Cholesterol crescents and plates in shoulder effusion of a rheumatoid patient.

bone marrow showed active marrow and normal granulocyte precursors, and he was started on methotrexate. He demonstrated a good initial response to methotrexate 7.5 mg weekly, but this was stopped due to neutropenia of 0.9 Â 10 9 /l. Cyclosporin was unsuccessful (gum hypertrophy and hypertension). Methotrexate was restarted, but with persisting asymptomatic neutropenia varying between 0.57 and 0.93 Â 10 9 /l. Methotrexate proved ineffective for the arthritis 6 months later. He was started on etanercept. He had an excellent clinical response, but with persistent neutropenia. Six months later, he presented to clinic with weight loss and left upper quadrant pain. Total white cell count was 8.9 Â 10 9 /l, with neutrophils of 6.79 Â 10 9 /l (very high for him). Ultrasound and CT scan showed multiple splenic abscesses. Blood cultures grew Staphylococcus aureus. Despite intensive intravenous antibiotics his C-reactive protein continued to rise and repeat CT showed no improvement. He had an elective splenectomy, complicated by post-operative sepsis and bleeding requiring repeat laparotomy and a 5-day ICU stay. Splenic histology confirmed staphylococcal abscesses. He made a full recovery, and is currently well, on no medication, with normal neutrophil counts. There have been previous reports of neutropenia with anti-TNF agents. We have found only one other report with etanercept in an ankylosing spondylitis patient, with two positive rechallenges [6]. The patient also developed neutropenia after an infliximab infusion. Agranulocytosis and neutropenia have been described with infliximab [6–8], one case requiring inpatient stay for intravenous antibiotics until the cultures were negative. A recent study of 130 patients on anti-TNF showed a cytopenia rate of 12%, mainly leucopenias, with none leading to serious infection [9]. Our first patient had no sepsis, but the second showed a rapid and dramatic neutropenia, and though cultures were negative she behaved as if septic. The third patient had pre-existing neutrope-nia, and developed a dramatic and life-threatening infection with staphylococcal abscesses in a most unusual location. All three patients had normal bone marrow examinations, suggesting that the neutropenia may be due to peripheral consumption rather than a primary marrow disorder. All three patients were strongly positive for IgG ANA (1/1280, 1/5120 and >1/5120, respectively), though a previous analysis showed no evidence of an association between ANA and neutropenia in RA anti-TNF patients [5]. None of the patients had symptoms of Sjo¨gren's syndrome. All three are negative for anti-neutrophil cytoplasmic antibodies, but we have not …