SHM Converge Scientific Abstract ePoster Gallery-Rheumatoid Arthritis on Long-Term Tocilizumab: A Rare Case of Cavitary Apical Lung Lesions From Mycobacterium Avium Complex (Mac) Infection

Rheumatoid Arthritis on Long-Term Tocilizumab: A Rare Case of Cavitary Apical Lung Lesions From Mycobacterium Avium Complex (Mac) Infection

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This case describes a 67-year-old woman with long-standing seropositive rheumatoid arthritis treated with tocilizumab for two years who developed a 3-month history of cough, blood-streaked sputum, weakness, shortness of breath, low-grade fevers, chills, and night sweats. She was an active smoker and had no known tuberculosis exposure. Initial labs showed no leukocytosis, and QuantiFERON-TB, hepatitis B/C, and HIV tests were negative.<br /><br />Chest CT revealed bilateral upper-lobe cavitary lesions, including a large right upper-lobe cavity and a smaller left upper-lobe lesion, raising concern for tuberculosis or malignancy. Bronchoscopy showed no endobronchial abnormalities, but bronchoalveolar lavage and sputum cultures grew acid-fast bacilli that were later identified as Mycobacterium avium complex (MAC), confirming pulmonary MAC infection.<br /><br />Because tocilizumab likely contributed to immunosuppression and infection risk, it was stopped. Her rheumatoid arthritis therapy was changed to leflunomide and low-dose prednisone. Infectious disease specialists started prolonged MAC treatment with amikacin for 12 weeks plus azithromycin, rifampin, and ethambutol for at least one year.<br /><br />The case highlights that patients receiving biologic agents, especially IL-6 inhibitors like tocilizumab, are at increased risk for opportunistic infections. Pulmonary MAC can present with cavitary lung lesions that mimic tuberculosis or cancer, making diagnosis challenging. Early bronchoscopy and extended cultures are important for diagnosis. Management requires balancing infection control with rheumatoid arthritis treatment, often through multidisciplinary care.

Asset Subtitle

Adriana Morales Rivera

Meta Tag

Author List Adriana Morales Rivera, Carlos Ramirez-Matos, Danielle Madison, Raul Tallo

Category Clinical Vignettes

Concept Opportunistic Infection

Concept Mycobacterium avium complex

Concept Biologic Immunosuppressive Therapy

Concept Pulmonary Mycobacterial Infection

Concept Cavitary Lung Lesion

Distinguished Non-Finalist

Presenter Organization Lakeland Regional Health

Presenting Author Adriana Morales Rivera

Track Adult

Keywords

rheumatoid arthritis

tocilizumab

pulmonary MAC infection

Mycobacterium avium complex

cavitary lung lesions

opportunistic infection

immunosuppression

bronchoscopy

amikacin

azithromycin

Opportunistic Infection

Mycobacterium avium complex

Biologic Immunosuppressive Therapy

Pulmonary Mycobacterial Infection

Cavitary Lung Lesion