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
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