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A3083 - Adalimumab Induced Sarcoidosis and Its Complications
Author Block: C. Kyung1, S. Mustafa1, M. Al-Halawani1, A. Cargill1, M. Al Ajam2, V. Ly2, D. Lazaro3; 1Department of Pulmonary and Critical Care Medicine, SUNY Downstate Medical Center, Brooklyn, NY, United States, 2Medicine: Division of Pulmonary Critical Care and Sleep Medicine, Department of Veterans Affairs NYHCCS Brooklyn, Brooklyn, NY, United States, 3Department of Rheumatology, Department of Veterans Affairs NYHCCS Brooklyn, Brooklyn, NY, United States.
Sarcoidosis is a disease characterized by the formation of granulomas in the lungs, lymph nodes, skin and other organs. Tumor Necrosis Factor is a cytokine that has been known to play a large role in the formation of this disease. There have been reports showing successful treatment of sarcoidosis with biological agents that inhibit this particular cytokine. However, paradoxically, these biological agents can be the cause of this disease as well.
Endobronchial Ultrasound (EBUS) can help with obtaining the diagnosis of sarcoidosis. However they have also been associated with mediastinal abscess formation in immunocompetent adults. We present a rare case which demonstrates both of these phenomena.
A 65 year-old African-American man transferred his care to the Brooklyn VA for his psoriatic arthritis. He had been maintained on Ustekinumab for years but was switched to adalimumab due to financial issues. Tuberculosis testing was negative. Two years later he presented to the Emergency Department complaining of progressively worsening exertional dyspnea, non productive cough and weight loss. Computed tomography (CT) of the chest showed innumerable irregular nodular densities with an upper and mid lung zone predominance. Bronchoscopy with right upper lobe transbronchial biopsies and EBUS guided transbronchial needle aspiration of the sub-carinal lymph node showed non-necrotizing granulomas. Stains for infectious etiologies were negative. Serum Angiotensin Converting Enzyme (ACE) level was elevated.
Adalimumab was stopped and oral prednisone therapy for presumed sarcoidosis was started. A month later he reported mild improvement in respiratory symptoms but had developed a low-grade fever and general malaise the week following the procedure. Repeat CT chest showed interval decrease in the nodular opacities. However the sub-carinal lymph node showed cystic changes with necrosis. Repeat bronchoscopy with EBUS was performed due to concerns of a hematological malignancy. When the sub-carinal lymph node was aspirated, purulent material was noted. Gram stain revealed inflammatory cells with gram-positive cocci in chains. Culture showed polymicrobial growth. Antibiotics were prescribed and Methotrexate was started. Follow-up revealed both clinical and radiographic improvement of the nodules and the mediastinal abscess.
We believe that adalimumab predisposed the patient to infection during the initial EBUS procedure seeding the sub-carinal lymph node with multiple microbes, which worsened with steroids. Steroids carry higher risks of infection compared to methotrexate in patients with rheumatoid arthritis. We suggest the use of preoperative antibiotic prophylaxis prior to EBUS and steroid sparing agents such as methotrexate in the treatment for these patients.