A RARE COMPLICATION OF TUMOR NECROSIS FACTOR INHIBITORS

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tumor necrosis factor (TNF)-inhibitors are one of the first line agents prescribed for management of rheumatoid arthritis (RA). Hemorrhagic pericardial effusion is a rare side effect of TNF inhibitors1,2, and if left untreated, may cause life threatening complications such as pericardial tamponade or cardiac arrest. CASE PRESENTATION: A thirty-four-year-old morbidly obese female with past medical history of Diabetes and RA presented to the emergency department after a syncopal episode with complains of shortness of breath and anxiety. An emergent Computed tomography scan was done which showed a large pericardial effusion. (Figure 1). As the patient was being transported to intensive care, she developed hypotension and hypoxia leading to cardiac arrest. Cardiopulmonary resuscitation was started. A bedside echocardiogram showed a large circumferential pericardial effusion with tamponade physiology (Figure 2). Return of spontaneous circulation was achieved after six rounds of compressions but the patient remained in obstructive shock requiring multiple vasopressors. An emergent bedside pericardiocentesis was performed and 60cc fluid was drained. She was then taken to the catheterization lab with further drainage of 550cc of hemorrhagic fluid. Post drainage her hypotension resolved and she was weaned off of all vasopressors. Pericardial studies showed an elevated red blood cell with a normal white blood cell count, negative culture and cytology. Autoimmune workup showed elevated histone antibodies. Of note, the patient had a history of seropositive, non-erosive RA which was managed with prednisone and adalimumab. Due to decreased response to adalimumab, patient was switched to etanercept and received her first dose one month prior to presentation which was discontinued after patient developed skin peeling. DISCUSSION: The exact mechanism of TNF-inhibitors causing pericardial tamponade is currently unknown. However, some have proposed a paradoxical flare up of the underlying autoimmune condition, immune-mediated or drug induced reactions as the cause. Even though RA can occasionally cause pericardial effusions, they are not typically hemorrhagic in nature. The significant medication history in our patient along with anti-histone antibodies made drug induced pericardial effusion the likely cause. More research needs to be done to ascertain the pathophysiology of effusions due to TNF-Inhibitors, as with increasing utility of TNF-inhibitors, they may be more common than currently documented. CONCLUSIONS: With increased use of TNF-inhibitors in autoimmune conditions, clinicians should be well aware of their side effect profile as a delayed diagnosis may lead to life threatening complications as was evident in our case. Reference #1: Lather HD, Kahlenberg JM. Hemorrhagic Pericardial Effusion with Tamponade: A Rare Adverse Effect of Infliximab-Case Report and Literature Review. Case reports in rheumatology. 2016;2016:2576496 Reference #2: Soh MC, Hart HH, Corkill M. Pericardial effusions with tamponade and visceral constriction in patients with rheumatoid arthritis on tumour necrosis factor (TNF)-inhibitor therapy. International journal of rheumatic diseases. 2009;12(1):74-77. DISCLOSURES: No relevant relationships by Kourtney Erickson, source=Admin input No relevant relationships by Sara Godil, source=Web Response No relevant relationships by Kareem Godil, source=Web Response No relevant relationships by Emilee Kurtz, source=Web Response