WHEN TO LEAVE THE LEFLUNOMIDE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Leflunomide (LEF) is a disease modifying antirheumatic drug. In this case report, we will highlight conditions which have been associated with LEF use and warrant immediate discontinuation early cholestyramine washout. CASE PRESENTATION: A 52 year old woman history of RA on prednisone LEF, stage 3 chronic kidney presented progressive bilateral lower extremity necrotizing cellulitis for the past 4 days. was held during her last hospitalization left pseudomonal thigh abscess but restarted discharge. She found to pseudomonas ecthyma gangrenosum E. coli bacteremia, she treated cefepime, metronidazole topical gentamicin. discontinued day 11 due purulent discharge from concerns induced skin ulcers. On 17, developed acute encephalopathy, hypoxic respiratory distress, renal failure, shock. CXR notable new upper lobe cavitary lesion. Bronchoscopy revealed diffuse alveolar hemorrhage (DAH). Findings were significant elevated serum BAL beta-d-glucan, galactomannan, bronchial biopsy microscopy suggestive histoplasma. Biopsy culture positive vancomycin resistant faecium. Patient lymphopenia IVIG Pneumocystis pneumonia prophylaxis started. washout started antimicrobials broadened meropenem, linezolid amphotericin B. Her status function failed improve. transitioned comfort care 32 passed. DISCUSSION: The risk severe infection therapy 8.2%. factors infections diabetes mellitus, older age, higher concomitant daily dosage corticosteroid (>7.5 mg/day). developing 3.7% occurred in patients receiving both prednisone. has reported cause DAH independently without infection. also implicated ulcer formation poor wound healing. Wound healing improves after LEF. converted into its active metabolite, teriflunomide. Teriflunomide levels not correlated adverse events. can be detected up 2 years well cleared by dialysis. Its half-life dramatically reduced 1-2 days CONCLUSIONS: We describe importance recognizing some less commonly seen manifestations toxicity. Early key, should performed if clinical presentation severe. REFERENCE #1: Keng LT, Lin MW, Huang HN, Chung KP. Diffuse damage patient rheumatoid arthritis under prolonged leflunomide treatment: Report Literature Review. Medicine (Baltimore). 2016;95(26):e4044. doi:10.1097/MD.0000000000004044 #2: Rozman Clinical pharmacokinetics leflunomide. Clin Pharmacokinet. 2002;41(6):421-430. doi:10.2165/00003088-200241060-00003 #3: Li EK, Tam LS, Tomlinson treatment arthritis. Ther. 2004;26(4):447-459. doi:10.1016/s0149-2918(04)90048-3 DISCLOSURES: No relevant relationships Debapria Das, source=Web Response no disclosure file Adnan Khan; Karen Pan; Daniele Valentini,