Drug free remission after steroid-dependent disappearance of lymphoproliferative disorder in rheumatoid arthritis patient treated with TNF-alpha blockade: case study.

Kosaku Oda,Mutsuko Minata

doi:10.1186/s40064-015-0798-9

Abstract

IntroductionTNF-α inhibitors plus MTX appear to have benefit in the longer-term reduction of RA. Boolean long-term remission under drug-free conditions is rare. The therapeutic mechanism and the factor of predicting response have not been clarified yet.Case descriptionA 24-year-old female rheumatoid arthritis (RA) patient, who once attained complete remission (CR) with the combination therapy with tumor necrosis factor alpha (TNF-alpha) inhibitor adalimumab (ADA) and methotrexate (MTX), showed the occurrence of Epstain- Barr virus (EBV)-associated lymphoproliferative disorder (LPD). Pulse treatment with methylprednisolone after the termination of anti TNF-α therapy resulted in the remission of EBV-associated LPD. The administration of prednisolone (PSL) was tapered off after the improvement of clinical symptoms and laboratory data. The patients achieved drug-free 12 months after urgent hospitalization and delivered healthy baby 2 years after hospital discharge. She has been complete drug-free Boolean remission for 5 years.Discussion and evaluationThe purpose of this brief case is report that we experienced the remission of LPD after CR with combined therapy with ADA and MTX. We believe this case report will be one of the paths for unveiling the pathogenesis and improving the treatment for RA.ConclusionsWe believe this case report will be one of the paths for unveiling the pathogenesis and improving the treatment for RA.

Highlights

Tumor necrosis factor alpha inhibitor (TNF-α) inhibitors plus MTX appear to have benefit in the longer-term reduction of rheumatoid arthritis (RA)
The purpose of this brief case is report that we experienced the remission of lymphoproliferative disorder (LPD) after complete remission (CR) with combined therapy with ADA and MTX
We described the RA patient who achieved CR with receiving combined therapy of ADA together with MTX, and that was followed by the occurrence and steroiddependent disappearance of immunodeficiency-associated

Summary

Background

Tumor necrosis factor-alpha (TNF-α) inhibitors have revolutionized the management of RA and other chronic inflammatory diseases. Disease activity was increased up to DAS28-CRP 5.1 (over right fingers, bilateral knees, right index middle ring PIP, and right ankle) and x-ray showed rapid destructive joints and high disease activity progression to Steinbrocker stage classification 3 within half a year after RA diagnosis She was referred to Takatsuki Red Cross Hospital for administration of anti-TNF-α inhibitor. The examinations for all these infections agents were negative except for high titers of anti-EBV antigen IgG (Table 1) Taken together these examinations, we diagnosed EB virus related B-cell LPD after the treatment with TNF-α inhibitor plus MTX, and that was in accordance with the 2008 WHO classification. She has completely attained drugfree Boolean remission for 5 years

Discussion and evaluation

Conclusions