- Email: [email protected]
CME examination
1.e8 Chirch et al
23.
24. 25.
26.
27. 28.
29.
30.
31. 32.
33. 34.
J AM ACAD DERMATOL
JULY 2014
pneumonia in patients receiving tumor necrosis factor-alpha antagonists. Clin Infect Dis 2006;43:e95-100. Gottlieb GS, Lesser CF, Holmes KK, Wald A. Disseminated sporotrichosis associated with treatment with immunosuppressants and tumor necrosis factor-alpha antagonists. Clin Infect Dis 2003;37:838-40. Barros MB, de Almeida Paes R, Schubach AO. Sporothrix schenckii and Sporotrichosis. Clin Microbiol Rev 2011;24:633-54. Slifman NR, Gershon SK, Lee JH, Edwards ET, Braun MM. Listeria monocytogenes infection as a complication of treatment with tumor necrosis factor alpha-neutralizing agents. Arthritis Rheum 2003;48:319-24. Pena-Sagredo JL, Hernandez MV, Fernandez-Llanio N, Gimenez-Ubeda E, Munoz-Fernandez S, Ortiz A, et al. Listeria monocytogenes infection in patients with rheumatic diseases on TNF-alpha antagonist therapy: the Spanish Study Group experience. Clin Exp Rheumatol 2008;26:854-9. Schuchat A, Swaminathan B, Broome CV. Epidemiology of human listeriosis. Clin Microbiol Rev 1991;4:169-83. Cartwright EJ, Jackson KA, Johnson SD, Graves LM, Silk BJ, Mahon BE. Listeriosis outbreaks and associated food vehicles, United States, 1998-2008. Emerg Infect Dis 2013;19:1-9. Centers for Disease Control and Prevention. Multistate outbreak of listeriosis associated with Jensen Farms cantaloupe—United States, August-September 2011. MMWR Morb Mortal Wkly Rep 2011;60:1357-8. Qutre A, Demoux AL, Soussan J, Frances Y, Rossi P. Clinical image: salmonella mycotic aneurysm in a patient receiving etanercept for rheumatoid arthritis. Arthritis Rheum 2012;64:942. Gordon MA. Salmonella infections in immunocompromised adults. J Infect 2008;56:413-22. Centers for Disease Control and Prevention. Surveillance for foodborne disease outbreaks—United States, 2009-2010. MMWR Morb Mortal Wkly Rep 2013;62:41-7. Negroni R. Cryptococcosis. Clin Dermatol 2012;30:599-609. Caron J, Michot C, Fabre S, Godreuil S, Guillot B, Dereure O. Aggressive cutaneous infection with Mycobacterium marinum
35.
36.
37. 38.
39. 40.
41.
42.
43.
44.
in two patients receiving anti-tumor necrosis factor-alfa agents. J Am Acad Dermatol 2011;65:1060-2. Ferreira J, Grochowsky J, Krakower D, Zuromskis P, Baden R, Cheifetz AS. Mycobacterium marinum: an increasingly common opportunistic infection in patients on infliximab. Am J Gastroenterol 2012;107:1268-9. Kump PK, Hogenauer C, Wenzl HH, Petritsch W. A case of opportunistic skin infection with Mycobacterium marinum during adalimumab treatment in a patient with Crohn’s disease. J Crohns Colitis 2013;7:e15-8. Young JD, McGwire BS. Infliximab and reactivation of cerebral toxoplasmosis. N Engl J Med 2005;353:1530-1. Lassoued S, Zabraniecki L, Marin F, Billey T. Toxoplasmic chorioretinitis and antitumor necrosis factor treatment in rheumatoid arthritis. Semin Arthritis Rheum 2007;36:262-3. Montoya JG, Liesenfeld O. Toxoplasmosis. Lancet 2004;363: 1965-76. Centers for Disease Control and Prevention. Multistate outbreak of human Salmonella typhimurium infections associated with aquatic frogs—United States, 2009. MMWR Morb Mortal Wkly Rep 2010;58:1433-6. Mermin J, Hutwagner L, Vugia D, Shallow S, Daily P, Bender J, et al. Reptiles, amphibians, and human Salmonella infection: a population-based, case-control study. Clin Infect Dis 2004; 38(suppl 3):S253-61. Dunne EF, Friedman A, Datta SD, Markowitz LE, Workowski KA. Updates on human papillomavirus and genital warts and counseling messages from the 2010 Sexually Transmitted Diseases Treatment Guidelines. Clin Infect Dis 2011;53(suppl 3):S143-52. Nordgaard-Lassen I, Dahlerup JF, Belard E, Gerstoft J, Kjeldsen J, Kragballe K, et al. Guidelines for screening, prophylaxis and critical information prior to initiating anti-TNF-alpha treatment. Dan Med J 2012;59:C4480. Bradford RD, Pettit AC, Wright PW, Mulligan MJ, Moreland LW, McLain DA, et al. Herpes simplex encephalitis during treatment with tumor necrosis factor-alpha inhibitors. Clin Infect Dis 2009;49:924-7.
To claim CME credit, complete this case-based posttest online at http://www.aad.org/JAAD/. Note: CME quizzes are available after the first of the month in which the article is published. A minimum score of 70% must be achieved to claim CME credit. If you have any questions, please contact the Member Resource Center of the American Academy of Dermatology at toll-free (866) 503-SKIN (7546), (847), 240-1280 (for international members), or by e-mailing [email protected].
CME examination Identification No. JA0714 July 2014 issue of the Journal of the American Academy of Dermatology.
Chirch LM, Cataline PR, Dieckhaus KD, Grant-Kels JM. J Am Acad Dermatol 2014;71:1-8.
J AM ACAD DERMATOL VOLUME 71, NUMBER 1
Directions for questions 1-4: Choose the single best response. A 49-year-old woman with severe plaque psoriasis refractory to topical agents is considering treatment with etanercept. On reviewing her history, you learn that she lived in a rural area near Louisville, Kentucky for 15 years after completing her education. She has been generally well other than her psoriasis. She is married with 2 healthy children who are in high school and is monogamous with her husband of 20 years. However, she admits to having had many male sexual partners in her youth. She denies any ongoing tobacco, alcohol, or drug use, but again admits to indiscretions with illicit drugs many years ago. She denies ever having injected drugs, but admits to smoking and snorting various recreational drugs. The patient is now a social worker by trade and has worked for the state correctional system as a case manager for the last several years. 1. The historical information detailed above puts the patient at particular risk for which infectious entities relevant to treatment with biologic therapy? a. Tuberculosis, cryptococcosis, and hepatitis B b. Tuberculosis, coccidioidomycosis, hepatitis C, and syphilis c. HIV, hepatitis B, chlamydia, and blastomycosis d. HIV, hepatitis C, tuberculosis, and histoplasmosis
e. Hepatitis C, tuberculosis, coccidioidomycosis, and herpes simplex virus 2. Based on her risks, what would be the most prudent set of tests to order in anticipation of beginning biologic therapy? a. Two sets of blood cultures, serum cryptococcal antigen, and serum quantiFERON assay b. Hepatitis B surface antigen and surface antibody, HIV serology, and urine histoplasma antigen c. Hepatitis B surface antigen, surface antibody, core total antibody, hepatitis C enzyme immunoassay, HIV serology, purified protein derivative skin testing, Histoplasma capsulatum serology d. Hepatitis B surface antigen, surface antibody, core total antibody, hepatitis C quantitative ribonucleic acid, serum quantiFERON, and Coccidioides immitis serology e. Urine chlamydia trachomatis nucleic amplification testing, serum rapid plasma reagin, purified protein derivative testing, and HIV serology
Chirch et al 1.e9
A 52-year-old Hispanic man is referred for possible biologic therapy for refractory psoriatic arthritis. In the course of taking his initial history, he tells you that he is originally from Ecuador but moved to the United States as a teenager many years ago. As a child in Ecuador, he received the Bacillus-Calmette-Gu erin (BCG) vaccination and has been told that his ‘‘skin test’’ for tuberculosis is positive because of that. He has been told that his test will always be positive, so it should not be repeated, and that he does not have active tuberculosis infection. He has not been tested for tuberculosis in many years. The patient feels well other than his skin and joint complaints, and denies fevers, sweats, chills, weight loss, or cough. 3. Which of the following statements is true about this patient? a. Because he does not have active tuberculosis, it is safe to proceed with biologic therapy without additional testing b. His purified protein derivative test should be repeated, and if truly positive, biologic therapy is contraindicated c. His positive purified protein derivative test is likely secondary to having received the BCG vaccination, so no additional workup is necessary before the initiation of biologic therapy d. If his positive purified protein derivative test is secondary to his having received the BCG vaccine, he is likely to have a positive serum quantiFERON gold test as well, so there is no role for this test in this patient e. A serum quantiFERON may help distinguish between latent and active tuberculosis in a patient who received the BCG vaccine 4. What is the best course of action for this patient at this time? a. Obtain a serum quantiFERON assay and, if negative, there is no need for additional workup; if positive, the positive purified protein derivative test should be repeated b. Repeat a positive purified protein derivative test; if still positive, biologic therapy is contraindicated c. Obtain a serum quantiFERON gold assay and, if negative, there is no need for additional workup and therapy may be initiated; if positive, obtain a chest radiograph, and if there is no evidence of active infection on radiography, proceed with biologic therapy d. Obtain a serum quantiFERON gold assay and, if negative, there is no need for additional workup and therapy may be initiated; if positive, obtain a chest radiograph, and if there is no evidence of active infection on radiography, the patient will require therapy for latent tuberculosis infection before the initiation of biologic therapy e. Both the positive purified protein derivative test and serum quantiFERON are unreliable; obtain a chest radiograph and sputum cultures for acid-fast bacteria, and if all results are negative, proceed with biologic therapy
23.
24. 25.
26.
27. 28.
29.
30.
31. 32.
33. 34.
J AM ACAD DERMATOL
JULY 2014
pneumonia in patients receiving tumor necrosis factor-alpha antagonists. Clin Infect Dis 2006;43:e95-100. Gottlieb GS, Lesser CF, Holmes KK, Wald A. Disseminated sporotrichosis associated with treatment with immunosuppressants and tumor necrosis factor-alpha antagonists. Clin Infect Dis 2003;37:838-40. Barros MB, de Almeida Paes R, Schubach AO. Sporothrix schenckii and Sporotrichosis. Clin Microbiol Rev 2011;24:633-54. Slifman NR, Gershon SK, Lee JH, Edwards ET, Braun MM. Listeria monocytogenes infection as a complication of treatment with tumor necrosis factor alpha-neutralizing agents. Arthritis Rheum 2003;48:319-24. Pena-Sagredo JL, Hernandez MV, Fernandez-Llanio N, Gimenez-Ubeda E, Munoz-Fernandez S, Ortiz A, et al. Listeria monocytogenes infection in patients with rheumatic diseases on TNF-alpha antagonist therapy: the Spanish Study Group experience. Clin Exp Rheumatol 2008;26:854-9. Schuchat A, Swaminathan B, Broome CV. Epidemiology of human listeriosis. Clin Microbiol Rev 1991;4:169-83. Cartwright EJ, Jackson KA, Johnson SD, Graves LM, Silk BJ, Mahon BE. Listeriosis outbreaks and associated food vehicles, United States, 1998-2008. Emerg Infect Dis 2013;19:1-9. Centers for Disease Control and Prevention. Multistate outbreak of listeriosis associated with Jensen Farms cantaloupe—United States, August-September 2011. MMWR Morb Mortal Wkly Rep 2011;60:1357-8. Qutre A, Demoux AL, Soussan J, Frances Y, Rossi P. Clinical image: salmonella mycotic aneurysm in a patient receiving etanercept for rheumatoid arthritis. Arthritis Rheum 2012;64:942. Gordon MA. Salmonella infections in immunocompromised adults. J Infect 2008;56:413-22. Centers for Disease Control and Prevention. Surveillance for foodborne disease outbreaks—United States, 2009-2010. MMWR Morb Mortal Wkly Rep 2013;62:41-7. Negroni R. Cryptococcosis. Clin Dermatol 2012;30:599-609. Caron J, Michot C, Fabre S, Godreuil S, Guillot B, Dereure O. Aggressive cutaneous infection with Mycobacterium marinum
35.
36.
37. 38.
39. 40.
41.
42.
43.
44.
in two patients receiving anti-tumor necrosis factor-alfa agents. J Am Acad Dermatol 2011;65:1060-2. Ferreira J, Grochowsky J, Krakower D, Zuromskis P, Baden R, Cheifetz AS. Mycobacterium marinum: an increasingly common opportunistic infection in patients on infliximab. Am J Gastroenterol 2012;107:1268-9. Kump PK, Hogenauer C, Wenzl HH, Petritsch W. A case of opportunistic skin infection with Mycobacterium marinum during adalimumab treatment in a patient with Crohn’s disease. J Crohns Colitis 2013;7:e15-8. Young JD, McGwire BS. Infliximab and reactivation of cerebral toxoplasmosis. N Engl J Med 2005;353:1530-1. Lassoued S, Zabraniecki L, Marin F, Billey T. Toxoplasmic chorioretinitis and antitumor necrosis factor treatment in rheumatoid arthritis. Semin Arthritis Rheum 2007;36:262-3. Montoya JG, Liesenfeld O. Toxoplasmosis. Lancet 2004;363: 1965-76. Centers for Disease Control and Prevention. Multistate outbreak of human Salmonella typhimurium infections associated with aquatic frogs—United States, 2009. MMWR Morb Mortal Wkly Rep 2010;58:1433-6. Mermin J, Hutwagner L, Vugia D, Shallow S, Daily P, Bender J, et al. Reptiles, amphibians, and human Salmonella infection: a population-based, case-control study. Clin Infect Dis 2004; 38(suppl 3):S253-61. Dunne EF, Friedman A, Datta SD, Markowitz LE, Workowski KA. Updates on human papillomavirus and genital warts and counseling messages from the 2010 Sexually Transmitted Diseases Treatment Guidelines. Clin Infect Dis 2011;53(suppl 3):S143-52. Nordgaard-Lassen I, Dahlerup JF, Belard E, Gerstoft J, Kjeldsen J, Kragballe K, et al. Guidelines for screening, prophylaxis and critical information prior to initiating anti-TNF-alpha treatment. Dan Med J 2012;59:C4480. Bradford RD, Pettit AC, Wright PW, Mulligan MJ, Moreland LW, McLain DA, et al. Herpes simplex encephalitis during treatment with tumor necrosis factor-alpha inhibitors. Clin Infect Dis 2009;49:924-7.
To claim CME credit, complete this case-based posttest online at http://www.aad.org/JAAD/. Note: CME quizzes are available after the first of the month in which the article is published. A minimum score of 70% must be achieved to claim CME credit. If you have any questions, please contact the Member Resource Center of the American Academy of Dermatology at toll-free (866) 503-SKIN (7546), (847), 240-1280 (for international members), or by e-mailing [email protected].
CME examination Identification No. JA0714 July 2014 issue of the Journal of the American Academy of Dermatology.
Chirch LM, Cataline PR, Dieckhaus KD, Grant-Kels JM. J Am Acad Dermatol 2014;71:1-8.
J AM ACAD DERMATOL VOLUME 71, NUMBER 1
Directions for questions 1-4: Choose the single best response. A 49-year-old woman with severe plaque psoriasis refractory to topical agents is considering treatment with etanercept. On reviewing her history, you learn that she lived in a rural area near Louisville, Kentucky for 15 years after completing her education. She has been generally well other than her psoriasis. She is married with 2 healthy children who are in high school and is monogamous with her husband of 20 years. However, she admits to having had many male sexual partners in her youth. She denies any ongoing tobacco, alcohol, or drug use, but again admits to indiscretions with illicit drugs many years ago. She denies ever having injected drugs, but admits to smoking and snorting various recreational drugs. The patient is now a social worker by trade and has worked for the state correctional system as a case manager for the last several years. 1. The historical information detailed above puts the patient at particular risk for which infectious entities relevant to treatment with biologic therapy? a. Tuberculosis, cryptococcosis, and hepatitis B b. Tuberculosis, coccidioidomycosis, hepatitis C, and syphilis c. HIV, hepatitis B, chlamydia, and blastomycosis d. HIV, hepatitis C, tuberculosis, and histoplasmosis
e. Hepatitis C, tuberculosis, coccidioidomycosis, and herpes simplex virus 2. Based on her risks, what would be the most prudent set of tests to order in anticipation of beginning biologic therapy? a. Two sets of blood cultures, serum cryptococcal antigen, and serum quantiFERON assay b. Hepatitis B surface antigen and surface antibody, HIV serology, and urine histoplasma antigen c. Hepatitis B surface antigen, surface antibody, core total antibody, hepatitis C enzyme immunoassay, HIV serology, purified protein derivative skin testing, Histoplasma capsulatum serology d. Hepatitis B surface antigen, surface antibody, core total antibody, hepatitis C quantitative ribonucleic acid, serum quantiFERON, and Coccidioides immitis serology e. Urine chlamydia trachomatis nucleic amplification testing, serum rapid plasma reagin, purified protein derivative testing, and HIV serology
Chirch et al 1.e9
A 52-year-old Hispanic man is referred for possible biologic therapy for refractory psoriatic arthritis. In the course of taking his initial history, he tells you that he is originally from Ecuador but moved to the United States as a teenager many years ago. As a child in Ecuador, he received the Bacillus-Calmette-Gu erin (BCG) vaccination and has been told that his ‘‘skin test’’ for tuberculosis is positive because of that. He has been told that his test will always be positive, so it should not be repeated, and that he does not have active tuberculosis infection. He has not been tested for tuberculosis in many years. The patient feels well other than his skin and joint complaints, and denies fevers, sweats, chills, weight loss, or cough. 3. Which of the following statements is true about this patient? a. Because he does not have active tuberculosis, it is safe to proceed with biologic therapy without additional testing b. His purified protein derivative test should be repeated, and if truly positive, biologic therapy is contraindicated c. His positive purified protein derivative test is likely secondary to having received the BCG vaccination, so no additional workup is necessary before the initiation of biologic therapy d. If his positive purified protein derivative test is secondary to his having received the BCG vaccine, he is likely to have a positive serum quantiFERON gold test as well, so there is no role for this test in this patient e. A serum quantiFERON may help distinguish between latent and active tuberculosis in a patient who received the BCG vaccine 4. What is the best course of action for this patient at this time? a. Obtain a serum quantiFERON assay and, if negative, there is no need for additional workup; if positive, the positive purified protein derivative test should be repeated b. Repeat a positive purified protein derivative test; if still positive, biologic therapy is contraindicated c. Obtain a serum quantiFERON gold assay and, if negative, there is no need for additional workup and therapy may be initiated; if positive, obtain a chest radiograph, and if there is no evidence of active infection on radiography, proceed with biologic therapy d. Obtain a serum quantiFERON gold assay and, if negative, there is no need for additional workup and therapy may be initiated; if positive, obtain a chest radiograph, and if there is no evidence of active infection on radiography, the patient will require therapy for latent tuberculosis infection before the initiation of biologic therapy e. Both the positive purified protein derivative test and serum quantiFERON are unreliable; obtain a chest radiograph and sputum cultures for acid-fast bacteria, and if all results are negative, proceed with biologic therapy