A 58-year-old woman diagnosed with seropositive, erosive and nodular rheumatoid arthritis (RA) with high titres of rheumatoid factor for 15 years. She had received previous treatment with different disease-modifying drugs (DMARDs): hydroxychloroquine, sulfasalazine, cyclosporine and leflunomide, which were withdrawn due to ineffectiveness. He followed background treatment with methotrexate 25mg/weekly/sc, prednisone 5-10mg/day variable and infliximab 5mg/kg/IV/8 weeks with acceptable disease control in the last 2 years with low activity without reaching complete remission.
He developed septic arthritis of the right ankle with synovial fluid culture positive for Staphylococcus aureus. Infliximab was withdrawn and treatment was started with intravenous antibiotherapy.
After 3 months she consulted for red eye, intense periorbital pain and photophobia. The patient presented with an upper peripheral corneal infiltrate in a crescent shape with extreme stromal thinning associated with scleritis. The culture of the corneal scraping was negative. On suspicion of severe QUP, treatment was started with prednisone 1mg/kg/day orally with no response. Megadoses of methylprednisolone 1g/IV/3 days were prescribed. In addition, surgical resection of the conjunctival tissue adjacent to the QUP and cyanoacrylate adhesive was performed to prevent ocular perforation. The patient responded poorly to treatment, with persistent pain, scleritis and corneal infiltrate. As there was not optimal control of her underlying disease, we decided to start an infusion of rituximab 1g/i.v. two infusions 15 days apart. Three weeks after the start of treatment, there was significant clinical improvement, with an inactive corneal leukoma without scleritis. She is currently being treated with i.v. rituximab on a schedule of RA every 8 months with good clinical control.