Abstract
We read with interest the review by Antonio Tristano [1] regarding neurological adverse events associated with antitumour necrosis factor alpha (anti-TNF-a) treatment. We believe that aseptic meningitis is also a potential complication of anti-TNF-a treatment and we report the following case. A 53-year-old plumber presented with 3 weeks of night sweats, fevers and generalised headache. There was no weight loss, recent foreign travel, occupational exposure to sewage or chemicals. He had a single female sexual partner and a recent negative human immunodeficiency virus (HIV) test. He had a pet dog and no further contact with animals or insect bites. His past history included IgA nephropathy (currently quiescent), hypothyroidism and an undifferentiated seronegative inflammatory arthritis. This had involved generalised joint pains but had particularly involved his right ankle and a biopsy had shown synovitis. He was HLA B27 negative. He had been treated with sulphasalazine, which was not tolerated. Despite methotrexate and oral steroids he had continuing right subtalar joint inflammation and adalimumab was added. At presentation his disease was inactive. His medications were levothyroxine, Humira (adalimumab) 40 mg/week since 2008 and oral methotrexate 20 mg/week since 2007 and his arthritis symptoms were well controlled. He was not taking non-steroidal antiinflammatory medication, and took paracetamol (acetaminophen) only for his headache. On admission, examination revealed a pyrexia, \5 splinter haemorrhages, normal heart sounds, chest, abdomen, neurological examination and no meningism, lymphadenopathy or oro-genital ulceration. Investigations showed white cell count 12.7 9 10/L (reference range 3.8–10.6 9 10/L), neutrophil count 9.16 9 10/L (reference range 1.8–6.5 9 10/L), monocyte count 1.12 9 10/L (reference range 0.2–0.8 9 10/L) with C-reactive protein, lactate dehydrogenase and blood film normal. IgA was mildly elevated at 4.11 g/L (reference range 0.8–4.0 g/L). Liver, renal, and thyroid function, plasma viscosity, creatinine kinase, chest X-ray and unenhanced MRI brain/ enhanced MRI spine were normal. Three sets of blood cultures were negative. Urinalysis including Bence-Jones protein and a myeloma screen were negative. Two urine specimens and a sputum specimen were also negative for auramine-phenol stain and tuberculosis (TB) culture after 6 weeks. Complement, extractible nuclear antigens, lupus anticoagulant, anticardiolipin antibody, double stranded DNA and antinuclear antibody were negative. Classical anti neutrophil cytoplasmic antibody (cANCA) was positive (titre 1:320), MPO and PR-3 negative. Cerebrospinal fluid (CSF) was measured serially (see Table 1). Oligoclonal bands were negative. A cytospin with immunophenotyping showed evidence of lymphocyte infiltration, the lymphocyte population consisting of both B and T cells. Cytology revealed reactive lymphocytes. Auramine-phenol stain for TB and TB culture was negative. Cryptococcal antigen and fungal cultures were negative after extended incubation. Herpes simplex virus DNA, enterovirus RNA and CMV (via PCR) were not detected. A CT scan of the thorax/abdomen/pelvis and trans-thoracic echocardiography were normal. HIV and hepatitis A. J. Hamilton (&) N. J. Gutowski Department of Neurology, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK e-mail: alexander.hamilton@nhs.net
Published Version
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