Polyarthritis in a patient with common variable immunodeficiency: a case report

Overview

The authors present here a case report of 50-years old patient with common variable immunodeficiency (CVID). She developed polyarticular arthritis that was coincident with multiple vaccinations (given from professional reasons). CVID was diagnosed at the age of 42 years on the basis of recurrent pneumonias, urinary tract infection, asymptomatic abscess in the small pelvis, and low levels of immunoglobulins: IgG (2.6 g/l) and IgA (0.5 g/l). Further, she developed insufficient specific autoantibody response after vaccinations against hepatitis A and enteroviruses infections (poliomyelitis). The regular replacement treatment with intravenous immunoglobulins (IVIG) was initiated in a dose of 350-400 mg per kg and month. Severe polyarthritic syndrome with clinical and radiological manifestations resembling rheumatoid arthritis (RA) developed at the age of 46 years. Except for rheumatoid factor (RF), ACR criteria of RA were fulfilled. Ureaplasma polyarthritis was considered and further excluded by therapeutical test with antibiotics. Efficacy of corticosteroids and antimalarials was insufficient, and sulphasalazine had to be withdrawn due to gastrointestinal intolerance. Since the disease activity was high (DAS = 6.95), methotrexate was added and good effect has been achieved (DAS response = 3.73, actual DAS = 3.15). In this context, corticosteroid treatment could be finished. Despite of full IVIG substitution during the 4-years of follow-up, recurrent infections of urinary tract appeared leading to methotrexate withdrawal. It caused further polyarthritis outbreak for that methotrexate was again added after 6 months. In this paper, putative contribution of vaccine administration to the onset of polyarthritis is discussed, particularly, with respect to genetic predisposition in a patient with positive family history of a father having RA and genotype HLA-DRB1*0101 and IL-1RN*2, both predisposing to autoimmune diseases and severe course of polyarthritis. Furthermore, risks of opportunistic infections and possible intensification of antibody immunodeficiency in patients with basal treatment of polyarthritis are discussed.

Key words:
common variable immunodeficiency, rheumatoid arthritis, vaccination, shared epitope methotrxate