Adalimumab Associated Pancytopenia and Reversible Lymphadenopathy

Abstract

Introduction: Adalimumab (Humira?) is a monoclonal antibody directed against TNF-a used for treatment of autoimmune conditions including Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing spondylitis, and Inflammatory Bowel Disease. Case Report: 70 year old female with a history of Ulcerative Colitis on adalimumab presented with a fever of 101? in the setting of progressive weakness over the last 6 months. Her last dose was 1 week prior, for a total duration of 15 months. Physical exam was significant for submandibular lymphadenopathy (left greater than right) without any rashes, bruises, or swelling. Labs showed pancytopenia with neutropenia (WBC 2.0, HgB 11.5, Plts 10, ANC 1.1). CT illustrated bilateral axillary lymphadenopathy and enlarged retroperitoneal lymph nodes from the level of the celiac axis to the groin. Adalimumab was discontinued, infectious workup was initiated, and cefepime was started for neutropenic fever. Soon after, with resolution of fever and negative infectious workup, cefepime was discontinued. Tbo-filgrastim was administered with an increase in the WBC count to 8.2 and ANC of 6.2. A lymph node biopsy revealed atypical lymphoid proliferation with necrotizing granulomas. Patient clinically remained stable with a concordant increase in all cell lines in the following days and was discharged. A repeat CT performed 2 weeks later illustrated complete resolution of the lymphadenopathy. Discussion: Anti-TNF-a therapies carry many potential adverse infectious and non-infectious consequences including hematological dyscrasias and lymphoma. This case highlights an uncommon potential side effect of Adalimumab, which has become a mainstay of treatment in patients with moderate-to-severe ulcerative colitis. In regards to the diffuse lymphadenopathy, lymphoma continues to be a debated association. Long term safety data from global clinical trials have recently illustrated that malignancy rates for adalimumab-treated patients are as expected for the general population. With respect to cases of cytopenias, TNF inhibitor therapy is associated with a significant reduction in peripheral blood neutrophil count. Currently there are no recommendations for monitoring of hematologic dyscrasias for those receiving adalimumab. It is prudent for monitoring to be standardized for prescribing clinicians, as subclinical abnormalities can be intervened on with discontinuation of therapy prior to presentation of sequelae requiring hospitalization.2064_A Figure 1. Lymphadenopathy2064_B Figure 2. No Lymphadenothapy2064_C Figure 3. Granulomatous Appearance