Dados do Trabalho

Title

SIMULTANEOUS RHEUMATOID ARTHRITIS AND B-CELL CHRONIC LYMPHOCYTIC LEUKEMIA: FROM ACTIVE TO COMPLETE REMISSION IN BOTH DISEASES USING RITUXIMAB

Background

Rheumatoid arthritis can be characterized as a systemic autoimmune condition that targets mainly joints and its components tissues, causing pain and loss of function. The treatment goes from some behavior changes such as nutritional education and the cease of smoking, to potent immunosuppressive agents. Chronic lymphocytic leukemia corresponds to a hematological neoplasia and its incidence significantly increases with the patient’s age, therefore, making common associations with other diseases. Despite having a similar inflammatory based core and rituximab in their therapeutic arsenal - a monoclonal antibody developed and approved to be used on humans in the 90’s, that targets the CD20 antigen, expressed on malignant B cells - both diseases rarely correlate.

Case report

A 61-year-old Brazilian female presented to our service with swelling in the small joints of both her hands associated with morning stiffness. Her laboratory results revealed a normal rheumatoid factor (RF), elevated anti-CCP antibody (66), high C-reactive protein (PCR) of 192 and elevated erythrocyte sedimentation rate (ESR) of 95. After 6 weeks of methotrexate and glucocorticoids the symptoms subsided but the control laboratory results presented a leukocytosis (25100) with predominance of lymphocytes. The retest after 7 days showed 25600 white blood cells with over 10000 lymphocytes and thrombocytopenia. She was referred to a hematologist, that through immunophenotyping of peripheral blood lymphocytes diagnosed chronic lymphocytic leukemia (CLL) and staged her as high-risk by the Rai staging system since she presented thrombocytopenia of 89000. The treatment of the CLL started with the triple therapy of fludarabine, cyclophosphamide and rituximab. After 3 doses she presented intolerance to the fludarabine with excessive vomit, nausea and worsening of thrombocyte levels (from 83000 to 43000). The hematologist opted to maintain the rituximab alone for 3 more doses. At our service we administrated two more doses of rituximab and now the patient presents complete remission in both diseases 2 years after the last dose.

Conclusion

This case reveals the importance of the close monitoring of patients with rheumatoid Arthritis and how a multidisciplinary approach can reconcile treatment of two complex pathologies with a single drug.