Infliximab-induced nonspecific interstitial pneumonia.

Internal Medicine at Riverside Methodist Hospital, Columbus, OH 43214, USA.
The American Journal of the Medical Sciences (Impact Factor: 1.52). 06/2012; 344(1):75-8. DOI: 10.1097/MAJ.0b013e31824c07e8
Source: PubMed

ABSTRACT Infliximab has well-established complications including injection site and allergic reactions, cytopenias, induction of autoimmune and demyelinating diseases and malignancy, especially lymphoma. Pulmonary complications are well documented and include serious respiratory infections from tuberculosis, fungal and opportunistic pathogens. This has prompted a Food and Drug Administration black-box warning recommending close surveillance for these diseases. Nonspecific interstitial pneumonitis (NSIP) secondary to tumor necrosis factor-alpha inhibitor (TNF-alpha) therapy is less well described. Rarely, TNF-alpha inhibitor therapy has been reported to cause NSIP when used in conjunction with other immunosuppressive agents. Literature search revealed 12 independent patients with presumed infliximab-induced NSIP in 8 separate publications; all patients were on concomitant steroid sparing immunosuppressive agents, complicating cause and effect. The authors report a case in which infliximab is surmised to cause NSIP in the absence of other steroid sparing immunosuppressants in a young female with ulcerative colitis. Of importance, the patient was taking no additional steroid sparing immunomodulating agents. The diagnosis was based on clinical presentation and radiologic and histopathological data. Cessation of infliximab and high-dose steroid therapy resulted in complete resolution of the patient's presenting signs and symptoms.

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    ABSTRACT: Background: The increase in the use of monoclonal antibodies (mAB) as a targeted therapy for a variety of diseases has been accompanied by an increase in reports of interstitial lung abnormalities in treated patients. Objective: Bronchoalveolar lavage (BAL) is routinely performed in these patients to rule out infection, so we sought to determine the BAL cellular pattern in individuals with mAB-induced lung disease (mAB-ILD). Methods: We utilized a case-control study design. Among patients treated with mAB, cases were defined as those with otherwise-unexplained interstitial lung abnormalities, which resolved after cessation of treatment, while controls were defined as those with interstitial abnormalities clearly explained by other etiologies. Results: From 2000 to 2012, we identified 9 cases and 7 controls. The mean age of the cases was 62.6 ± 26 years and 6 were female. The most common radiographic finding was diffuse ground-glass opacities. The most common BAL cellular pattern was mixed inflammation with moderate lymphocytic and mild neutrophilic alveolitis. The cases had a higher mean lymphocyte count than the controls (40.1 ± 32.6 vs. 13.1 ± 25.5, p = 0.008). The rest of the BAL cellular analyses were similar between the 2 groups. The median CD4:CD8 ratio in 7 patients with >15% lymphocytes was 0.9 (0.6-3). There was no significant difference in the CD4:CD8 ratio between the 2 groups. Conclusions: Mixed inflammation with moderate lymphocytic and mild neutrophilic alveolitis is the most common BAL cellular pattern in patients with mAB-ILD. Such findings may be useful for the early identification of mAB-ILD. © 2014 S. Karger AG, Basel.
    Respiration 06/2014; 88(3). DOI:10.1159/000362521 · 2.92 Impact Factor
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    ABSTRACT: Pulmonary involvement in Crohn's disease (CD) may precede the development of intestinal inflammation, but in most cases occurs during the course of treatment, either as an extra-intestinal manifestation, due to secondary infections, or as a side effect of the therapy itself. This case highlights the differential diagnosis and work up for multiple pulmonary nodules that developed in a patient with CD who had been in remission on Infliximab therapy. Even though infectious causes, such as Mycobacteria and Fungi, account for majority of these cases, the possibility of non-infectious conditions such as autoimmune disorders should also be considered.
    The Clinical Respiratory Journal 05/2014; DOI:10.1111/crj.12168 · 2.20 Impact Factor
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    ABSTRACT: There are several reports of anti-tumor necrosis factor (TNF)-induced lung disease, especially in patients with rheumatologic diseases. Adalimumab is an anti-TNF drug used to induce and maintain remission in patients with immune-mediated diseases, such as Crohn's disease. Although pulmonary disorders could be an extra-intestinal manifestation of inflammatory bowel disease, biologic therapy could also be a cause of lung injury. Only few cases of adalimumab-induced lung toxicity have been reported, and the majority of them were in patients with rheumatologic diseases. Lung injury secondary to anti-TNF therapy should, after ruling out other etiologies, be considered in patients who have a temporal association between the onset of respiratory symptoms and the exposure to these drugs. A compatible pattern in the biopsy and the clinical improvement after discontinuation of the anti-TNF drug would strongly support the diagnosis.

Kim M Jordan