The Journal of the Arkansas Medical Society Issue 5 Volume 115 | Page 19

CASE STUDY Multiple Sclerosis-Like Neurologic Symptoms In a Rheumatoid Arthritis Patient On Etanercept Ripudaman Munjal, MD; 1 Chad Walker, DO; 2 Gagan Dhillon, MD; 1 Shraddha Rayamajhi, MD; 1 Wasique Mirza, MD; 1 Sunil Kumar, MD; 3 Madhukar Reddy Kasarla, MD; 4 Kiran Panuganti, MD; 5 Abhijeet Ramanujam, MD; 6 Gaurav Jain, MD; 7 Sumit Fogla, MD; 8 Shashank Kraleti, MD; 9 Naveen Patil, MD; 10 Sudheer Reddy Koyagura, MD, MPH; 11 Arun Chaudhury, MD 12 Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, Penn.; 2 Regional Hospital of Scranton, Scranton, Penn.; 3 Neshoba County Hospital, Philadelphia, Miss.; 4 Parkway Surgical and Cardiovascular Hospital, Wise Health System, Fort Worth, Tex.; 5 Presbyterian Hospital (Texas Health), Denton, Tex.; 6 Woodland Memorial Hospital, Sacramento, Cal.; 7 Berkshire Medical Center, Pittsfield, Mass.; 8 Beaumont Hospital, Grosse Pointe, Mich.; 9 UAMS, Little Rock, Ark.; 10 Arkansas Department of Health, Little Rock, Ark.; 11 Northwest Arkansas Medical Center, Bentonville, Ark.; 12 GIM Foundation, Little Rock, Ark. 1 Keywords Altered mental status, diplopia, drug Introduction adverse effect, biologics, TNF alpha antagonist Biologics, targeting and antagonizing a specific biologic pathway, are a common class of medica- tions in current medical care. These medications are considered relatively safe and have well-defined side effect(s). However, unpredictable adverse effect(s) (A/Es) may arise, thus necessitating alert- ness and clinical suspicion during their clinical use. Here we describe such an associative condition in which an adult male patient with long-standing rheumatoid arthritis on chronic disease control with the TNF– α (tumor necrosis factor alpha) antagonist etanercept developed sub-acute altered mental status, fatigue and unilateral headaches, facial pain, and diplopia on lateral gaze. Abstract W e report the case of a 35-year- old gentleman who developed fatigue, cognitive changes de- scribed as “fogginess,” unilateral head- ache, same-sided facial numbness and diplopia on left lateral gaze, while on the tumor necrosis factor alpha (TNF- α ) an- tagonist etanercept for management of long-standing rheumatoid arthritis. MRI of brain, MR angiography of cerebral circulation, and analyses of cerebrospinal fluid (CSF) were normal. No oligoclonal bands were detected in the CSF. C reactive protein and sedimentation rates were nor- mal. Lyme titer was positive and 43 and 66 kDa IgG antibodies were detected. The decision was taken to stop etanercept. In addition, the patient was treated with ceftriaxone for presumed Lyme disease. Though no frank evidence of demyelination was obtained, the symptom complex resembled presentation of multiple sclerosis. Tumor necrosis factor (TNF)– α inhibitors belong to a class of disease-modifying antirheumatic drugs that have revolutionized the treatment of inflammatory rheumatologic disorders. Despite their clinical benefit in rheumatologic condi- tions, TNF- α inhibitors have been implicated in the development of CNS and peripheral nervous system disorders. Clinical alertness shall help to detect and avoid cataclysmic neurologic adverse outcomes re- lated to anti-TNF– α therapy. Case report A 35-year-old, well-built male individual with a pleasant personality, and history of polyarticular joint disease due to seronegative rheumatoid arthritis for the last 16 years was admitted to our hospital for evaluation of persistent headache and visual symp- toms. The patient initially presented with left unilat- eral daily headache around the left eye radiating to the back of the left occiput described as a squeezing, pressure sensation; left-sided facial pain and numb- ness, and left-sided diplopia for four-to-six-week duration. His primary care physician started him on Fioricet and nortriptyline, which did not improve the symptoms. The headache seemed to be worse in the night. He denied any chest pain, nausea, vomiting, or cough. He was initially provided with a provisional diagnosis of migraine and treated accordingly. How- ever, there was no improvement of symptoms. There was associated cognitive impairment and emotional lability, described by the subject as low energy, decreased concentration, and “fogginess,” which prompted for hospital admission for evaluation of altered mental status. The patient had a long-standing history of inflammatory polyarthritis. He was on chronic ste- roid therapy and a presentation consistent with sero-negative symmetric inflammatory polyarthritis. Alongside, the patient had co-existing proximal mus- cle weakness and elevated CPK, thus inflammatory myopathy being in the differential. Earlier, in August 2013, prednisone was stopped. The patient was bridged with Medrol, which was gradually tapered and then started on Enbrel (etanercept) for manage- ment of joint disease. The patient had no known drug allergies (only documented allergy was to cashew), no rashes or psoriasis. The patient was on etanercept for approximate- ly the last 28 months. During his hospital admission for evaluation of these emergent conditions including diplopia, detailed eye examination was performed. His fundus examination was normal. Cranial nerves examination revealed full extraocular movements, but diplopia on left gaze. Using a red glass test, it localized the abnormal image to abduction of the left eye, likely involving dysfunction of the sixth cranial nerve. Facial sensation reported a decrease in pinprick over V1 and V2 on the left side. Motor examination revealed full power in the upper and lower extremities with intact reflexes. The neurologic symptoms were presumed to be related to the use of etanercept and a decision was taken to stop the NUMBER 5 NOVEMBER 2018 • 115