A 60-year-old woman presented with fatigue and weight loss, along with pain in the proximal interphalangeal joints of both hands, wrists, elbows, shoulders, knees, and metatarsophalangeal joints. She was diagnosed with RA at a local clinic six months ago. Her symptoms were not relieved with six months of continuous treatment of DMARDs, and the patient had fever. When the patient referred to our hospital, she experienced severe pain in the small- and medium-sized joints throughout the body and significant swelling in the interphalangeal joints of all painful joints. She described her joints as having a burning sensation, accompanied by significant morning stiffness. She was positive for antinuclear antibody and negative for RF. Additionally, she had a high titer of anti-cyclic citrullinated peptide antibody, an erythrocyte sedimentation rate of 48 mm/h, and a CRP level of 13.3 mg/L (Table 2). Using the 28-Joint Disease Activity Scale (DAS28), her diagnosis of RA was confirmed with a disease activity score of 6.04, suggesting a high degree of disease activity.
Next, we initially administered methotrexate (MTX), tofacitinib, and etoricoxib because of the ineffectiveness of multiple DMARDs, for which the patient experienced insignificant joint pain relief. The patient experienced vomiting after MTX administration. For several reasons, the patient refused low-dose steroids to relieve pain. As this patient was resistant to first-line DMARDs, we initiated adalimumab (40 mg subcutaneously every other week) (Hisun Biopharmaceutical Co., Ltd.) therapy after screening the patient for hepatitis virus infection, LTBI, and other infectious conditions according to the British Society for Rheumatology DMARDs safety guidelines. Compared to DMARDs, the patient responded better to adalimumab therapy. Unfortunately, the patient had a concealed history of a sexual partner with HIV/AIDS. However, her DAS28 score decreased to 4.9 after two weeks of ADA treatment, and symptoms such as joints pain and weakness were significantly relieved. Nonetheless, after RA was in control, HIV was detected in her blood, with a quantitative HIV-1 RNA test revealing values of 1.31E+5 IU/mL, accompanied by a decreased CD4+ lymphocyte count. Considering that she had difficult-to-treat RA combined with HIV/AIDS, her swollen and painful joints were uncontrolled. In addition, the patient was ineffective against DMARDs. Steroids may have accelerated the replication of HIV-RNA and induce other infections. After discussion with the patient, adalimumab therapy was continued, and HAART was initiated. HIV-1 RNA viral replication was controlled, and the CD4+ lymphocyte count continued to increase (Figure 1). After one year of ADA therapy, LTBI and other infections did not occur. She had no fever, and her fatigue had significantly improved. Her case was considered as RA remission, with a DAS28 score of 1.40.