Efficacy of Tocilizumab in a Patient with Adult-onset Still's Disease and Elevated Coxsackie B Viral Titers

摘要

Adult-onset Still's disease (AOSD) is a rare, inflammatory disorder characterized by arthralgia, evanescent, salmon-colored rash, daily fevers, lymphadenopathy, pharyngitis, and hepatosplenomegaly. Frequently seen laboratory abnormalities include leukocytosis, transaminitis, elevated ferritin and acute phase reactant levels, and aberrant production of pro-inflammatory cytokines. The inciting etiology of this syndrome is unknown, and both viruses and bacteria have been isolated in patients with AOSD leading to the hypothesis that infection triggers an autoimmune response. Treatment is empirical and includes symptom control with non-steroidal anti-inflammatory drugs and corticosteroids, as well as disease modifying anti-rheumatic drugs (DMARDS) and biologic agents. While biologic agents such as TNFa-blockers and IL-1 inhibitors have established efficacy in treating AOSD, emerging literature suggests that IL-6 inhibitors, which are generally used for rheumatoid arthritis, can be used in cases refractory to first-line treatment. We present the case of a 32 year old male with elevated coxsackie viral titers and AOSD refractory to numerous immunomodulating agents who experienced disease remission with Tocilizumab, thus suggesting a possible subset of patients in whom this less established regimen may have efficacy.