A 62‐year‐old woman with a medical history of rheumatoid arthritis (RA), diabetes mellitus, and hypertension presented with fever of 102°F and 10/10 diffuse abdominal, lower back, and flank pain for the past week. Her pain was associated with nausea and vomiting. She had no history of constipation, diarrhea, jaundice, abdominal distension, dysuria, or hematuria. Her RA was being treated with methotrexate and adalimumab. Her last dose of adalimumab was 6 weeks ago. On exam she had a fever of 102°F and tenderness over her lower thoracic spine. Her abdominal exam was normal. Laboratory evaluation showed white blood cell count 13.6, C‐reactive protein 25.7, and erythrocyte sedimentation rate 99.7. A CT scan of the abdomen and pelvis showed a soft‐tissue mass in the right paravertebral area with T11 vertebral body destruction. Blood culture and aspiration from the paravertebral abscess grew group D Salmonella enteritidis and Salmonella typhi.
Salmonella osteomyelitis is rare and represents only 0.8% of all Salmonella infections. Of these, a mere 0.5% affect the spine. Salmonella bacteremia is recognized by Toll‐like receptors 2, 4, and 5 (TLR‐2, ‐4, and ‐5). This activates cytokines and phagocytes, which leads to final clearance of the Salmonella. Patients treated with anti‐TNF agents have reduced TLR‐4.
Use of anti‐TNF agents reduces the levels of TLF‐4, which may prevent the recognition of invasive Salmonella species. This may have contributed to osteomyelitis in this patient, which is otherwise a rare infection.
P. Shivaprasad ‐ none; A. Subhi ‐ none; R. Pepe ‐ none
To cite this abstract:Shivaprasad P, Ahmad S, Pepe R. Salmonella Osteomyelitis in a Patient on the Anti‐Tnf Agent Adalimumab. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 396. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/salmonella-osteomyelitis-in-a-patient-on-the-antitnf-agent-adalimumab/. Accessed May 22, 2019.