Abstract
BackgroundThe utilization of monoclonal antibodies has become more widespread over the past decade. However, the development of non-caseating granulomas with the use of monoclonal antibodies, such as ustekinumab, is not widely reported in the literature.Case presentationWe report a case of a 50-year-old Caucasian male who presented complaining of weight loss and shortness of breath. He was receiving ustekinumab for refractory psoriasis but had no other significant medical comorbidities. On physical examination, reduced breath sounds on the right side were noted. Blood cultures were drawn on presentation and came back negative in 48 hours. A chest computed tomography scan revealed a large right lung mass in addition to right-sided pleural effusion. Therapeutic thoracocentesis was done; fluid cytology and analysis were negative for malignancy, acid-fast bacilli, or fungal infections. A positron emission tomography scan showed multifocal radiotracer uptake including within right lung mass, multiple bones, lymph nodes, liver and spleen. Biopsies showed hyalinized non-necrotizing granulomas. Immunohistochemical stains for AE1/AE3, cytokeratin 7 and 20, and thyroid transcription factor 1, were all negative. He was started on steroid therapy, and ustekinumab was discontinued and the follow-up computed tomography after a few months showed substantial improvement. However, over the course of next 4 months patient developed hepatic dysfunction and recurrent ascites and ultimately underwent transjugular intrahepatic portosystemic shunt placement. Furthermore, he was started on azathioprine and steroids were tapered. He improved clinically and was discharged from our hospital within a week.ConclusionsThis case highlights the need for careful consideration of patient medication history while evaluating the possible differential diagnoses that may contribute to a patient’s presentation.
Highlights
Monoclonal antibody therapies have been frequently used in recent years in the treatment of chronic inflammatory disorders due to their distinctive immunosuppressive and selective properties
Case presentation A 50-year-old Causcasian man with a known history of refractory psoriasis on treatment with ustekinumab presented with a complaint of significant weight loss and shortness of breath
The decision was made to start him on azathioprine, avoid anti-tumor necrosis factor (TNF) or monoclonal antibody (mAb) agents as well as methotrexate due to its hepatic side effects, and to slowly taper his prednisone dosage with subsequent follow-up in our out-patient clinic
Summary
Monoclonal antibody therapies have been frequently used in recent years in the treatment of chronic inflammatory disorders due to their distinctive immunosuppressive and selective properties. Case presentation A 50-year-old Causcasian man with a known history of refractory psoriasis on treatment with ustekinumab presented with a complaint of significant weight loss and shortness of breath. He denied a previous similar episode and any maculopapular rash or urticarial reaction after taking ustekinumab He was fatigued but recalled no chest pain, palpitations, night sweats, cough, or recent infections. A chest computed tomography (CT) scan was performed and revealed a large right lung mass with adjacent nodularity in addition to rightsided pleural effusion (Fig. 1a), and possibility of primary lung malignancy was raised. The decision was made to start him on azathioprine, avoid anti-tumor necrosis factor (TNF) or mAb agents as well as methotrexate due to its hepatic side effects, and to slowly taper his prednisone dosage with subsequent follow-up in our
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