Sarcoid- like Phenomenon - ustekinumab induced granulomatous reaction mimicking diffuse metastatic disease: a case report and review of the literature

Abstract

Background The 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 presentation We 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. Conclusions This 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.

Non-Infectious Pneumonitis and Acute Respiratory Distress Syndrome in a Patient on Ustekinumab Treatment: Case Report and Literature Review

“…Common reactions encompass headache, bronchitis, abdominal pain, diarrhea, and fever. Adverse effects include hypersensitivity, infections, non-melanoma skin cancer, reversible posterior leukoencephalopathy syndrome, and pulmonary complications such as cryptogenic organizing pneumonia, interstitial or eosinophilic pneumonia, sarcoid-like reactions, and the rare manifestation of ARDS [ 9 ].…”

Splenic sarcoid reaction mimicking metastases in patients after uterine cancer surgery: a report of two cases

“…We excluded possible cases of sarcoidosis. For cases of drug-induced sarcoid reactions, rapid improvement has been reported after drug discontinuation [ 7 , 24 , 34 , 35 ]. However, in some cases, the sarcoid reactions persist for more than 1 year after the drug is discontinued [ 34 , 36 ].…”

Emerging Molecular Targets for the Treatment of Refractory Sarcoidosis

“…However, no data is currently available in patients with sarcoidosis. Similarly to IL-17 antagonists, several cases of induced or worsened sarcoidosis with ustekinumab or guselkumab have been reported in the literature (71)(72)(73)(74).…”