Reiter’s syndrome (reactive arthritis)with trismus after intravesical BCG immunotherapy : a case report. Asian J Oral & Maxillofac Surg. 2011;23:25-7.

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原文題目(出處): Reiter’s syndrome (reactive arthritis)with trismus after intravesical BCG immunotherapy : a case report. Asian J Oral & Maxillofac Surg. 2011;23:25-7.

原文作者姓名: Noriko Hatano,Hisako Hikiji,Minoru Matsubara,Hideto Saijo,Daichi Chikazu,Katsumi Ohashi,Yoshiyuki Mori,Takafumi Susami, Tetsuya Yoda,Tsuyoshi Takato

通訊作者學校: Oral and maxillofacial surgery ,The university of Tokyo,Bunkyo-ku,Tokyo,Japan

報告者姓名(組別): 王紹光 Intern B 組

報告日期: 100/10/14

內文:

A. Introduction:

 Intravesical( 膀 胱 內 的 ) Bacillus Calmette-Guerin (BCG)( 卡 介 苗 ) immunotherapy is considered useful for some patients with primary superficial bladder carcinoma

 60% of patients undergoing this therapy develop several side effects such as pneumonitis( 肺 炎 ), sepsis( 敗 血 ),multiple organ failure, and severe granulomatous inflammation(嚴重肉芽腫發炎)

 Reiter’s syndrome (reactive arthritis) is one of the major side effects caused by urinary tract infection (UTI) (尿道感染) triggered by BCG

 Reactive arthritis is considered to be derived from infection by microorganisms via membranes of the digestive(消化道), urogenital(泌尿生殖道), or respiratory systems

 This is the first report of Reiter’s syndrome with reactive temporomandibular arthritis caused by BCG immunotherapy.

B. Case report

 A 48-year-old male underwent transurethral resection(經尿道的切除術)of a bladder tumor( 膀 胱 腫 瘤 )under a diagnosis of bladder carcinoma in the Department of Urology at the University of Tokyo Hospital on August 17, 2004.

 After bladder carcinoma resection, a total of eight intravesical BCG immunotherapy treatments using an immunobladder were planned and started from September 10.

 However, after the fifth treatment, the patient developed a fever and reactive arthritis on October 14, and so the treatment was discontinued.

 The symptoms included trismus(牙關緊閉), whereby he could not even put one finger into his mouth, eating disorder, limited ambulation(有限的步行)due to painful swelling of the bilateral knee joints, a fever of 39 °C, blepharedema(臉浮 腫), and blepharoconjunctivitis(臉結膜炎)

 The patient was diagnosed with Reiter’s syndrome since he had the triad of arthritis(關節炎), urethritis(尿道炎), and conjunctivitis(結膜炎).

 Sharp pain of the bilateral temporomandibular area was more marked than at any other joint.

 The laboratory data on October 18 are shown in Tables 1 and 2.

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 These results indicated possible tuberculosis infection.

 He was then administered rifampicin at 450mg and isoniazid at 200mg per day, and the anti-inflammatory drug diclofenac sodium (voltarenR) several days after.

 By the end of October, he gradually became able to walk with physiotherapy.

 The swelling of the knee joints fully resolved by January 2005, and he could walk normally.

 The mouth-opening distance increased, although the sharp pain of the left temporomandibular joint persisted.

 HLA antigen presence, one of the potent indices of Reiter’s syndrome, was investigated on November 5, 2004. No positive indices [HLA-A31(19),HLA-B61(40), B48, or HLA-B27] were detected. Urinalysis for the acid fast bacillus on November 5, 2004,and January 7, 2005, revealed negative results.

 The severe pain of the temporomandibular joint persisted and, therefore, the attending urologist referred him to our maxillofacial surgery department on April 1, 2005.

 It had been 5 months since the reactive arthritis was first noted.

 The maximum mouth opening distance was 38mm at the first visit.

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 MRI showed no disc dislocation of the temporomandibular joints

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 He was instructed to undergo physiotherapy for mouth opening for 2weeks with the aid of diclofenac sodium.

 Physiotherapy treatments

 To position the mandible slowly to the left and right sides, and then forwards and backwards 10 times, respectively.

 To open the mouth as wide as possible 10 times, with the fingers in the mouth.

 To do three sets of these exercises daily according to instructions given in written form.

 He continued the exercise for 3 months without medication, and the pain reduced.

 The more he exercised, the more smoothly he was able to move and open his mouth.

 He became able to open his mouth without inconvenience after 7 months of this treatment.

 Panoramic radiography showed no change of the temporomandibular joint after 1 year of this therapy.

 At present, he can open his mouth total distance of 48mm with neither pain nor difficulty.

C. Discussion

 We have reported a case of Reiter’s syndrome with reactive temporomandibular arthritis caused by BCG immunotherapy.

 There are a few reports concerning Reiter’s syndrome (reactive arthritis) caused by intravesical BCG immunotherapy.

 However, these did not comment on temporomandibular arthritis.

 Reviewing the literature, this is the first report of Reiter’s syndrome of the tem- poromandibular joint following intravesical BCG immunotherapy.

 Furthermore, this case is rare because the temporomandibular area pain was severe and lasted for a prolonged period.

 Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is useful for antitumor therapy for some patients with primary superficial bladder carcinoma, or, particularly, superficial carcinoma.

 However, for intravesical BCG immunotherapy, there have been many reports of side effects such as pneumonitis, sepsis, multiple organ failure, and severe granulomatous inflammation.

 Nevertheless, after urinary tract infection (UTI) of BCG, dermatitis(皮膚炎)and blepharoconjunctivitis occur secondarily.

 HLA-B27, one of the indices of Reiter’s syndrome, was negative in this case.

 However, a diagnosis of Reiter’s syndrome is more likely, because about 44% of

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migrans(特殊的遊走性紅斑), accompanied by meningiris or flu-like symptoms.

 The second reason is that he had a history of intravesical BCG immunotherapy treatments which may cause Reiter’s syndrome.

 Considering the fact that the present patient showed the triad of arthritis, urethritis, and conjunctivitis, he was diagnosed with Reiter’s syndrome.

 The pain of the temporomandibular area persisted for a prolonged period.

 Sharp pain of the temporomandibular area was more marked than that of other areas such as the knee joints.

 The inflammatory level might have been higher in the temporomandibular area than in the other joints at the time he developed this disease.

 The patient seemed to have recovered from the primary stage of acute inflammation on the first visit to our department, although the pain of the temporomandibular area still persisted.

 The reason why only the left temporomandibular pain persisted with less pain in the right temporomandibular joint was unclear.

 The irregular contour of the left condylar corical bone may affect this pain.

 Mouth-opening exercise with the use of anti-inflammatory drugs relieved the pain of the temporomandibular joint.

 These results suggest that controlled rehabilitation is effective to recover the function of the temporomandibular joint.

題號 題目

1

以下關於 Reiter’s syndrome(reactive arthritis)何者為非?

(A) 是免疫中介引起的

(B) 有三種表徵: 關節炎、非淋菌性尿道炎及結膜炎

(C) Reiter 是第一個發現這個病的人 (D) HIV 病人常發生 reactive arthritis

答案(C) 出處:Oral and maxillofacial pathology-3rd edition p.781~782

題號 題目

2

以下關於 Reiter’s syndrome(reactive arthritis)何者為非?

(A) 常發生在老年人身上,男女比為 6:1

(B) 20%以下的病人會發生於口腔中,且會出現無痛的紅斑丘疹 (erythematous papules)於頰黏膜和顎

(C) 組織學上類似 psoriasis,因有微膿腫產生於上皮的淺層,及過度

角化(hyperkeratosis) (D) 可用 NSAID 治療

答案(A) 出處:Oral and maxillofacial pathology-3rd edition p.781~782

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