherapy enhance the risk of Listeria monocytogenes meningitis? Ann Rheum Dis 2004;63:462–3.
[Free Full Text] - Bowie VL, Snella KA, Gopalachar AS, Bharadwaj P. Listeria meningitis associated with infliximab. Ann Pharmacother 2004;38:58–61.
[Abstract/Free Full Text] - Dixon W, Hyrich K, Watson K, Silman A, Symmons D and The BSR Biologics Register. Serious infection rates in patients receiving biologic therapy in the United Kingdom. Rheumatology 2005;44(Suppl. 1):i11.[CrossRef]
- Katsarolis I, Tsiodras S, Panagopoulous P et al. Septic arthritis due to Salmonella enteritidis associated with infliximab use. Scand J Infect Dis 2005;37:304–6.[Medline]
- Natea MG, Radstake T, Joosten LA, van der Meer JW, Barrera P, Kullberg BJ. Salmonella septicemia in rheumatoid arthritis patients receiving anti-tumour necrosis therapy: association with decreased interferon-gamma production and Toll-like receptor 4 expression. Arthritis Rheum 2003;48:1853–7.[CrossRef][Web of Science][Medline]
- Salmonella infections in England and Wales. CDR Weekly 2004;15:14.
- Pinner RW, Schuchat A, Swaminathan B et al. Role of foods in sporadic listeriosis. II. Microbiologic and epidemiologic investigation. The Listeria Study Group. JAMA 1992;267:2081–2.
[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||