Abstract
Objectives Tumour necrosis factor (TNF)-α inhibitors are immunosuppressants used in autoimmune conditions. Rarely, they may be implicated in central and peripheral demyelination. We present two cases highlighting this spectrum.
Methods Case report.
Results The first case is of a 48-year-old man who presented with three months of weakness in his upper and then lower limbs, occurring on a background of ulcerative colitis on infliximab. Nerve conduction studies revealed reduced compound muscle action potentials across multiple nerves in the upper and lower limbs, including proximally, in-keeping with multiple foci of conduction block. GM1 antibodies were negative. With an impression of multifocal motor neuropathy with conduction block, he was commenced on intravenous immunoglobulin and made a marked clinical recovery. Infliximab was changed to vedolizumab for his ulcerative colitis.
The second case is of a 45-year-old female who presented with a relapsing syndrome of diplopia, dysarthria, and left facial and right hemi-body sensory changes, occurring on a background of rheumatoid arthritis on adalimumab. MRI showed enhancing and non-enhancing demyelinating lesions in the supratentorium, brainstem and spinal cord. With an impression of multiple sclerosis-like central demyelination, she was given pulsed intravenous methylprednisolone before rituximab was commenced as dual treatment for this and her rheumatoid arthritis, with eventual marked clinical improvement.
Conclusions TNF-α inhibitors are used widely for a range of autoimmune conditions but can rarely be implicated in demyelinating disease.1 Our cases highlight the spectrum of central and peripheral demyelination that can occur with this therapy, and how management can be safely navigated.
Reference
Taylor T, Galloway J, Davies R, Hyrich K, Dobson R. Demyelinating Events Following Initiation of Anti-TNFα Therapy in the British Society for Rheumatology Biologics Registry in Rheumatoid Arthritis. Neurol Neuroimmunol Neuroinflamm. 2021;8(3):e992.
