C42-38 Unexpected Consequences: Paradoxical Sarcoidosis From TNF Alpha Inhibitors

Abstract Introduction Sarcoidosis is a granulomatous disorder that involves multiple organ systems. Most patients diagnosed with sarcoidosis have lung involvement, interestingly about 50% of patients with sarcoidosis initially present after having abnormal chest imaging. There is no known cause that initiates sarcoidosis, but patients with an activated inflammatory state are predisposed to develop sarcoidosis. Use of TNF-alpha inhibitors such as adalimumab for other conditions can trigger a sarcoid like disease manifestation with granulomas accumulating in the lungs, skin, and lymph nodes Case Presentation 46-year-old male patient with a past medical history of psoriasis as well as psoriatic arthritis on Adalimumab, Lynch syndrome, obstructive sleep apnea, hypertension, diabetes mellitus Type 2 who presented to the pulmonology clinic for follow up after multiple hospital admissions for pneumonia was readmitted for severe coughing episode resulting in syncope in clinic and abnormal chest imaging, Upon arrival at the ED, the patient’s vitals were within normal limits Labs significant for WBC: 13.8, Na: 135, Glucose: 177, Abs Mono Auto: 2.0, Lactate: 2.3. VBG showed pH 7.48, pCO2 34, and HCO3 25. CT PE showed multiple masses in the RUL, RLL, and left lung concerning for metastatic disease and bilateral pleural effusion. Patient recent bronchoscopy with biopsy which showed non-necrotizing granulomatous inflammation. Fungitell, Blastomyces, Histoplasma, RF, CCP, ANA, Anca, ACE level, connective tissue disease profile were ordered to investigate infectious versus autoimmune causes, studies were unremarkable. Treated with Methotrexate, Azithromycin and Ceftriaxone empirically for infectious causes, and IV steroids q8, in addition to bronchodilators. Fortunately, the patient recovered over a few days and was discharged on oral antibiotics, PPI, and steroids. Conclusion This case highlights how use of TNF-alpha inhibitors for other conditions such as psoriasis can lead to a sarcoid like reaction. Even though this is rare, it has been recognized in approximately 1 case per 2800 TNF-alpha inhibitor patients. In addition to discontinuing use of TNF-alpha inhibitors, it is prudent to treat with methotrexate and prednisone for management of the sarcoid reaction. Additional evaluation will include repeating cardiac MRI and chest CT to monitor improvement and ensuring there is no cardiac involvement. There is a great risk of relapsing 2-6 months after cessation of steroids. Moving forward patients that develop these reactions while on TNF-alpha inhibitor treatment will need to avoid TNF-alpha inhibitors and likely will need to switch to other classes of biologics for management of psoriasis or other autoimmune conditions. This abstract is funded by: None