Dudler, J.

Gerster, J.

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LETTERJ. C. Gerster Æ J. DudlerCellulitis caused by Capnocytophaga cynodegmi associatedwith etanercept treatment in a patient with rheumatoid arthritisReceived: 2 April 2004 / Accepted: 2 April 2004 / Published online: 14 July 2004 Clinical Rheumatology 2004Capnocytophaga are facultative anaerobic gram-negativebacteria, part of the normal ﬂora of the oral cavity ofhumans and domestic animals such as dogs and cats.There are two main pathogenic species isolated fromanimal sources, C. canimorsus and C. cynodegmi [2].Three species of Capnocytophaga have been isolatedfrom human sources: C. ochronacea, C. gingivalis andC. sputigena [1].Bacteria are inoculated by direct dog or cat bite andcause local, or very rarely, disseminated infections.Splenectomy, chronic alcoholism and diabetes mellitushave all been reported to be signiﬁcant risk factors [1, 2,3]. In recent years, use of tumor necrosis factor (TNF)-ablocking agents to treat rheumatoid arthritis (RA) hasincreased, but concerns have arisen about opportunisticinfections with these therapies [4]. We report the caseof a patient treated with etanercept for RA who devel-oped local cellulitis a few days after a bite from her owncat.Case reportA 63-year-old RA patient treated successively with goldsalts, sulfasalazine, methotrexate and leﬂunomide overthe years was given etanercept 25 mg twice weekly inNovember 2002. Treatment was concomitant withprednisone 7.5 mg daily, diclofenac 75 mg daily andhydroxychloroquine 400 mg once a day, three medica-tions she had started many years before.In March 2003, she was bitten by her cat on the leftshin. A few days later, she developed a painful swellingof the calf. She was afebrile and had no signs of RAﬂare. Red pinkish nodules, about 4·5 cm in size, onthe anterior part of the left calf necrosed secondarilyafter a few days (Fig. 1). There was no purulentdischarge, no lymphangitis or inguinal lymphadenop-athy. A small bite scar, 4 mm in length, could be seen.Bacteria of the species Capnocytophaga grew in themicrobiologic specimens collected by needle aspiration.C. cynodegmi was identiﬁed by ampliﬁcation andsequencing of the 16S rRNA. The erythrocyte sedi-mentation rate (ESR) was 26 mm/h, leucocyte count10,500/mm3 with a normal diﬀerential and haemoglo-bin 127 g/l. Clarithromycin 1 g daily was given for10 days and etanercept interrupted. Evolution wasfavourable; the cutaneous lesions healed progressivelywithout sequelae.J. C. Gerster (&) Æ J. DudlerRheumatology Department, CHUV,1011 Lausanne, SwitzerlandE-mail: Jean-Charles.Gerster@chuv.hospvd.chFig. 1 Local skin necrosis related to C apnocytophaga cynodegmilocal infectionClin Rheumatol (2004) 23: 570–571DOI 10.1007/s10067-004-0950-3DiscussionCapnocytophaga represent an opportunistic germ of lowpathogenicity, part of normal oral ﬂora. In some cases,these bacteria can cause a local abscess [5] or even sep-ticaemia with a fatality rate as high as 25% [6]. Infec-tions with these microorganisms have been previouslyreported in immunocompromised hosts [2]. In ourpatient, long-term corticosteroid therapy could by itselfbe a predisposing factor. However, anti-TNF-a therapyappears to have played a more important role in thisinfection as our patient had been bitten by her cats onnumerous occasions over the years, without previousproblem.In our review of the literature, we did not ﬁnd reportsof Capnocytophaga infection in association with TNF-ablocking agents, a germ which does not seem to causearthritis, in contrast to Pasteurella multocida alsotransmitted by scratches or domestic animal bites, whichcan cause severe arthritis [7].References1. Talan DA, Citron DM, Abrahamian FM, Moran GJ, GoldsteinEJC (1999) Bacteriologic analysis of infected dog and cat bites.N Engl J Med 340:85–922. Scully RE, Mark EJ, McNeely WF, Ebeling SH, Ellender SM(1999) Case records of the Massachusetts General Hospital, case17–1999. N Engl J Med 340:1819–18263. Sarma PS, Mohanty S (2001) Capnocytophaga cynodegmicellulitis, bacteremia and pneumonitis in a diabetic man. J ClinMicrobiol 39:2028–20294. Ellerin T, Rubin RH, Weinblatt ME (2003) Infections and anti-tumor necrosis factor a therapy. Arthritis Rheum 48:3013–30225. Henzen C, Streit E (1993) Zervikalabszess durch Capnocy-tophaga ochracea. Schweiz Med Wochenschr 123:1165–11686. Pers C, Gahrn-Hansen B, Frederiksen W (1996) Capnocytoph-aga canimorsus septicemia in Denmark, 1982–1995: review of 39cases. Clin Infect Dis 23:71–757. Chevalier X (2003) Attention quand le chat sort ses griﬀes! Apropos d’arthrites septiques. Lett Rhumatol 296: 35–40571

Cellulitis caused by Capnocytophaga cynodegmi associated with etanercept treatment in a patient with rheumatoid arthritis

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Cellulitis caused by Capnocytophaga cynodegmi associated with etanercept treatment in a patient with rheumatoid arthritis

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