Nephritis, cerebritis, and myositis after adalimumab therapy in a patient with rheumatoid arthritis: a case report

International Journal of General Medicine Dovepress open access to scientific and medical research C A S E R E P O RT International Journal of General Medicine downloaded from https://www.dovepress.com/ by 5.196.129.157 on 12-Jul-2018 For personal use only. Open Access Full Text Article Nephritis, cerebritis, and myositis after adalimumab therapy in a patient with rheumatoid arthritis: a case report This article was published in the following Dove Press journal: International Journal of General Medicine Narges E Omran 1 Abdulsalam A Noorwali 2 1 Department of Internal Medicine and Rheumatology, Al-Noor Specialist Hospital, Makkah, Saudi Arabia; 2 Department of Internal Medicine and Rheumatology, Umm Al Qura University Hospital, Makkah, Saudi Arabia Introduction Correspondence: Narges E Omran Department of Internal Medicine and Rheumatology, Al-Noor Specialist Hospital, PO Box 6251, Makkah 21955, Saudi Arabia Tel +966 59 442 1399 Email Early diagnosis and treatment of rheumatoid arthritis (RA) is very important. The use of disease-modifying antirheumatic drugs (DMARDs) during the first few months of the disease minimizes the adverse sequelae of RA.2 For non-responders, biological agents are recommended.3 Although the treatment with antitumor necrosis factor alpha (anti-TNFα) had been shown to trigger autoimmune responses, such as a lupus-like syndrome,1 the clinical presentation of immune-mediated complications induced by adalimumab treatment, especially a lupus-like syndrome, is very rare,17 with various signs and symptoms, including the less common induction of systemic lupus erythematosus (SLE) with end-organ damage.4 Written informed consent has been provided by the patient to have the case details and pictures published. 151 submit your manuscript | www.dovepress.com International Journal of General Medicine 2018:11 151–154 Dovepress © 2018 Omran and Noorwali. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/IJGM.S154835 Powered by TCPDF (www.tcpdf.org) Abstract: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that mainly affects the joints, therefore, may cause deformities and disability if untreated. The first line of treatment is disease-modifying antirheumatic drugs (DMARDs). When the patient fails to respond to DMARDs, mainly methotrexate, then second-line therapy is required. Tumor necrosis factor α (TNFα) plays an important role in the pathogenesis of RA; however, the treatment with anti-TNFα medications is challenging. It may trigger the autoimmune system and result in producing antibodies that induce symptoms and signs mimic to systemic lupus erythematosus (SLE), and in rare situations can affect vital organs with severe and life-threatening complications. We report on a 38-year-old Saudi woman with longstanding erosive RA, who was diagnosed based on the 1987 classification criteria. She developed life-threatening SLE, and seroconversion of antinuclear antibodies (ANA), anti-double-stranded DNA, with severe systemic involvement (cerebritis, nephritis, myositis, and polyneuropathy), shortly after treatment with adalimumab. Adalimumab was started as anti TNFa therapy (after the failure of traditional therapy), SLE and other autoimmune diseases were ruled out by clinical history, examination, and laboratory investigations, including negative ANAs and anti-double-stranded DNA. When both tests turned out persistently positive even after stopping adalimumab, specific diagnostic and therapeutic modalities were required during her acute illness. Keywords: rheumatoid, arthritis, tumor necrosis factor, adalimumab, anti-TNF, systemic lupus erythematosus Omran and Noorwali International Journal of General Medicine downloaded from https://www.dovepress.com/ by 5.196.129.157 on 12-Jul-2018 For personal use only. Case presentation A 38-year-old Saudi woman presented to the emergency department with generalized fatigue and weakness. She had been affected by RA for 13 years, RA was diagnosed based on the 1987 diagnostic criteria,5 according to which, the patient had bilateral hand polysymmetric inflammatory arthritis with morning stiffness for more than 1 hour and positive rheumatoid radiographic abnormalities on X ray (periarticular osteopenia, decreased joint space, and marginal erosions). She developed bilateral hand irreversible deformities within the first 2 years of her disease (ulnar deviation, Z deformity, swan neck, and boutonniere deformities), with restricted wrists movement and impaired hand grip (Figure 1). She had no previous history of skin rash, malar rash, muscle weakness, numbness, and no cardiopulmonary symptoms or any symptoms or signs suggestive of SLE or other associated autoimmune diseases. She was treated for several years with DMARDs; methotrexate 15 mg/week, hydroxychloroquine 200 mg twice daily, and steroid with a maintenance dose of prednisolone 7.5 mg daily (she was given frequent short courses of steroid), as well as calcium, vitamin D, and alendronate. During the course of the treatment, there were periods of remission and flare up. Due to persistent and active inflammatory arthritis for almost 6 months, she was followed up in the rheumatology clinic with the following: number of swollen joints:10; number of tender joints: 15; morning stiffness for more than 1 hour; high erythrocyte sedimentation rate (ESR); and positive C-reactive protein. Her disease activity assessment (28) score of 5.2 meant that she had highly active disease.6 Adalimumab was added to her treatment as second-line therapy after the failure of traditional DMARDs based on the American Col- Figure 1 Rheumatoid arthritis of the hand with deformity. 152 Powered by TCPDF (www.tcpdf.org) submit your manuscript | www.dovepress.com Dovepress Dovepress lege of Rheumatology treatment guidelines.3 Initial laboratory results showed normal liver and kidney function, mild normocytic normochromic anemia, high ESR of 50 mm/h, C-reactive protein 4 mg/dL, rheumatoid factor 456, and anticyclic citrullinated peptide being strongly positive. Hepatitis B and C serology were normal, with a negative antinuclear antibody (ANA) of 0.3 IU/mL (<1), a negative anti-DNA 15 IU/mL (<30), a negative purified protein derivative test, and normal chest X-ray. Her arthritic symptoms improved dramatically. However, 6 weeks after the administration of adalimumab, she (...truncated)