The Open Rheumatology Journal




ISSN: 1874-3129 ― Volume 13, 2019

A Case of Erosive Polyarthritis in a Patient Diagnosed With a Suspicion of Atypical Mycobacteria



Hani Almoallim*, 1, 2, 3, Laila Alharbi1, 3, Zainab Alshareef 2, Ghassan Wali1, 2
1 Department of Medicine, Medical College, Umm Alqura University, Saudia Arabia
2 Department of Medicine, King Faisal Specialist Hospital and Research Center, Saudia Arabia
3 Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Saudia Arabia

Abstract

In this report, we introduce a case of erosive polyarthritis in a 55-year-old female diagnosed with Mycobacterium abscessus pulmonary infection. Her arthritis has been worsened after use of DMARDs. The patient demonstrated a significant response to the antimicrobial regimen that was administered. We call special attention to the possibility of Mycobacterium abscessus being a cause of reactive polyarthritis, particularly if symptoms worsened after use of disease-modifying antirheumatic drugs (DMARDs), but further studies are necessary for clarification.

Keywords: : Mycobacterium abscessus, rheumatoid arthritis, polyarthritis..


Article Information


Identifiers and Pagination:

Year: 2013
Volume: 7
First Page: 64
Last Page: 66
Publisher Id: TORJ-7-64
DOI: 10.2174/1874312901307010064

Article History:

Received Date: 10/4/2013
Revision Received Date: 3/7/2013
Acceptance Date: 4/7/2013
Electronic publication date: 28/8/2013
Collection year: 2013

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 898
Abstract HTML Views: 904
PDF Downloads: 209
Total Views/Downloads: 2011

Unique Statistics:

Full-Text HTML Views: 521
Abstract HTML Views: 575
PDF Downloads: 157
Total Views/Downloads: 1253
Geographical View

© Almoallim et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the Department of Medicine, Medical College, Umm Alqura University, Saudia Arabia; Tel: 00966505703935; Fax: 0096625501000, Ext. 4652; E-mail: Hanialmoallim@hotmail.com




INTRODUCTION

Mycobacterium abscessus (M. abscessus) is a non-tuberculous mycobacterium (NTM) and an emerging pathogen causing skin, soft tissue and pulmonary infections [1Zhao P, Zhang YY, Li YB, Zhu Y, Wan KL. Diagnosis of pulmonary disease caused by Mycobacterium abscessus: a case report J Int Med Res 2011; 39(3): 968-75.]. M. abscessus is the third most frequently recovered NTM respiratory pathogen in the United States and accounts for approximately 80% of NTM respiratory disease isolates [2Griffith D, Aksamit T, Brown-Elliott B, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases Am Thorac Soc 2007; 175: 367-416.]. Conditions such as rheumatoid arthritis and other chronic diseases with pulmonary manifestations can predispose a person to NTM pulmonary disease [3Winthrop KL, Chang E, Yamashita S, Iademarco M, LoBue PA. Nontuberculous mycobacteria infections and anti–tumor necrosis factor-α therapy Em Infectious Diseases 2009; 15(10) Available: http://wwwnc.cdc.gov/eid/article/15/10/09-0310.htm].

Atypical mycobacteria can affect soft tissues and joints directly [4Kanik KS, Greenwald DP. Mycobacterium avium/ Mycobacterium intracellulare complex-associated arthritis masquerading as a seronegative rheumatoid arthritis J Clin Rheumatol 2000; 6(3): 154-7., 5Berger E, Batra P, Ralston J, Sanchez MR, Franks AG. A typical mycobacteria infection in an immunocompromised patient Dermatolo Online J 2010; 16(11) Available: http://dermatology.cdlib.org/1611/articles/21_2010-05-18/berger.html] or indirectly through suspected immunological mechanisms in a reactive way [4Kanik KS, Greenwald DP. Mycobacterium avium/ Mycobacterium intracellulare complex-associated arthritis masquerading as a seronegative rheumatoid arthritis J Clin Rheumatol 2000; 6(3): 154-7.,6Maricic MJ, Alepa F. Reactive arthritis after mycobacterium avium-intracellulare infection: Poncet's disease revisited Am J Med 1990; 88(5): 549-0.]. The latter form was described thoroughly recently as reactive arthritis associated with TB or (Poncet’s disease) [7Abdulaziz S, Almoallim H, Ibrahim A, et al. Poncet's disease (reactive arthritis associated with tuberculosis): retrospective case series and review of literature Clin Rheumatol 2012; 31(10): 1521-8.]. However, the risk of infections with mycobacteria in general increases in patients with rheumatic diseases [8Brassard P, Kezouh A, Suissa S. Antirheumatic. Drugs and the risk of tuberculosis Clin Infect Dis 2006; 43: 717-22.] and particularly with the use of disease-modifying antirheumatic drugs (DMARDs) and biological therapies [4Kanik KS, Greenwald DP. Mycobacterium avium/ Mycobacterium intracellulare complex-associated arthritis masquerading as a seronegative rheumatoid arthritis J Clin Rheumatol 2000; 6(3): 154-7.].

Precise data on the incidence and prevalence of NTM lung disease is limited by the fact that unlike tuberculosis, these infections are generally not reportable to public health authorities [9Babafemi T, Glassroth J. Non-tuberculous mycobacterial lung diseases Infect Dis Clin North Am 2012; 24: 769-89.]. In Saudi Arabia, there is no reliable estimates of incidence or prevalence of NTM infection. Though there is only one case series of chronic lung disease caused by M. abscessus, in two immunocompetent patients [10Bright V, Sue Elizabeth S, Majed O, Sahal A. First case report of chronic pulmonary lung disease caused by Mycobacterium abscessus in two immunocompetent patients in Saudi Arabia Ann Saudi Med 2012; 32(3): 312-4.].

In this article, we report a case of seronegative erosive polyarthritis in an elderly female patient who has been discovered to have M. abscessus pulmonary infection. This case is an example of the possibility of M. abscessus being a cause of reactive polyarthritis, particularly if symptoms worsened after the use of DMARDs.

CASE REPORT

A 55- year old Saudi female patient newly diagnosed as a case of osteoporosis and polymyalgia rheumatic was presented to the outpatient rheumatology clinic in December 2011 at King Faisal Specialist Hospital and Research Center, in Jeddah, with a month-long history of bilateral hand joints pain and morning stiffness lasting for 1 hour. She had no other joints involvement or any systemic symptoms.

Hand examination revealed tenderness over the metacarpophalangeal (MCPs), proximal interphalangeal (PIPs) and wrists joints but there was no swelling. Laboratory studies showed that WBCs= 12.8 × l (4.00-11.0 x 109/L) erythrocyte sedimentation rate (ESR) =15 mm/hr (<30 mm/hr), C-reactive protein (CRP) = 0.459 mg/dl (0-5mg/dl). Antinuclear antibodies, rheumatoid factor & anti-citrullinated protein peptide antibody (ACPA) were negative. Ultrasound exam of hands showed erosions in the right second MCP and effusion in both second MCPs and wrists joints. At that time she was diagnosed as inflammatory arthritis. Methotrexate 12.5 mg/week, folic acid 5mg/week and 10 mg prednisolone once daily were initiated.

In April 2012, she was still complaining of hand joints pain and morning stiffness. Arthritis remained active despite the treatment with methotrexate. A biological treatment was considered. The PPD skin test showed 15 mm reaction and CXR showed left lower lobe nodule. She denied any symptoms suggestive of tuberculosis (TB). Patient was referred to the Infectious Diseases (ID) and Isoniazid (INH) with pyridoxine were initiated. Two weeks later she developed a productive cough, an intermittent fever and a night sweat. A sputum culture and Computed tomography (CT) scans of the chest were arranged.

In her follow up in June 2012 with ID service, only one culture showed acid-fast bacilli of atypical mycobacterium further identification grew M. abscessus. Polymerase chain reaction (PCR) for mycobacterium was negative. The patient did not meet the American Thoracic Society (ATS) criteria for NTM [11Fujita K, Tanaka E, Kazuhiro H, Yoshiaki K, Taguchi Y. An Autopsy case of mycobacterium abscessus: pulmonary infection complicated with rheumatoid arthritis Intern Med 2008; 47: 1273-76.]. The sputum culture was repeated. She was maintained on INH. Meanwhile, it was considered that probably she had transient infectious process. In July 2012, a biological treatment was initiated, Etanercept; which is a TNF blocker (Enbrel) administered at a dose of 50 mg subcutaneous every one week.

On her follow up in September 2012, she demonstrated improvement in her arthritis but still had nonspecific symptoms with vague history of productive cough, intermittent undocumented fever, weight loss (4 kg) and the new development of chest pain. The decision was made to continue on Enbrel while she was being worked up for the presence of NTM.

By the end of September 2012 the repeated culture grew Mycobacterium Avium Complex (MAC) isolation. CT-chest showed left pleural-based granuloma. The ID service evaluation considered M. abscessus as the likely atypical mycobacterium causing the symptoms and MAC was considered as a contamination. Azithromax, ciprofloxacin and doxycycline were initiated as a treatment for M. abscessus. The biological therapy was discontinued.

In November 2012, she had the same non-specific complaints of productive cough and intermittent undocumented fever with no improvement on the antibiotic regimen that was given. Ethmbutol was added to add further coverage to include MAC but it was discontinued after one month. The subsequent culture was negative.

In December 2012, she newly developed aziothromax allergic reaction in form of gastrointestinal upset. The first culture and sensitivity showed intermediate resistant to Aziothromax. Therefore, linezolid was initiated and Aziothromax was discontinued.

In January 2013 with her follow up in rheumatology clinic, her symptoms improved. She gained 2Kg and her appetite was back to normal. She demonstrated significant improvement in her joint symptoms. The ultrasound exam of hands showed mild effusion in her joints. She remained off Enbrel and we decided to continue on the same treatment with follow up.

DISCUSSION

It was a challenge to diagnose an infection caused by NTM as it requires a high index of suspicion. Acid-fast stains are often negative. Thus the organism is not typically detected in routine bacterial culture [12Wang S-X, Yang C-J, Chen Y-C, Lay C-J, and Tsai C-C. Septic arthritis caused by mycobacterium fortuitum and mycobacterium abscessus in a prosthetic knee joint: case report and review of literature Intern Med 2008; 47: 1273-6.]. A single positive sputum culture, especially with a small number of organisms, is generally regarded as an indeterminate diagnosis of NTM lung disease. Patients should have at least three sputum specimens collected on separate days and analyzed for AFB to optimize positive predictive value of sputum analysis [2Griffith D, Aksamit T, Brown-Elliott B, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases Am Thorac Soc 2007; 175: 367-416.]. In the patient reported here there was only one positive culture while the diagnostic criteria established by the ATS in1997 required 2 or more cultures that were positive for the pathogen [11Fujita K, Tanaka E, Kazuhiro H, Yoshiaki K, Taguchi Y. An Autopsy case of mycobacterium abscessus: pulmonary infection complicated with rheumatoid arthritis Intern Med 2008; 47: 1273-76.].

The chest radiograph from patients with M. abscessus lung disease usually shows multilobar, patchy, reticulonodular, or mixed interstitial–alveolar opacities with upper lobe predominance. Cavitation occurs in only approximately 15% of cases [2Griffith D, Aksamit T, Brown-Elliott B, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases Am Thorac Soc 2007; 175: 367-416.]. HRCT of the lung frequently shows associated cylindrical bronchiectasis and multiple small (<5 mm) nodules. Overall, the radiographic pattern is similar to the nodular bronchiectatic form of MAC lung disease [2Griffith D, Aksamit T, Brown-Elliott B, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases Am Thorac Soc 2007; 175: 367-416.]. However, the chest radiograph of our patient here demonstrated tiny opacities at the left lower lung and a pleural based nodule of the same side in the chest high-resolution computed tomography (HRCT) scan. The classical radiological findings of NTM infections in the HRCT are cylindrical bronchiectasis and multiple small (<5 mm) nodules with upper lobe predominance [2Griffith D, Aksamit T, Brown-Elliott B, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases Am Thorac Soc 2007; 175: 367-416.]. Recently, two cases from Saudi Arabia about a NTM lung infection without arthritis showed fibronodular infiltration in the radiological imaging [10Bright V, Sue Elizabeth S, Majed O, Sahal A. First case report of chronic pulmonary lung disease caused by Mycobacterium abscessus in two immunocompetent patients in Saudi Arabia Ann Saudi Med 2012; 32(3): 312-4.]. There is a single pleural base nodule with erosive polyarthritis in the case presented here. We could not find a similar presentation following a thorough literature search.

Inflammatory markers such as ESR or CRP are normal in about 60% of patients with early RA [13Emery P. The Dunlop-Dottridge Lecture: prognosis in inflammatory arthritis: the value of HLA genotyping and the oncological analogy J Rheumatol 1997; 24: 1436-42.]. In the case presented here, CRP level was normal based on the value of our laboratories (0-5mg/L). Despite this normal level, the patient had erosive polyarthritis and was suspected to have a NTM infection. Nevertheless, the CRP level may be used as a marker of significant bacterial infection [14Weis N, Almdal T. C-reactive protein--can it be used as a marker of infection in patients with exacerbation of chronic obstructive pulmonary disease? Eur J Intern Med 2006; 17(2): 88-91.].

Macrolides, such as clarithromycin and azithromycin (AZM), are frequently the only oral antibiotics that are active against M. abscessus [15Choi GE, Shin SJ, Won CJ, et al. Macrolide treatment for mycobacterium abscessus and mycobacterium massiliense infection and inducible resistance Am J Respir Crit Care Med 2012; 1; 186(9): 917-25.]. M. abscessus isolates are uniformly resistant to the standard anti-tuberculous agents [2Griffith D, Aksamit T, Brown-Elliott B, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases Am Thorac Soc 2007; 175: 367-416.]. Treatment for M. abscessus was initiated for the patient reported here with azithromax, ciprofloxacin and doxycycline. The second positive culture that isolated MAC was considered as a contamination as supported by other reports [16Martins AB, Matos E D, Lemos AC. Infection with the mycobacterium avium complex in patients without predisposing conditions – a case report and literature review Braz J Infect Dis 2005; 9(2): 173-9.]. MAC is a co-infection in approximately 15% of patients with M. abscessus lung disease [9Babafemi T, Glassroth J. Non-tuberculous mycobacterial lung diseases Infect Dis Clin North Am 2012; 24: 769-89.]. This is the explanation of Ethambutol trial in this case report. The patient showed no improvement so she was retained back to cover only M. abscessus that were effective in improving her condition. It was concluded that the treatment should be based on M. abscessus despite the lack of definitive diagnosis as suggested by ATS [11Fujita K, Tanaka E, Kazuhiro H, Yoshiaki K, Taguchi Y. An Autopsy case of mycobacterium abscessus: pulmonary infection complicated with rheumatoid arthritis Intern Med 2008; 47: 1273-76.]. It was planned to continue minimum of 2-4 months on a combination antibiotic therapy as recommended [9Babafemi T, Glassroth J. Non-tuberculous mycobacterial lung diseases Infect Dis Clin North Am 2012; 24: 769-89., 17Lyu J, Jang HJ, Song JW, et al. Outcomes in patients with mycobacterium abscessus pulmonary disease treated with long-term injectable drugs Respir Med 2011; 105(5): 781-.] hoping to reach 80.5% successful treatment outcome as reported [17Lyu J, Jang HJ, Song JW, et al. Outcomes in patients with mycobacterium abscessus pulmonary disease treated with long-term injectable drugs Respir Med 2011; 105(5): 781-.].

The relationship between rheumatic diseases and infectious etiologies has been an area for extensive research. In a study where joint tissue of RA patients was screened for bacteria using sensitive pan-bacteria PCR, no bacterial DNA was found [18Chen T, Rimpilainen M, Luukkainen R, et al. Bacterial components in the synovial tissue of patients with advanced rheumatoid arthritis or osteoarthritis: analysis with gas chromatography-mass spectrometry and pan-bacterial polymerase chain reaction Arthritis Rheum 2003; 49(3): 328-4.]. However, a bacterial cell wall component, muramic acid, was detectable in few RA and OA patients in the same cohort [19van der Heijden IM, Wilbrink B, Tchetverikov I, et al. Presence of bacterial DNA and bacterial peptidoglycans in joints of patients with rheumatoid arthritis and other arthritides Arthritis Rheum 2000; 43(3): 593-8.]. Several studies have implicated bacterial cell wall components as having multiple immunologic activities that may contribute to joint inflammation [20Inman RD, Stone MA. Reactive arthritis: etiology and pathogenesis In: Hochberg M, Silman A, Smolen J, Weinblatt M, Weisman M, Eds. Rheumatology. 5th ed. Philadelphia: Elsevier 2012.]. We did not perform a bacterial cell wall study in the presented case. However, the association between bacterial cell wall components and reactive arthritis could be a form of typeIII hypersensitivity reaction.

On the one hand, M. abscessus in the case presented here may have played a triggering role in inducing erosive polyarthritis through possibly breaking tolerance to self-antigens. This might be through nonspecific mechanisms not related to the classical molecular mimicry [20Inman RD, Stone MA. Reactive arthritis: etiology and pathogenesis In: Hochberg M, Silman A, Smolen J, Weinblatt M, Weisman M, Eds. Rheumatology. 5th ed. Philadelphia: Elsevier 2012.]. On the other hand, polyarthritis in the patient presented here had been present for a long time and resulted in development of erosions. RA is a likely diagnosis with this possibility and serves simply as a risk factor for M. abscessus. It was suggested in several reports that RA would be associated with M. abscessus and NTM pulmonary disease in general even in the absence of treatment with immunosuppressant [11Fujita K, Tanaka E, Kazuhiro H, Yoshiaki K, Taguchi Y. An Autopsy case of mycobacterium abscessus: pulmonary infection complicated with rheumatoid arthritis Intern Med 2008; 47: 1273-76.,21Origuchi T, Migita K, Kawakami A, et al. Atypical mycobacteriosis in two patients with rheumatoid arthritis Mod Rheumatol 2002; 12: 76-9.]. It is possible that the short use of methotrexate might have triggered this M. abscessus infection as it a rapidly growing opportunistic mycobacterial pathogen. The use of DMARDs and biological therapies represent risk factors for acquiring M. abscessus [5Berger E, Batra P, Ralston J, Sanchez MR, Franks AG. A typical mycobacteria infection in an immunocompromised patient Dermatolo Online J 2010; 16(11) Available: http://dermatology.cdlib.org/1611/articles/21_2010-05-18/berger.html, 22Steyaert S, Stappaerts G, Mareen P, Dierick J. Soft tissue infections with atypical mycobacteria in two patients with inflammatory rheumatic diseases using TNF-inhibitors and/or leflunomide Acta Clin Belg 2011; 66(2): 144-7.]. However, the case presented here had long lasting history of non-specific complaints that labeled here as fibromyalgia. These symptoms could be retrospectively had been attributed to M. abscessus infection.

Another explanation for polyarthritis presented in the case reported here can be based on the concept of reactive arthritis in response to M. abscessus infection. The majority of clinical presentation of arthritis associated with TB (Poncet’s disease) was at time of initial presentation of TB [7Abdulaziz S, Almoallim H, Ibrahim A, et al. Poncet's disease (reactive arthritis associated with tuberculosis): retrospective case series and review of literature Clin Rheumatol 2012; 31(10): 1521-8.]. However, this concept should be expanded as some cases may present during or after treatment of TB [7Abdulaziz S, Almoallim H, Ibrahim A, et al. Poncet's disease (reactive arthritis associated with tuberculosis): retrospective case series and review of literature Clin Rheumatol 2012; 31(10): 1521-8.]. M. abscessus was reported to be complicated with RA [11Fujita K, Tanaka E, Kazuhiro H, Yoshiaki K, Taguchi Y. An Autopsy case of mycobacterium abscessus: pulmonary infection complicated with rheumatoid arthritis Intern Med 2008; 47: 1273-76.]. The presence of erosions in the case reported here may not support the possibility of this arthritis being a reactive one to M. abscessus. Another possibility is that M. abscessus might cause erosions and this case is just an example.

CONCLUSION

We report a case of M. abscessus pulmonary infection associated with seronegative erosive polyarthritis. The explanation of polyarthritis could be that it is either a reactive arthritis associated with M. abscessus or seronegative RA induced by M. abscessus. We recommend that M. abscessus should be included in the differential diagnosis of polyarthritis in any patient in an endemic area with a thorough search for primary site of infection particularly if symptoms worsened after use of DMARDs [4Kanik KS, Greenwald DP. Mycobacterium avium/ Mycobacterium intracellulare complex-associated arthritis masquerading as a seronegative rheumatoid arthritis J Clin Rheumatol 2000; 6(3): 154-7.] as was observed in our case. In M. abscessus infection a routine bacterial culture will not detect the organism and acid-fast stains are often negative [12Wang S-X, Yang C-J, Chen Y-C, Lay C-J, and Tsai C-C. Septic arthritis caused by mycobacterium fortuitum and mycobacterium abscessus in a prosthetic knee joint: case report and review of literature Intern Med 2008; 47: 1273-6.]. After identification of M. abscessus a long-term treatment with a combination antibiotic therapy consisting of macrolides should be initiated.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

This work was supervised and supported by the Alzaidi Chair of Research in Rheumatic Disease at Umm Alqura University. The authors are very grateful to Dr. Khadijah Bawazeer for reviewing our manuscript.

REFERENCES

[1] Zhao P, Zhang YY, Li YB, Zhu Y, Wan KL. Diagnosis of pulmonary disease caused by Mycobacterium abscessus: a case report J Int Med Res 2011; 39(3): 968-75.
[2] Griffith D, Aksamit T, Brown-Elliott B, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases Am Thorac Soc 2007; 175: 367-416.
[3] Winthrop KL, Chang E, Yamashita S, Iademarco M, LoBue PA. Nontuberculous mycobacteria infections and anti–tumor necrosis factor-α therapy Em Infectious Diseases 2009; 15(10) Available: http://wwwnc.cdc.gov/eid/article/15/10/09-0310.htm
[4] Kanik KS, Greenwald DP. Mycobacterium avium/ Mycobacterium intracellulare complex-associated arthritis masquerading as a seronegative rheumatoid arthritis J Clin Rheumatol 2000; 6(3): 154-7.
[5] Berger E, Batra P, Ralston J, Sanchez MR, Franks AG. A typical mycobacteria infection in an immunocompromised patient Dermatolo Online J 2010; 16(11) Available: http://dermatology.cdlib.org/1611/articles/21_2010-05-18/berger.html
[6] Maricic MJ, Alepa F. Reactive arthritis after mycobacterium avium-intracellulare infection: Poncet's disease revisited Am J Med 1990; 88(5): 549-0.
[7] Abdulaziz S, Almoallim H, Ibrahim A, et al. Poncet's disease (reactive arthritis associated with tuberculosis): retrospective case series and review of literature Clin Rheumatol 2012; 31(10): 1521-8.
[8] Brassard P, Kezouh A, Suissa S. Antirheumatic. Drugs and the risk of tuberculosis Clin Infect Dis 2006; 43: 717-22.
[9] Babafemi T, Glassroth J. Non-tuberculous mycobacterial lung diseases Infect Dis Clin North Am 2012; 24: 769-89.
[10] Bright V, Sue Elizabeth S, Majed O, Sahal A. First case report of chronic pulmonary lung disease caused by Mycobacterium abscessus in two immunocompetent patients in Saudi Arabia Ann Saudi Med 2012; 32(3): 312-4.
[11] Fujita K, Tanaka E, Kazuhiro H, Yoshiaki K, Taguchi Y. An Autopsy case of mycobacterium abscessus: pulmonary infection complicated with rheumatoid arthritis Intern Med 2008; 47: 1273-76.
[12] Wang S-X, Yang C-J, Chen Y-C, Lay C-J, and Tsai C-C. Septic arthritis caused by mycobacterium fortuitum and mycobacterium abscessus in a prosthetic knee joint: case report and review of literature Intern Med 2008; 47: 1273-6.
[13] Emery P. The Dunlop-Dottridge Lecture: prognosis in inflammatory arthritis: the value of HLA genotyping and the oncological analogy J Rheumatol 1997; 24: 1436-42.
[14] Weis N, Almdal T. C-reactive protein--can it be used as a marker of infection in patients with exacerbation of chronic obstructive pulmonary disease? Eur J Intern Med 2006; 17(2): 88-91.
[15] Choi GE, Shin SJ, Won CJ, et al. Macrolide treatment for mycobacterium abscessus and mycobacterium massiliense infection and inducible resistance Am J Respir Crit Care Med 2012; 1; 186(9): 917-25.
[16] Martins AB, Matos E D, Lemos AC. Infection with the mycobacterium avium complex in patients without predisposing conditions – a case report and literature review Braz J Infect Dis 2005; 9(2): 173-9.
[17] Lyu J, Jang HJ, Song JW, et al. Outcomes in patients with mycobacterium abscessus pulmonary disease treated with long-term injectable drugs Respir Med 2011; 105(5): 781-.
[18] Chen T, Rimpilainen M, Luukkainen R, et al. Bacterial components in the synovial tissue of patients with advanced rheumatoid arthritis or osteoarthritis: analysis with gas chromatography-mass spectrometry and pan-bacterial polymerase chain reaction Arthritis Rheum 2003; 49(3): 328-4.
[19] van der Heijden IM, Wilbrink B, Tchetverikov I, et al. Presence of bacterial DNA and bacterial peptidoglycans in joints of patients with rheumatoid arthritis and other arthritides Arthritis Rheum 2000; 43(3): 593-8.
[20] Inman RD, Stone MA. Reactive arthritis: etiology and pathogenesis In: Hochberg M, Silman A, Smolen J, Weinblatt M, Weisman M, Eds. Rheumatology. 5th ed. Philadelphia: Elsevier 2012.
[21] Origuchi T, Migita K, Kawakami A, et al. Atypical mycobacteriosis in two patients with rheumatoid arthritis Mod Rheumatol 2002; 12: 76-9.
[22] Steyaert S, Stappaerts G, Mareen P, Dierick J. Soft tissue infections with atypical mycobacteria in two patients with inflammatory rheumatic diseases using TNF-inhibitors and/or leflunomide Acta Clin Belg 2011; 66(2): 144-7.

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


SCImago Journal Ranking

SCImago Journal & Country Rank

Browse Contents



Webmaster Contact: info@benthamopen.net
Copyright © 2019 Bentham Open