Case Study – Immunosuppressive Drugs

00:01 Okay, let’s move on to a question. This is Bioligics Case 1.

00:06 A woman who has moved from South East Asia to work for a high-tech company in California develops severe psoriatic arthritis.

00:15 She is started on Abatacept after clearing pre-screening lab work.

00:21 Three weeks later she returns with an upper respiratory tract infection.

00:26 She started on some amoxicillin.

00:28 Two later she returns with a productive cough and a chest x-ray as follows.

00:38 Okay, the most reasonable course of action would be - A, check the liver function tests to rule out a hepatitis B reactivation; B, discontinue the antibiotics, that she has a viral not a bacterial infection; C, recheck the TB status of the patient. Do TB cultures and skin tests and consider whether referral to a TB center is reasonable; or D, prescribe a second round of amoxicillin as the patient has not had enough medication for a response.

01:18 Good, you checked C. What's going on here? Well, A was incorrect because the chest x-ray is not compatible with that picture.

01:28 B is incorrect, although admittedly a viral infection is possible.

01:33 The fact that she has an immune suppressive drug should also raise some alarms in your own head especially in the exam.

01:41 C is correct, D is incorrect. Now if this was a regular infection she would have responded.

01:48 If she doesn’t respond the antibiotic is probably the wrong one.

01:53 C is correct, this is an x-ray of Miliary TB, the pre-initiation workup was probably poorly done.

02:00 As with most biologics, there's a potential for immune suppression and reactivation of latent disease.

02:07 She's from a high risk area of TB. Other high risk areas include the North in Alaska and Canada, the southern half of Africa, the west coast of South America, and much of the Middle East and India.

02:21 So what ended up happening? The patient was taken off her biologics and she was treated with more appropriate lower intensity medications.

02:30 She was started on anti-TB medications and she recovered fully and happily she's now the vice president of international sales at her company.

02:38 The doctor? Well, the doctor was stripped off his license and he now works as a carnie guessing the weight of tourists at a theme park in North Dakota.

02:47 Well, that’s it. I know that you're gonna do very well on your exams and I know you that you won't end up as carnies.