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Anti-TNF Induced Sarcoidosis-Like Disease in Rheumatoid Arthritis Patients: Review Cases from the RA UCLouvain Brussels Cohort. Rheumatol Ther 2022; 9:763-770. [PMID: 35133578 PMCID: PMC8964854 DOI: 10.1007/s40744-022-00424-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/11/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Drug-induced sarcoidosis-like disease is a rare side effect of anti-tumor necrosis factor (anti-TNF) agents in rheumatoid arthritis (RA) patients. The most commonly involved organs in such condition are the lungs, skin, and lymph nodes. The aim of this study is to report the number of cases and the clinical manifestations of sarcoidosis induced by anti-TNF in our RA UCLouvain Brussels cohort. Methods All case records of RA patients ever treated with a TNF inhibitor and presenting anti-TNF induced sarcoidosis in our rheumatology centers from 2000 to 2021 were retrospectively reviewed. Results Our RA UCLouvain Brussels cohort includes 2492 patients. Among them, 697 patients have been or are exposed to a TNF inhibitor. Only four patients with sarcoidosis induced by anti-TNF were identified and reviewed. Patient 1 was classified as incomplete Heerfordt syndrome. Patient 2 was a case of sarcoid-like granulomatosis manifesting as life-threatening hypercalcemia, acute kidney injury and atypical parenchymal pneumopathy. Patients 3 and 4 developed pulmonary sarcoidosis with hilar adenopathies. The TNF inhibitor was etanercept for the first three patients and infliximab for the last one. The time occurrence of sarcoidosis was highly variable after anti-TNF exposure. All patients recovered after glucocorticoid treatment and the discontinuation of the anti-TNF agent. Conclusions This case highlights this rare paradoxical side effect and the variability of the clinical presentation. Further studies should analyze the immunopathology of such conditions.
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Necrotizing Granulomas in a Patient With Psoriasis and Sarcoidosis After Adalimumab-Medication-Induced Reaction or Reactivation of Latent Disease? Am J Dermatopathol 2019; 41:661-666. [PMID: 30839343 DOI: 10.1097/dad.0000000000001394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
In this report, we describe a case of a patient with a clinical history of systemic sarcoidosis and psoriasis who developed biopsy-confirmed perforating and necrotizing cutaneous granulomas after 12 months of treatment with adalimumab, a tumor necrosis factor-alpha-inhibiting, anti-inflammatory, biologic medication, prescribed for the patient's psoriasis. Although rare reports of a "sarcoidosis-like" reaction associated with select tumor necrosis factor-alpha agents exist, to the best of our knowledge, perforating and necrotizing cutaneous granulomas after treatment with adalimumab has not been previously reported. Given the patient's history of systemic sarcoidosis, the differential diagnosis includes reactivation of latent sarcoidosis with adalimumab as a trigger.
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Schreiber J, Müller-Ladner U. [Treatment of rheumatic diseases and pulmonary toxicity]. DER PNEUMOLOGE 2018; 15:404-412. [PMID: 32288712 PMCID: PMC7101753 DOI: 10.1007/s10405-018-0209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Rheumatic diseases are treated with manifold different drugs that can potentially be pneumotoxic. Adverse effects of drug therapy may induce a wide variety of bronchopulmonary and pleural disorders, which can have a life-threatening course. These side effects rarely have pathognomonic features; therefore, drug-induced diseases are relevant differential diagnoses of pulmonary manifestations of rheumatic diseases, infections, and other independent genuine pulmonary diseases. Diagnosis is based mainly on verification of a compatible disease pattern and exclusion of differential diagnoses, as well as on assessment of the temporal relationship and the consequences of drug abstention.
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Affiliation(s)
- J. Schreiber
- Klinik für Pneumologie, Universitätsklinikum der Otto-von-Guericke-Universität Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Deutschland
| | - U. Müller-Ladner
- Rheumatologie und Klinische Immunologie, Kerckhoff-Klinik Bad Nauheim, Bad Nauheim, Deutschland
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Yang LS, Dowling D. A Rare Complication of Infliximab. Gastroenterology 2018; 154:e5-e6. [PMID: 28807842 DOI: 10.1053/j.gastro.2017.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/08/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Linda S Yang
- Department of Gastroenterology, University Hospital Geelong, Victoria, Australia
| | - Damian Dowling
- Department of Gastroenterology, University Hospital Geelong, Victoria, Australia
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Kim TK, Kang SH, Moon HS, Sung JK, Jeong HY, Eun HS. Pulmonary Sarcoidosis That Developed During the Treatment of a Patient With Crohn Disease by Using Infliximab. Ann Coloproctol 2017; 33:74-77. [PMID: 28503520 PMCID: PMC5426197 DOI: 10.3393/ac.2017.33.2.74] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/08/2016] [Indexed: 12/14/2022] Open
Abstract
For inflammatory bowel disease (IBD), antitumor necrosis factor treatment offers a new direction for both patients and medical doctors. This treatment has dramatically improved the quality of life for patients with ulcerative colitis and Crohn disease (CD). However, with increasing usage and longer follow-up periods, a wider range of possible adverse effects may be encountered. We report an unusual case of pulmonary sarcoidosis developed during the treatment of a patient with CD by using infliximab. A 30-year-old male who had been treated for CD with infliximab for 18 months was admitted due to abnormal opacities on chest radiography. Chest computed tomography displayed clustered small nodules in both lobes and enlarged multiple lymph nodes. The patient was diagnosed with sarcoidosis from the results of a biopsy of the subcarinal lymph node. Lung lesions were improved five months after infliximab was stopped.
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Affiliation(s)
- Tae Kyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Sun Hyung Kang
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hee Seok Moon
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Kyu Sung
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hyun Yong Jeong
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hyuk Soo Eun
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
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Numakura T, Tamada T, Nara M, Muramatsu S, Murakami K, Kikuchi T, Kobayashi M, Muroi M, Okazaki T, Takagi S, Eishi Y, Ichinose M. Simultaneous development of sarcoidosis and cutaneous vasculitis in a patient with refractory Crohn's disease during infliximab therapy. BMC Pulm Med 2016; 16:30. [PMID: 26864464 PMCID: PMC4750217 DOI: 10.1186/s12890-016-0193-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 02/03/2016] [Indexed: 02/06/2023] Open
Abstract
Background Paradoxical inflammations during anti-TNF-α therapy are defined as adverse effects such as psoriasiform skin lesions, uveitis and sarcoidosis-like granulomas induced by immune reactions, not by infectious agents. Here, we report a very rare case of the simultaneous development of sarcoidosis and cutaneous vasculitis in a patient with refractory Crohn’s disease during infliximab therapy and both of which resolved spontaneously without the cessation of infliximab. Case presentation In September 2000, 23-year old Japanese male was diagnosed with Crohn’s disease. Prednisolone in combination with mesalazine was introduced at first and succeeded for almost one year. In June 2002, since his gastrointestinal symptoms relapsed and were refractory, infliximab (IFX) therapy 5 mg/kg was introduced. In February 2011, because he had repeated arthralgia almost every intravenous IFX administration, IFX was increased to 10 mg/kg under the diagnosis of a secondary failure of IFX. In December 2012, he complained of slight dry cough and an itchy eruption on both lower limbs, and he was referred to our hospital due to the appearance of bilateral hilar lymphadenopathy on chest X-ray examination. Chest computed tomogram revealed bilateral hilar lymphadenopathy and fine reticulonodular shadows on the bilateral upper lungs. Serum calcium, angiotensin-converting enzyme and soluble interleukin 2 receptor levels were not elevated, but the titer of antinuclear antibody was considerably elevated. Mycobacterium infection was carefully excluded. Trans-bronchial lung biopsy showed non-caseating epithelioid cell granulomas compatible with sarcoidosis. The skin biopsy of the right limb was diagnosed as leukocytoclastic vasculitis. The patient was diagnosed as having a series of paradoxical inflammations during anti-TNF-α therapy. Since his paradoxical inflammations were not severe and opportunistic infections were excluded, IFX was cautiously continued for refractory Crohn’s disease. Nine months later, not only his intrathoracic lesions but also his cutaneous lesions had spontaneously resolved. Conclusion Physicians caring for patients with anti-TNF-α therapy should know that, based on a careful exclusion of infectious agents and thoughtful assessment of the patient’s possible risks and benefits, paradoxical inflammations can be resolved without the cessation of anti-TNF-α therapy.
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Affiliation(s)
- Tadahisa Numakura
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Tsutomu Tamada
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Masayuki Nara
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai, Japan.
| | - Soshi Muramatsu
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Koji Murakami
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Toshiaki Kikuchi
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - Makoto Kobayashi
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Miho Muroi
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Tatsuma Okazaki
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | | | - Yoshinobu Eishi
- Department of Human Pathology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
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Scailteux LM, Guedes C, Polard E, Perdriger A. Sarcoïdose survenant chez des patients traités par adalimumab pour un rhumatisme inflammatoire : à propos de deux cas et revue de la littérature. Presse Med 2015; 44:4-10. [DOI: 10.1016/j.lpm.2014.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 04/12/2014] [Accepted: 06/18/2014] [Indexed: 01/11/2023] Open
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Marigliano B, Soriano A, Margiotta D, Vadacca M, Afeltra A. Lung involvement in connective tissue diseases: a comprehensive review and a focus on rheumatoid arthritis. Autoimmun Rev 2013; 12:1076-84. [PMID: 23684699 DOI: 10.1016/j.autrev.2013.05.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/03/2013] [Indexed: 12/20/2022]
Abstract
The lungs are frequently involved in Connective Tissue Diseases (CTDs). Interstitial lung disease (ILD) is one of the most common pleuropulmonary manifestations that affects prognosis significantly. In practice, rheumatologists and other physicians tend to underestimate the impact of CTD-ILDs and diagnose respiratory impairment when it has reached an irreversible fibrotic stage. Early investigation, through clinical evidence, imaging and - in certain cases - lung biopsy, is therefore warranted in order to detect a possible ILD at a reversible initial inflammatory stage. In this review, we focus on lung injury during CTDs, with particular attention to ILDs, and examine their prevalence, clinical manifestations and histological patterns, as well as therapeutic approaches and known complications till date. Although several therapeutic agents have been approved, the best treatment is still not certain and additional trials are required, which demand more knowledge of pulmonary involvement in CTDs. Our central aim is therefore to document the impact that lung damage has on CTDs. We will mainly focus on Rheumatoid Arthritis (RA), which - unlike other rheumatic disorders - resembles Idiopathic Pulmonary Fibrosis (IPF) in numerous aspects.
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Affiliation(s)
- Benedetta Marigliano
- Department of Clinical Medicine and Rheumatology, University Campus Bio-Medico of Rome, Italy
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Tong D, Manolios N, Howe G, Spencer D. New onset sarcoid-like granulomatosis developing during anti-TNF therapy: an under-recognised complication. Intern Med J 2012; 42:89-94. [PMID: 22389903 DOI: 10.1111/j.1445-5994.2011.02612.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Tumour necrosis factor-alpha (TNF-a) antagonists have advanced the treatment of inflammatory arthropathies, and are even considered for use in refractory sarcoidosis with some success. Paradoxically, cases of new onset sarcoidosis-like diseases are increasingly reported in patients receiving TNF-a antagonists. Here, we report three cases of sarcoid-like granulomatosis that developed during treatment with TNF-a antagonists. Review of the Biologics clinic data base at Westmead, Sydney, Australia identified three patients whom, during anti-TNF therapy, developed non-caseating granulomas consistent with sarcoidosis. These three cases are described with review of the literature from 2000 to 2009 using PubMed. One hundred and sixty-nine patients within our data base were reviewed for the period 2003–2009. Sarcoidosis-like granulomas developed in three patients within a period of 3 to 36 months of treatment with etanercept and/or adalimumab. All cases demonstrated non-infective, non-caseating granulomas on renal or lymph node biopsy. Improvement was seen in two cases upon cessation of TNF-a antagonist and steroid therapy. Interestingly, clinical deterioration was noted upon re-challenge with the same TNF-a antagonist in one patient. To date, a total of 37 cases of sarcoid-like granuloma development after anti-TNF therapy have been reported in the literature. Development of sarcoidosis-like granulomatosis in patients treated with TNF-a antagonists is a phenomenon previously under-recognised. All three anti-TNF agents have been observed to cause this phenomenon, suggesting a ‘class effect’ rather than being drug specific.
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Affiliation(s)
- D Tong
- Department of Rheumatology, Westmead Hospital, Sydney, New South Wales, Australia.
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11
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Lamrock E, Brown P. Development of cutaneous sarcoidosis during treatment with tumour necrosis alpha factor antagonists. Australas J Dermatol 2012; 53:e87-90. [PMID: 23157794 DOI: 10.1111/j.1440-0960.2011.00863.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The use of tumour necrosis factor alpha (TNF-α) antagonists is increasing in the field of dermatology. These agents have been used for multiple inflammatory and immune skin conditions, but most notably, psoriasis. Adverse effects of anti-TNF-α agents have been reported, including the paradoxical development of sarcoidosis. We present an unusual case of limited cutaneous sarcoidosis developing while the patient was on etanercept therapy, and a review of the current literature.
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Affiliation(s)
- Edwina Lamrock
- Department of Dermatology, Royal North Shore Hospital, St Leonards, NSW 2065, Australia.
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12
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Stephenson SR, Campbell SM, Drew GS, Magro CM. Palisaded neutrophilic and granulomatous dermatitis presenting in a patient with rheumatoid arthritis on adalimumab. J Cutan Pathol 2011; 38:644-8. [PMID: 21592182 DOI: 10.1111/j.1600-0560.2011.01716.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sean R Stephenson
- Department of Medical Education, Ohio University College of Osteopathic Medicine, Athens, OH, USA
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13
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Ramos-Casals M, Perez-Alvarez R, Perez-de-Lis M, Xaubet A, Bosch X. Pulmonary disorders induced by monoclonal antibodies in patients with rheumatologic autoimmune diseases. Am J Med 2011; 124:386-94. [PMID: 21531225 DOI: 10.1016/j.amjmed.2010.11.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 10/29/2010] [Accepted: 11/01/2010] [Indexed: 12/11/2022]
Abstract
Monoclonal antibodies have emerged as a new class of agents causing drug-related pulmonary involvement in patients with systemic rheumatologic autoimmune diseases. The most frequently associated noninfectious pulmonary diseases are interstitial pneumonia (118 cases reported by August 2010), sarcoid-like disease and vasculitis (40 cases), and 97% of cases are associated with agents blocking tumor necrosis factor (TNF), a cytokine implicated in pulmonary fibrosis, granuloma formation, and maintenance. Drug-induced interstitial pneumonia has a poor prognosis, with an overall mortality rate of around one-third, rising to two-thirds in patients with pre-existing interstitial disease. Sarcoid-like disease has a better prognosis, with resolution or improvement in 90% of cases. Although the evidence comes overwhelmingly from case reports and case series, suggested recommendations for patient management include a detailed pre-therapeutic evaluation, early identification of symptoms suggestive of pulmonary disease, and tailored therapy. Mycobacterial infection should be exhaustively investigated, especially after anti-TNF administration. Large, prospective, postmarketing studies including nonbiological agents as controls may help elucidate the real risk of pulmonary disease in patients with rheumatologic autoimmune diseases receiving monoclonal antibodies.
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Affiliation(s)
- Manuel Ramos-Casals
- Department of Autoimmune Diseases, Laboratory of Autoimmune Diseases Josep Font, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Spain
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14
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Development of sarcoidosis 6-month post discontinuation of etanercept: coincidence or real association? Clin Rheumatol 2011; 30:1095-8. [DOI: 10.1007/s10067-011-1704-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/02/2011] [Accepted: 01/27/2011] [Indexed: 10/18/2022]
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Kerjouan M, Jouneau S, Lena H, Luraine R, Desrues B, Delaval P. Sarcoïdose pulmonaire apparue sous étanercept. Rev Mal Respir 2011; 28:360-4. [DOI: 10.1016/j.rmr.2010.08.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 08/31/2010] [Indexed: 10/18/2022]
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17
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Amital A, Shitrit D, Adir Y. The lung in rheumatoid arthritis. Presse Med 2010; 40:e31-48. [PMID: 21196098 DOI: 10.1016/j.lpm.2010.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 11/05/2010] [Accepted: 11/08/2010] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is a common inflammatory disease, affecting about 1% of the population. Although a major portion of the disease burden including excess mortality is due to its extra-articular manifestations, the prevalence of RA-associated lung disease is increasing. RA can affect the lung parenchyma, airways, and the pleura; and pulmonary complications are directly responsible for 10 to 20% of all mortality. Even though pulmonary infection and drug toxicity are frequent complications of RA, lung disease directly associated with the underlying RA is more common. The prevalence of a particular complication varies based on the characteristics of the population studied, the definition of lung disease used, and the sensitivity of the clinical investigations employed. An overview of lung disease associated with RA is presented here with an emphasis on parenchymal lung disease, pleural effusion, and airway involvement.
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Affiliation(s)
- Anat Amital
- Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
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Abstract
Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Tumor necrosis factor (TNF)-alpha is an important player in granuloma formation, and recent clinical trials have investigated the efficacy of TNF-alpha inhibitors in sarcoidosis. Paradoxically, there are several case reports in the medical literature describing the development of sarcoidosis in patients treated with TNF-alpha inhibitors. We describe 3 cases of TNF-alpha antagonist-induced sarcoidosis: 1 case of pulmonary, ocular and cutaneous sarcoidosis developing in a patient receiving infliximab for erosive rheumatoid arthritis, 1 case of etanercept-induced sarcoidosis in a patient with seronegative rheumatoid arthritis, and 1 case of sarcoidosis developing in a patient receiving etanercept for erosive rheumatoid arthritis. We also provide a brief discussion on the role of TNF alpha in granuloma formation and implications in the use of TNF-alpha antagonists in autoimmune disease.
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Kanellopoulou T, Filiotou A, Kranidioti H, Dourakis SP. Sarcoid-like granulomatosis in patients treated with anti-TNFα factors. A case report and review of the literature. Clin Rheumatol 2010; 30:581-3. [DOI: 10.1007/s10067-010-1603-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 10/08/2010] [Indexed: 11/25/2022]
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Takahashi H, Kaneta K, Honma M, Ishida-Yamamoto A, Ashida T, Kohgo Y, Ohsaki Y, Iizuka H. Sarcoidosis during infliximab therapy for Crohn's disease. J Dermatol 2010; 37:471-4. [PMID: 20536653 DOI: 10.1111/j.1346-8138.2010.00861.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Tumor necrosis factor-alpha (TNF-alpha) antagonists are effective for inflammatory diseases, such as Crohn's disease, rheumatoid arthritis (RA) and psoriasis. Although TNF-alpha antagonists are also useful for sarcoidosis, paradoxical occurrence of sarcoidosis or sarcoidal reaction may be observed. We report a Crohn's disease patient, who developed sarcoidosis during infliximab therapy. A 35-year-old man had been receiving infliximab for 7 months for Crohn's disease. He developed cough and fever, accompanied by an infiltrated erythematous plaque on his right knee. The chest radiography, skin biopsy and laboratory findings were all consistent with sarcoidosis.
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Abbas SA, Syed YI, Dushianthan A, Barry S. Multiple pulmonary micronodules in a patient with Crohn's disease. BMJ Case Rep 2010; 2010:2010/aug05_1/bcr0120102666. [PMID: 22767662 DOI: 10.1136/bcr.01.2010.2666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Sarcoidosis is a terrific mimicker and can present in many different ways. The case of a middle-aged woman with Crohn's disease who attended the gastroenterology clinic for routine follow-up is presented. She had dry cough and breathlessness for a few weeks. A chest x-ray showed scattered multiple bilateral pulmonary micronodules. This finding on her chest x-ray posed a diagnostic challenge, especially in view of the fact that she was previously treated with immunosuppressants to control her Crohn's disease. A diagnosis of sarcoidosis was established by various tests including lung biopsy, which showed non-caseating granulomas. Within a few weeks of beginning systemic steroid treatment, improvement was noticed in symptoms and lung function tests.
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Affiliation(s)
- S A Abbas
- Department of Respiratory Medicine, Llandough University Hospital, Penarth, UK.
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Viguier M, Richette P, Bachelez H, Wendling D, Aubin F. Paradoxical adverse effects of anti-TNF-alpha treatment: onset or exacerbation of cutaneous disorders. Expert Rev Clin Immunol 2010; 5:421-31. [PMID: 20477038 DOI: 10.1586/eci.09.18] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
TNF-alpha antagonists have been shown to be very effective for the treatment of various rheumatic and nonrheumatic diseases, including psoriasis, and for off-label use in other inflammatory and immune-mediated disorders. However, the increasing use of these agents has led to the recognition of several paradoxical cutaneous adverse effects. New onset or exacerbation of cutaneous psoriasis, cutaneous vasculitis and sarcoidosis have been described. Further characterization and more precise diagnosis of these adverse events are warranted to provide further insights into the pathogenic mechanisms involved and to optimize their management. Herein, we present a review of the different clinical patterns of these paradoxical cutaneous adverse disorders, and we propose recommendations for their management.
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Affiliation(s)
- Manuelle Viguier
- Université Paris 7, Inserm U697 and Department of Dermatology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Toussirot E, Pertuiset E. [TNFα blocking agents and sarcoidosis: an update]. Rev Med Interne 2010; 31:828-37. [PMID: 20510487 DOI: 10.1016/j.revmed.2010.02.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 12/09/2009] [Accepted: 02/06/2010] [Indexed: 11/30/2022]
Abstract
Increased production of TNFα by alveolar macrophages and involvement of TNFα in granuloma formation suggest that this cytokine is involved in the pathophysiology of sarcoidosis. The three available TNFα blocking agents have been tested in sarcoidosis refractory to corticosteroids or immunosuppressive drugs. Data are available from isolated case reports or limited series of patients treated in open label trials with favourable issue with anti-TNFα monoclonal antibodies. Two randomized placebo controlled studies evaluated the efficacy of infliximab in pulmonary and extra-pulmonary sarcoidosis, showing that infliximab improves significantly extra-pulmonary disease. There is no significant difference between infliximab and placebo in the treatment of pulmonary manifestations. Etanercept showed no efficacy for treating ocular sarcoidosis in a controlled trial and for pulmonary disease in an open label trial. Paradoxical cases of proven sarcoidosis have been reported in patients receiving anti-TNFα agents for chronic inflammatory rheumatic diseases. A literature review identified 28 cases, including 16 with etanercept, eight with infliximab and four with adalimumab. Although these cases were mainly reported with etanercept, paradoxical sarcoidosis has been reported with the three available anti-TNFα agents, suggesting a class effect. Changes in the cytokine balance may be involved in these cases of induced sarcoidosis, which must be known by the clinician.
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Affiliation(s)
- E Toussirot
- Service de rhumatologie, pôle de pathologies aiguës et chroniques, transplantation, éducation (PACTE), hôpital Minjoz, CHU, 25000 Besançon, France.
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[Interstitial lung disease and anti-TNF-alpha therapy in rheumatoid arthritis: Two different patterns?]. Rev Mal Respir 2010; 27:232-7. [PMID: 20359615 DOI: 10.1016/j.rmr.2010.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Accepted: 09/21/2009] [Indexed: 10/19/2022]
Abstract
The first lung complications of anti-TNF-alpha therapy in rheumatoid arthritis (RA) that were reported were infections. Recently, interstitial lung disease (ILD) has been described as a consequence of this treatment. We report two cases of women treated with anti-TNF-alpha therapy for RA who both developed exacerbations of their preexisting ILD thought to be due to the treatment. In one case, this complication occurred 2 months after anti-TNF-alpha therapy, whereas the delay of occurrence was 26 months in the second case. Based on these two cases and on the first 40 observations in the literature, we hypothesize that ILD may be exacerbated according to two distinct patterns during anti-TNF-alpha treatment for RA, occurring early (most frequently) or late after treatment was started, with a mean of 4 and 26 months, respectively. Other features that may differ between these two presentations include the risk factors, the anti-TNF-alpha molecule used, the histopathological pattern, and the prognosis.
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25
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Development of sarcoidosis following etanercept treatment: a report of three cases. Rheumatol Int 2010; 32:1049-53. [DOI: 10.1007/s00296-009-1349-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 12/29/2009] [Indexed: 12/22/2022]
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26
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Massara A, Cavazzini L, La Corte R, Trotta F. Comment on: Sarcoid-like granulomatosis in patients treated with tumour necrosis factor blockers: 10 cases. Rheumatology (Oxford) 2010; 49:1019-21; author reply 1021-2. [PMID: 20056768 DOI: 10.1093/rheumatology/kep431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Viguier M, Richette P, Bachelez H, Wendling D, Aubin F. Manifestations cutanées paradoxales des anti-TNF-alpha. Ann Dermatol Venereol 2010; 137:64-71; quiz 63, 78-9. [DOI: 10.1016/j.annder.2009.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Accepted: 07/04/2009] [Indexed: 11/16/2022]
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Wiens A, Correr CJ, Pontarolo R, Venson R, Quinalha JV, Otuki MF. A systematic review and meta-analysis of the efficacy and safety of etanercept for treating rheumatoid arthritis. Scand J Immunol 2009; 70:337-44. [PMID: 19751268 DOI: 10.1111/j.1365-3083.2009.02296.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The aim of this study was to evaluate the efficacy and safety of etanercept (ETA) for treating rheumatoid arthritis. A systematic review was performed to search for randomized clinical trials comparing subcutaneous doses of ETA at 25 mg twice a week or 50 mg weekly to a placebo group, with or without methotrexate. Studies of low quality (less than 3 points on Jadad's scale) were excluded. The efficacy was assessed by using the criteria of the American College of Rheumatology (ACR). Safety data were evaluated based on serious adverse events, serious infections, malignancy and deaths. Withdrawals as a result of adverse events or lack of efficacy were also evaluated. Eight studies met the inclusion criteria, comprising 2385 patients. In the efficacy meta-analysis, a greater number of ETA-treated patients achieved the efficacy criteria within 6 months of treatment, where the relative risk (RR) was 2.94 [2.27, 3.81] for achieving ACR20, 5.28 [3.12, 8.92] for ACR50 and 4.83 [1.74, 13.47] for ACR70. After 1 year, the RR for achieving ACR20, ACR50 and ACR70 were 1.14 [1.07, 1.23], 1.36 [1.21, 1.53] and 1.56 [1.30, 1.88], respectively. This response rates were higher for ETA-treated patients in comparison with control group patients. For safety, there were no statistically significant differences between treated patients and controls. This was also confirmed by withdrawals as a result of adverse events, which were not statistically different between the two groups. However, more patients withdrew from control groups because of a lack of efficacy as compared with ETA groups (RR = 0.48 [0.30, 0.78]).
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Affiliation(s)
- Astrid Wiens
- Universidade Federal do Paraná, Pharmacy Department, Curitiba, Paraná, Brazil
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Mahtab S, Gérard L, Laurent M, Anne DM, Hervé W, Annabel M. Facial granulomatous nodules during etanercept treatment for psoriasis. Int J Dermatol 2009; 48:1025-7. [DOI: 10.1111/j.1365-4632.2009.04080.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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30
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Daien CI, Monnier A, Claudepierre P, Constantin A, Eschard JP, Houvenagel E, Samimi M, Pavy S, Pertuiset E, Toussirot E, Combe B, Morel J. Sarcoid-like granulomatosis in patients treated with tumor necrosis factor blockers: 10 cases. Rheumatology (Oxford) 2009; 48:883-6. [DOI: 10.1093/rheumatology/kep046] [Citation(s) in RCA: 204] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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31
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Massara A, Cavazzini L, La Corte R, Trotta F. Sarcoidosis appearing during anti-tumor necrosis factor alpha therapy: a new "class effect" paradoxical phenomenon. Two case reports and literature review. Semin Arthritis Rheum 2009; 39:313-9. [PMID: 19147181 DOI: 10.1016/j.semarthrit.2008.11.003] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Revised: 10/23/2008] [Accepted: 11/08/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To report 2 cases of sarcoidosis that developed during treatment with tumor necrosis factor alpha (TNFalpha) antagonists, infliximab and adalimumab, used for inflammatory rheumatic disease and to review previously reported cases. METHODS We describe 2 patients, the first with psoriatic arthritis, the second with rheumatoid arthritis, who developed noncaseating granulomas of the lungs consistent with sarcoidosis while being treated with anti-TNFalpha drugs. A retrospective review of the literature was performed using the PubMed database. RESULTS In our patients sarcoidosis developed after 2 years of continuous treatment with infliximab and adalimumab. Both patients presented with low-grade fever, chest pain, and dyspnea. The diagnosis of sarcoidosis was established by the typical well-formed noncaseating granulomas on transbronchial biopsy, after excluding all other granulomatous conditions. Following withdrawal of anti-TNFalpha agents and a brief course of steroids, the clinical picture resolved. Thirteen additional cases of sarcoidosis that developed after anti-TNFalpha treatment have been reported, and in 9 of these the causative agent was etanercept. CONCLUSIONS The development of sarcoidosis during treatment with TNFalpha antagonists represents a rare and paradoxical adverse event. The occurrence of sarcoidosis with all 3 available agents suggests a new "class effect" probably linked to a cytokine disequilibrium in patients receiving anti-TNFalpha treatment.
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Affiliation(s)
- Alfonso Massara
- Sezione di Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Ferrara, Ferrara, Italy.
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32
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Developing of granulomatous thyroiditis during etanercept therapy. Clin Rheumatol 2008; 28 Suppl 1:S17-9. [DOI: 10.1007/s10067-008-1046-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Accepted: 11/12/2008] [Indexed: 11/27/2022]
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33
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Adalimumab-induced noncaseating granuloma in the bone marrow of a patient being treated for rheumatoid arthritis. Rheumatol Int 2008; 29:437-9. [DOI: 10.1007/s00296-008-0691-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2007] [Accepted: 08/11/2008] [Indexed: 10/21/2022]
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34
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Association of infections and tuberculosis with antitumor necrosis factor alpha therapy. Curr Opin Rheumatol 2008; 20:320-6. [PMID: 18388525 DOI: 10.1097/bor.0b013e3282fa74f7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Ishiguro T, Takayanagi N, Kurashima K, Matsushita A, Harasawa K, Yoneda K, Tsuchiya N, Miyahara Y, Yamaguchi S, Yano R, Tokunaga D, Saito H, Ubukata M, Yanagisawa T, Sugita Y, Kawabata Y. Development of sarcoidosis during etanercept therapy. Intern Med 2008; 47:1021-5. [PMID: 18520114 DOI: 10.2169/internalmedicine.47.0602] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This report describes a 65-year-old woman who developed granulomatous lesions consistent with sarcoidosis during etanercept therapy for rheumatoid arthritis. Hilar and mediastinal lymphadenopathy and multiple nodules in both lung fields developed 21 months after administration of etanercept. Noncaseating epithelioid cell granulomas consistent with sarcoidosis were detected in a lung biopsy specimen and in the parietal pleura obtained via thoracotomy. Diseases showing similar histologic changes were excluded, and a diagnosis of sarcoidosis was made. Etanercept was discontinued, which resulted in symptomatic relief, improvement of oxygenation and radiologic findings. There is substantial evidence of tumor necrosis factor-alpha involvement in the induction and maintenance of granuloma formation; however, we should keep in mind that granulomatous disease, such as sarcoidosis, can develop during treatment with a tumor necrosis factor-alpha blocking agent, such as etanercept.
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Affiliation(s)
- Takashi Ishiguro
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Kumagaya.
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Tournadre A, Ledoux-Eberst J, Poujol D, Dubost JJ, Ristori JM, Soubrier M. Exacerbation of interstitial lung disease during etanercept therapy: Two cases. Joint Bone Spine 2007; 75:215-8. [PMID: 17977770 DOI: 10.1016/j.jbspin.2007.04.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2006] [Accepted: 04/03/2007] [Indexed: 12/23/2022]
Abstract
We report two cases of interstitial lung disease possibly related to TNF alpha antagonist therapy (etanercept) in patients with rheumatoid arthritis. In both cases, pre-existing interstitial lung disease worsened during etanercept therapy. We found 19 previously published cases of interstitial lung disease in patients who were taking TNF alpha antagonists and had no evidence of infection, raising the possibility of a causal link with the medication. The potential pathophysiological mechanisms remain unknown. Caution is in order when using TNF alpha antagonists in patients with pre-existing lung disease. The development or exacerbation of interstitial lung disease in a patient on TNF alpha antagonist therapy should lead to investigations for a cause. Should these investigations prove negative, the treatment must be discontinued.
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Affiliation(s)
- Anne Tournadre
- CHU Clermont-Ferrand, Rheumatology Department, G. Montpied Teaching hospital, 63 000 Clermont-Ferrand, France
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37
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Agarwal R, Srinivas R, Gupta D. Disseminated tuberculosis after anti-TNFalpha treatment. Lancet 2007; 370:564; author reply 565. [PMID: 17707746 DOI: 10.1016/s0140-6736(07)61288-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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38
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Mutlu GM, Mutlu EA, Bellmeyer A, Rubinstein I. Pulmonary adverse events of anti-tumor necrosis factor-alpha antibody therapy. Am J Med 2006; 119:639-46. [PMID: 16887405 DOI: 10.1016/j.amjmed.2006.01.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2005] [Revised: 12/29/2005] [Accepted: 01/15/2006] [Indexed: 12/01/2022]
Abstract
It is well established that anti-tumor necrosis factor-alpha (TNFalpha) antibody is an efficacious disease-modifying drug for rheumatoid arthritis and Crohn's disease. Unfortunately, its long-term use can be associated with ominous pulmonary adverse events, most notably mycobacterial and fungal lung infections. To this end, reactivation of latent tuberculosis infection represents a serious concern of anti-TNFalpha antibody therapy. Given the anticipated increase in the approved indications for these drugs, community-based physicians should be made aware of these events for implementation of better patient selection for anti-TNFalpha antibody therapy and initiation of appropriate measures once these adverse events are observed. This review will address this issue by outlining: 1) the role of TNFalpha in host inflammatory response to injury, particularly during mycobacterial and fungal infections; 2) the salutary effects of anti-TNFalpha antibody therapy in human diseases; and 3) the ominous pulmonary adverse events associated with these drugs.
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Affiliation(s)
- Gökhan M Mutlu
- Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill 60611, USA.
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Schoe A, van der Laan-Baalbergen NE, Huizinga TWJ, Breedveld FC, van Laar JM. Pulmonary fibrosis in a patient with rheumatoid arthritis treated with adalimumab. ACTA ACUST UNITED AC 2006; 55:157-9. [PMID: 16463430 DOI: 10.1002/art.21716] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Abraham Schoe
- Department of Rheumatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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40
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Bratcher JM, Korelitz BI. Toxicity of infliximab in the course of treatment of Crohn's disease. Expert Opin Drug Saf 2006; 5:9-16. [PMID: 16370952 DOI: 10.1517/14740338.5.1.9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Infliximab is a monoclonal antibody directed against the pro-inflammatory mediator TNF-alpha, which was approved in the US in 1998 for treatment-resistant Crohn's disease. Since that time, the indications have dramatically expanded to include rheumatoid arthritis, ankylosing spondylitis, psoriasis and most recently, active ulcerative colitis. Although the safety profile in the initial studies was quite favourable, subsequent studies have shown that a small percentage of patients reported severe side effects, including pneumonia, tuberculosis, lymphoma, drug-induced lupus and hepatotoxicity. Although these complications are rare, it is important to properly screen patients for predisposing conditions before beginning treatment. Furthermore, concurrent use of other immunosuppresive agents, such as 6-mercaptopurine, may reduce the incidence of less serious side effects, such as arthralgias, myopathies and other antibody-associated diseases. Since its approval, infliximab has revolutionised the treatment of Crohn's disease and has shown benefit in a variety of other inflammatory conditions, but significant toxicities can occur that necessitate thorough screening protocols and periodic clinical evaluation.
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Affiliation(s)
- Jason M Bratcher
- Lenox Hill Hospital and NYU School of Medicine, Department of Gastroenterology, 100 East 77th Street, New York, NY 10021-1882, USA
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41
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O'Shea FD, Marras TK, Inman RD. Pulmonary sarcoidosis developing during infliximab therapy. ACTA ACUST UNITED AC 2006; 55:978-81. [PMID: 17139647 DOI: 10.1002/art.22351] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Finbar D O'Shea
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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42
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González-López MA, Blanco R, González-Vela MC, Fernández-Llaca H, Rodríguez-Valverde V. Development of sarcoidosis during etanercept therapy. ACTA ACUST UNITED AC 2006; 55:817-20. [PMID: 17013853 DOI: 10.1002/art.22238] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Phillips K, Weinblatt M. Granulomatous lung disease occurring during etanercept treatment. ACTA ACUST UNITED AC 2005; 53:618-20. [PMID: 16082636 DOI: 10.1002/art.21336] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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