A 52-year-old woman is evaluated due to 2 weeks of fever, fatigue, nonproductive cough, and dyspnea, which began shortly after visiting her family in Ohio. She also lost 1.5 kg (3.3 lb) over the same period. The patient has a history of rheumatoid arthritis and has been taking adalimumab for the past 6 months. She had negative tuberculosis skin testing prior to beginning the drug. Temperature is 38 C (100.4 F), blood pressure is 130/70 mm Hg, pulse is 92/min, and respirations are 18/min. Physical examination reveals bilateral lung crackles, mild generalized lymphadenopathy, and hepatosplenomegaly. Chest x-ray shows bilateral nodular densities and hilar lymphadenopathy. Urine testing is positive for a fungal antigen. Which of the following pathogenic processes is most important during the development of this patient's infection?

Question

A 52-year-old woman is evaluated due to 2 weeks of fever, fatigue, nonproductive cough, and dyspnea, which began shortly after visiting her family in Ohio.  She also lost 1.5 kg (3.3 lb) over the same period.  The patient has a history of rheumatoid arthritis and has been taking adalimumab for the past 6 months.  She had negative tuberculosis skin testing prior to beginning the drug.  Temperature is 38 C (100.4 F), blood pressure is 130/70 mm Hg, pulse is 92/min, and respirations are 18/min.  Physical examination reveals bilateral lung crackles, mild generalized lymphadenopathy, and hepatosplenomegaly.  Chest x-ray shows bilateral nodular densities and hilar lymphadenopathy.  Urine testing is positive for a fungal antigen.  Which of the following pathogenic processes is most important during the development of this patient's infection?

Quizplus · Accepted Answer

Eductional Objective: Tumor necrosis factor-alpha inhibitors are associated with impairments to the cell-mediated immune response and increase the risk of infection with intracellular bacteria and granulomatous fungi (eg, Histoplasma capsulatum).  Histoplasma replicates within the intracellular space of macrophages and can spread from the lungs to the lymph nodes and the reticuloendothelial system (liver, spleen, bone marrow).

A 52-Year-Old Woman Is Evaluated Due to 2 Weeks of Fever