Certolizumab pegol
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Sarcoidosis: case report A 69-year-old woman developed sarcoidosis during treatment with certolizumab pegol for rheumatoid arthritis. The woman presented to hospital with general fatigue, low-grade fever and loss of appetite for 1 month. A review of her history revealed that she had been diagnosed with rheumatoid arthritis at the age of 60 years, and she had subsequently been treated with sulfasalazine [salazosulfapyridine] and unspecified corticosteroids, with resolution of polyarthralgia. Two years later, she started receiving adalimumab injections due to worsening polyarthritis. However, she subsequently developed injection site reaction; hence, after 1 year of treatment, adalimumab was replaced with etanercept. Since her polyarthritis did not sufficiently improve on etanercept, etanercept was switched to certolizumab pegol. At the time of her current presentation, she had been receiving certolizumab pegol [route and dosage not stated] for 6 years. At admission, her body temperature was 37.4°C. Physical examination revealed ulnar deviation of the fingers of bilateral hands. Rheumatoid factor was elevated to 40 IU/mL. Respiratory function testing revealed the following: forced vital capacity 1.60L, vital capacity 1.64L, diffusion capacity of the lung for carbon monoxide 8.42 mL/min/mmHg and forced expiratory volume of 1.30L in 1 second. Ophthalmic evaluation revealed findings consistent with granulomatous uveitis, including corner nodules and snowball opacities of vitreous bodies in bilateral eyes. Chest X-ray revealed bilateral hilar lymphadenopathy. CT scan of the chest revealed mediastinal lymphadenopathy and bilateral hilar and multiple micronodules distributed predominantly in both upper lobes. Gallium (Ga) scintigraphy revealed increased uptake of 68Ga in the mediastinal and bilateral hilar lymph nodes. Analysis of bronchoalveolar lavage fluid revealed a cell count of 2.43 x 105mL with a cell differential of 25.0% lymphocytes, 68.0% macrophages and 1.0% neutrophils, and a CD4/CD8 ratio of 99.0. Sarcoidosis secondary to certolizumab pegol was suspected; hence, she underwent video-assisted thoracoscopic biopsy. Specimens from right hilar lymph node and the right upper lobe revealed noncaseous epithelioid cell granulomas, compatible with sarcoidosis. In the meantime, while the pathological results of the video-assisted thoracoscopic biopsy were awaited, she noticed a subcutaneous nodule in her right knee. A biopsy of the subcutaneous nodule also revealed noncaseous epithelioid cell granulomas. Therefore, sarcoidosis secondary to certolizumab pegol was diagnosed. The woman discontinued certolizumab pegol. She was treated with prednisolone, and she subsequently became asymptomatic. Her laboratory test results gradually improved. Prednisolone was eventually tapered without recurrence of sarcoidosis, while the rheumatoid arthritis was controlled with abatacept. Koda K, et al. Systemic sarcoidosis associated with certolizumab pegol treatment for rheumatoid arthritis: A case report and review of the literature.
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