Knee and Ankle Joints (fig. 1b). after One Injection of Tocilizumab, Serum Crp and Saa Levels Became Normal and Morning Stiffness and Shoulder Pain Improved. By

tocilizumab, serum CRP and SAA levels became normal and morning stiffness and shoulder pain improved. By March 2009, a total of five infusions of tocilizumab had been administered without any exacerbation of symptoms or any elevation of serum CRP or SAA levels. MMP3 reduced from 508-727 to 334 ng/ml. Ga-citrate scintigraphy also showed a marked reduction of uptake in the bilateral shoulders and hands, and in the left ankle joint (Fig. 1B). However, just before the sixth administration, cholecystitis occurred and tocilizumab treatment had to be stopped. At 3 months after the cessation, the disease activity flared up with shoulder pain and morning stiffness, leading to an increase in the methylprednisolone dose from 6 mg/day to 8 mg/day. In this report, we demonstrated the ameliorative effect of tocilizumab on symptoms caused by RS3PE. To the best of our knowledge, this is the first report to evince the efficacy of tocilizumab for RS3PE. A response to low-dose corticosteroids and absence of relapse after 2 years of treatment are characteristics of RS3PE [5] but our patient was refractory to corticosteroids and then the present case was thought to be a rare one. Increased serum concentration of IL-6 has been observed in patients with RS3PE [2, 3], and therefore IL-6 inhibition with tocilizumab might constitute a novel strategy for treatment of RS3PE. Indeed, reported here, tocilizumab treatment resulted in a remarkable suppression of clinical symptoms, accompanied by a reduction in MMP3 levels as well as in Ga-citrate uptake in joints. Although tocilizumab treatment had to be discontinued due to the complication of cholecystitis in the patient, tocilizumab can be considered a viable option for treatment of refractory RS3PE.