Allergic Compressive Optic Neuropathy in a Patient with Ulcerative Colitis Treated with Infliximab

Abstract

Introduction: Infliximab was approved for the treatment of ulcerative colitis in the fall of 2005. Common side effects of anti-tumor necrosis factor therapy include fevers, rash, anaphylactoid reactions, as well as hematological manifestations. We report a case of an infliximab allergic reaction causing compressive optic neuropathy. Case report: A 41-year-old female with diagnosed with ulcerative colitis 21 years ago, hypothyroidism, and Grave's disease was started on infliximab for ulcerative colitis therapy. She received three injections of infliximab with successful induction of remission. During the fourth infusion she developed right hand and forearm edema, both known reactions to infusion, with no further complications. Prior to the sixth infusion, the patient had sutures removed from her right upper eyelid from a recent right upper eyelid lengthening procedure due to exophthalmos. She had followed ophthalmology for Grave's disease optic neuropathy in the past. Fifteen minutes into the sixth infusion, she was noted to have worsening of right optic neuropathy with associated facial edema. The infusion was stopped and the patient went to the ER, where a CT scan of the orbits showed interval increase in edema of extraocular muscles causing compression of the optic nerve. The reaction was deemed to be secondary to infliximab and she was started on steroids with successful resolution of symptoms. However, due to concern of worsening ulcerative colitis and after discussion with her ophthalmologist, infliximab was attempted again four months after the reaction. She was pre-medicated with prednisone a day prior to the infusion as well as hydrocortisone and diphenhydramine on the day of infusion. During this infusion of infliximab, the patient again had a similar reaction and therapy was halted. Discussion: Infliximab has a well-known side effect profile, which includes facial/hand edema, rashes, and even fevers as common reactions. However, to our knowledge this is the first report associating infliximab with allergic compressive optic neuropathy. This current vignette highlights the importance of recognizing compressive optic neuropathy as a consequence of a delayed allergic reaction to the infliximab infusion.