The Journal of the Arkansas Medical Society Issue 5 Volume 115 | Page 21

velopment of multiple sclerosis-like symptoms. This SNP, (rs1800693) however, does not occur in rheumatoid arthritis or other autoimmune diseases like psoriasis or Crohn’s disease. 14 This SNP, how- ever, predisposes to primary biliary cirrhosis. 16 It has been proposed that this SNP may predispose to increased demyelination upon exposure to TNF antagonists. 14 Routine genotyping for these predis- posing SNPs may not be clinically feasible. Our patient continues to have multiple joint problems, including shoulder and hip pain, and fre- quent knee joint problems. Our patient was started on abatacept as an alternative biologic, after discus- sion of the possibility of use of tocilizumab, tofaci- tinib, and rituximab. The continued need for use of these biologics also raised suspicion for paraneo- plastic condition, which is currently being evaluated. In summary, the present case highlights that use of TNF– α agent etanercept may cause mul- tiple sclerosis-like symptoms including fatigue and personality changes, sensory deficits, and neuromy- opathy, including diplopia due to involvement of the cranial nerves supplying the extraocular muscles. Aggressive identification of evolving symptoms shall prevent adverse neurologic outcomes. Addendum: The association and clinical presentation shall be reported to the FDA Medwatch. References 1. Bosch X, Saiz A, Ramos-Casals M. Monoclonal antibody therapy-associated neurological dis- orders. Nature Rev Neurol. 2011;7:165–172. 2. Sharief MK, Hentges R. Association between tu- mor necrosis factor-alpha and disease progres- sion in patients with multiple sclerosis. N Engl J Med. 1991;325:467–472. 3. Joo W, Yoshioka F, Funaki T, Rhoton AL Jr. Mi- crosurgical anatomy of the abducens nerve. Clin Anat. 2012 Nov;25(8):1030-42. 4. Ali F, Laughlin RS. Asymptomatic CNS demy- elination related to TNF– α inhibitor therapy. Neurol Neuroimmunol Neuroinflamm. 2016 Oct 28;4(1):e298. 5. Barreras P, Mealy MA, Pardo CA. TNF-alpha in- hibitor associated myelopathies: A neurological complication in patients with rheumatologic disorders. J Neurol Sci. 2017 Feb 15;373:303- 306. 6. Kaltsonoudis E, Zikou AK, Voulgari PV, Konitsi- otis S, Argyropoulou MI, Drosos AA. Neuro- logical adverse events in patients receiving anti-TNF therapy: a prospective imaging and electrophysiological study. Arthritis Res Ther 2014;16:125. 7. Mohan N, Edwards ET, Cupps TR, Olive- rio PJ, Sandberg G, Crayton H, Richert JR, Siegel JN. Demyelination occurring dur- ing anti-tumor necrosis factor alpha ther- apy for inflammatory arthritides. Arthritis Rheum. 2001 Dec;44(12):2862-9. 8. Solomon AJ, Spain RI, Kruer MC, Bourdette D. Inflammatory neurological disease in pa- tients treated with tumor necrosis factor alpha inhibitors. Mult Scler 2011;7:1472–1487. Advertise in the best place to reach 4,400 Arkansas physicians 9. Tristano AG. Neurological adverse events asso- ciated with anti-tumor necrosis factor α treat- ment. J Neurol. 2010 Sep;257(9):1421-31. 10. Hofman FM, Hinton DR, Johnson K, Merrill JE. Tumor necrosis factor identified in multiple sclerosis brain. J Exp Med. 1989;170:607–612. 11. Couderc M, Mathieu S, Tournadre A, Dubost JJ, Soubrier M. Acute ocular myositis occur- ring under etanercept for rheumatoid arthritis. Joint Bone Spine. 2014 Oct;81(5):445-6.  12. Robinson WH, Genovese MC, Moreland LW. Demyelinating and neurologic events reported in association with tumor necrosis factor alpha antagonism: by what mecha- nisms could tumor necrosis factor alpha antagonists improve rheumatoid arthritis but exacerbate multiple sclerosis? Arthritis Rheum2001;44:1977–1983. 13. Galiè E, Jandolo B, Martayane A, Renna R, Koudriavtseva T. Multiple sclerosis activated by anti-tumor necrosis factor α (Etanercept) and the genetic risk. Neurol India. 2016 Sep- Oct;64(5):1042-4. 14. Gregory AP, Dendrou CA, Attfield KE, Haghikia A, Xifara DK, Butter F, Poschmann G, Kaur G, Lambert L, Leach OA, Prömel S, Punwani D, Felce JH, Davis SJ, Gold R, Nielsen FC, Sie- gel RM, Mann M, Bell JI, McVean G, Fugger L. TNF receptor 1 genetic risk mirrors outcome of anti-TNF therapy in multiple sclerosis. Na- ture. 2012 Aug 23;488(7412):508-11. 15. Sicotte NL, Voskuhl RR. Onset of multiple scle- rosis associated with anti-TNF therapy. Neu- rology. 2001 Nov 27;57(10):1885-8. 16. Mells GF, et al. Genome-wide association study identifies 12 new susceptibility loci for primary biliary cirrhosis. Nature Gen- et. 2011;43:329–332. For more advertising information, contact Penny Henderson at 501.224.8967 or [email protected] NUMBER 5 NOVEMBER 2018 • 117