PT - JOURNAL ARTICLE AU - Pratyusha Tirumanisetty AU - Jose William Sotelo AU - Michael Disalle AU - Meenal Sharma TI - Pneumatosis intestinalis: cost paid for rheumatoid arthritis treatment AID - 10.1136/bcr-2019-229329 DP - 2019 Jul 01 TA - BMJ Case Reports PG - e229329 VI - 12 IP - 7 4099 - http://casereports.bmj.com/content/12/7/e229329.short 4100 - http://casereports.bmj.com/content/12/7/e229329.full SO - BMJ Case Reports2019 Jul 01; 12 AB - A 75-year-old woman with rheumatoid arthritis on rituximab presented with a 1-week history of constipation and abdominal distension. Subsequent workup showed presence of air in the bowel wall without perforation initially. Due to positive blood cultures, worsening leucocytosis and high suspicion for perforation, an exploratory laparotomy was performed revealing necrotic bowel, walled off perforation and abscess. Patient underwent right hemicolectomy with diversion loop ileostomy. Clinicians must recognise that monoclonal antibodies like rituximab can mask signs of inflammation and therefore should maintain a high index of suspicion for intestinal perforation when evaluating patients with minimal symptoms and pneumatosis intestinalis.