Pulmonary sarcoid-like granulomatosis during etanercept treatment for inflammatory arthritis: A case series and literature review

Abstract

Rationale: Tumor necrosis factor-alpha (TNF-α) inhibitors have been implicated in the development of sarcoid-like granulomatous inflammation when used for treatment of a variety of immune-related diseases. The mechanisms are not completely understood, and the clinical, radiographic and histologic findings of this condition require further description. The literature surrounding this is largely limited to single case reports. Objectives: The objective of this study was to describe pulmonary sarcoid-like granulomatosis in 5 patients receiving etanercept therapy prescribed for inflammatory arthritis. Methods: We retrospectively reviewed the medical records of 5 patients who developed granulomatous sarcoid-like manifestations while on treatment with etanercept for inflammatory arthritis. Data surrounding clinical features and radiographic and histologic findings, as well as clinical outcomes, were described. Results: Median time from initiation of treatment to development of symptoms was 36 months (range 7-60 months). All patients had radiographic abnormalities on chest imaging, with 4 patients having adenopathy on thoracic imaging, and 2 of the 5 patients having parenchymal involvement. Biopsy evidence of granulomatous inflammation was seen in all patients. Three of 5 patients had discontinuation of etanercept when the diagnosis was made, and all experienced improvement. Of the 2 patients that were continued on etanercept, 1 had spontaneous improvement and the other had stable, asymptomatic radiographic abnormalities. Only 1 patient was treated with corticosteroids. Conclusion: Pulmonary sarcoid-like granulomatosis is incompletely understood and establishing the causal role of these drugs in sarcoid-like lung disease is difficult. We hope that the addition of these 5 cases of etanercept-related pulmonary sarcoid-like granulomatosis will add to our future understanding of this response to etanercept and other anti-TNF-α agents.