Antitumor Necrosis Factor-Alpha (TNF-α) Infliximab-Induced Pleural Effusion and Pericarditis in Crohn’s Disease

Abstract

Crohn’s disease (CD) is a chronic inflammatory disease that can be associated with intestinal and extraintestinal manifestations. Some patients are treated with infliximab, an antitumor necrosis factor-alpha (TNF-α) agent, to help them achieve and maintain clinical and biochemical remission. However, some patients with CD can present severe adverse effects such as drug-induced lupus and rarely present with pleural space and pericardium involvement. We report a case of an 18-year-old Hispanic male with CD who acquired anti-TNF-α-induced lupus after infliximab therapy presenting with pleural effusion and pericarditis. The patient presented with a 2-week history of pleuritic chest pain. Initial laboratory workup was remarkable for leukocytosis and increased inflammatory markers. Imaging and cardiovascular studies were consistent with pericarditis and pleural effusions. Serositis was initially thought to be reactive secondary to the current Mycoplasma pneumoniae infection. He was treated with colchicine 0.6 mg PO TID for six weeks and azithromycin 500 mg PO for seven days. Pain improved after discharge but resurfaced on the day of infliximab infusion. Imaging and cardiovascular studies demonstrated the persistence of pleural effusions and pericarditis. Ultrasound-guided thoracentesis was consistent with exudative pleural effusions. Rheumatological workup was remarkable for increased antihistone antibodies, consistent with drug-induced lupus. Infliximab-induced pericarditis and pleural effusions are rarely reported in the literature. It is thought that infliximab may have a proinflammatory activity or have a delayed type III hypersensitivity reaction. The first line of therapy of anti-TNF-α-induced lupus is the withdrawal of the offending drug. Our patient is unique as few cases of anti-TNF-α-induced pleural effusion and pericarditis in CD are reported. After discontinuing the offending drug, ustekinumab was started, and maintaining a steroid and colchicine regimen, the patient’s chest pain improved. Antihistone antibodies have returned to normal one month after starting ustekinumab.

Acute Chest Pain as an Infusion Reaction to Vedolizumab

“…A variety of common therapeutic agents have been documented as potential causes including analgesics, antidepressants, antihistamines, hormones, antibiotics, and beta-agonist inhalers [ 9 ]. Chest pain related to anti-TNFα therapy has been reported, manifesting as pleural effusion and pericarditis in a patient with Crohn's disease that developed drug-induced lupus [ 10 ]. In our case, possible etiologies for chest pain were investigated and reasonably excluded twice based on clinical data and laboratory findings in the emergency department and the internal medicine ward.…”

Drug-induced lupus erythematosus

“…ANAs and anti-dsDNA are very common (90% of cases) 55 as well as anti-cardiolipin antibodies (25% of cases), 45 but anti-histone antibodies are usually negative 2 . Anti-dsDNA antibodies are predominantly IgM with less systemic pathogenicity than the IgG antibodies found in idiopathic SLE, and therefore, this anti-TNFα-induced LE is less severe 53 .…”

A Review of Extraintestinal Manifestations & Medication-Induced Myocarditis and Pericarditis in Pediatric Inflammatory Bowel Disease

“…There were two cases of carditis proposed to be secondary to IFX [25,29]. In the case report by Fonseca et al, the patient developed symptoms of pleuropericarditis 12 weeks after initial IFX exposure, but 24 hours after the most recent infusion.…”