Microbiology Fundamentals 2nd Edition by Jennifer Bunn,Marjorie Kelly Cowan

Exercise 1

C A S E F I L E

A Body Attacking Itself
A 57-year-old woman was admitted to the acute care unit where I was working as an RN. Her admitting diagnosis was rheumatoid arthritis (RA). Her past medical history was significant for gastric ulcers and insulindependent diabetes. She had been seen by her primary care physician in the clinic, who decided to admit her after examining her and listening to her history of symptoms.
This patient was unique in that her symptoms had begun quite suddenly 2 days prior, rather than insidiously as is usually the case in RA. She had awoken with moderately severe pain in her knees, ankles, hands, and feet. She also complained of extreme fatigue and stated that she felt as though she had the flu. She had a low-grade fever on admission. Her other vital signs were normal. Her hands, knees, and ankles were mildly swollen and were warm to the touch. She had difficulty moving due to joint pain and was having difficulty managing at home.
Blood work was ordered, including a complete blood count (CBC), chemistry panel, anti-CPP, ESR (erythrocyte sedimentation rate), rheumatoid factor (RF), and C-reactive protein. X rays were also ordered of the affected joints. Test results indicated that the patient was mildly anemic. The ESR was elevated and the patient was positive for both rheumatoid factor and anti-CPP. X rays showed soft tissue swelling around the affected joints, but little destruction of cartilage or damage to the bone was seen, which was not surprising considering the patient had had symptoms for such a short time.
Given that the patient had a history of GI (gastrointestinal) bleeding and had brittle diabetes, the physician decided to start the patient on Enbrel (entanercept), a tumor necrosis factor (TNF) inhibitor. I questioned why the patient was not started on a steroid, as is usually the case. The physician explained that starting the patient on anti-inflammatory drugs might have precipitated another stomach ulcer, and steroids such as prednisone are known to affect blood glucose levels; therefore, the physician felt that the patient would do better on a TNF inhibitor such as Enbrel. Before starting the patient on the drug, the physician screened her for hepatitis and tuberculosis. All of her screening tests were negative, and within 2 weeks the patient was in remission and feeling great.
• How is tumor necrosis factor significant in rheumatoid arthritis?
• How do TNF inhibitors reduce inflammation?