Abstract
Introduction: Adalimumab is an anti-tumour necrosis factor (anti-TNF) monoclonal antibody and an important part of the treatment regime for autoimmune conditions including inflammatory bowel disease. We present a case of adalimumab induced pleuropericarditis and discuss the diagnosis challenges we faced. Case History: A 22-year-old male presented to the emergency department with 3 days history of headache, malaise, fever and right-sided chest pain. He was diagnosed with ulcerative colitis 8 months ago but failed to respond to mesalazine, requiring high dose steroids to induce disease remission. His mesalazine was stopped after 4 months and he was initiated on adalimumab 2 months prior to the current presentation. At presentation, he had a temperature of 38.7 °C (101.6 °F) but no other physical signs. His inflammatory markers were raised, and the chest x-ray was clear. He was started on empirical intravenous antibiotics on suspicion of the underlying infective process. On day 4 the patient developed a new pleural rub and crepitations on both lung bases. An urgent echocardiogram and computed tomography scan of the thorax abdomen and pelvis revealed pleural effusion and a 1.8 cm diameter pericardial effusion. Extensive investigation including virology screen, autoimmune screen and pleural fluid analysis were normal. Diagnosis, Management and Outcome: This case was discussed in a multidisciplinary meeting. A diagnosis of pleuropericarditis secondary to adalimumab was made. Adalimumab and antibiotics were stopped, and he was started on a course of oral steroids. The patient responded well to the treatment and his symptoms resolved. Conclusion: Rare drug toxicity should be part of differential diagnosis, especially in young patients with unusual presentation. An early multidisciplinary approach is crucial for a positive outcome. The patient should be actively involved in decision making to improve long term outcome.
Highlights
Adalimumab is an anti-tumour necrosis factor monoclonal antibody and an important part of the treatment regime for autoimmune conditions including inflammatory bowel disease
Anti-tumor necrosis factor monoclonal antibodies are the mainstay of treatment for a number of inflammatory and autoimmune conditions including ulcerative colitis, Crohn's disease rheumatoid arthritis, psoriasis, and ankylosing spondylitis
A recent review of VigiBase, the largest global database for reporting drug adverse reaction showed that pleuropericarditis secondary to anti-TNF is an extremely rare occurrence with only 94 reported cases out of 1175934 all cases on anti-TNF and for adalimumab 16/486,470
Summary
Adalimumab is an anti-tumour necrosis factor (anti-TNF) monoclonal antibody and an important part of the treatment regime for autoimmune conditions including inflammatory bowel disease. Case History: A 22-year-old male presented to the emergency department with 3 days history of headache, malaise, fever and right-sided chest pain He was diagnosed with ulcerative colitis 8 months ago but failed to respond to mesalazine, requiring high dose steroids to induce disease remission. His mesalazine was stopped after 4 months and he was initiated on adalimumab 2 months prior to the current presentation. Anti-tumor necrosis factor (anti-TNF) monoclonal antibodies are the mainstay of treatment for a number of inflammatory and autoimmune conditions including ulcerative colitis, Crohn's disease rheumatoid arthritis, psoriasis, and ankylosing spondylitis. In 16 cases of adalimumab induced pleuropericarditis, up to half were due to underlying infection, over a quarter due to autoimmune etiology and a quarter had another drug contributing [1]
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