Discontinuation of infliximab in a 59-year-old female presenting with acute pericarditis and a moderate-to-large pericardial effusion resulted in complete symptomatic resolution.
Case Report (n=1)
Does discontinuation of infliximab resolve recurrent pericarditis in a patient with suspected infliximab-induced pericarditis?
Infliximab-induced pericarditis is a rare but recognized adverse reaction that can be managed by maintaining a high index of suspicion and discontinuing the offending drug.
Abstract Introduction Infliximab is a commonly used tumor necrosis factor (TNF) alpha inhibitor. Adverse reactions include reactivation of tuberculosis, serum sickness. A rare, reported complication includes pericarditis. Case Presentation A 59-year-old female with chronic respiratory failure, sarcoidosis, pulmonary hypertension presented with acute chest pain that improved when leaning forward. Laboratory results revealed elevated troponin, C-reactive protein, and brain natriuretic peptide. A chest X-ray raised concern for an enlarged cardiac contour, while an electrocardiogram showed normal sinus rhythm with low voltage. Transthoracic echocardiography demonstrated a moderate-to-large pericardial effusion with diastolic collapse of the right ventricle, and a fibrinous/inflammatory mass along the free wall. A heart catheterization did not show equalization of diastolic pressures. A pericardial window was performed to drain the fibrinous fluid and evaluate the underlying etiology. The patient was treated with nonsteroidal anti-inflammatory drugs, colchicine, and prednisone. The infectious workup, including bacterial, viral, fungal, and acid-fast bacilli (AFB) pericardial fluid cultures, was negative. Fluid cytology and a recent PET scan did not raise concerns for malignancy. Autoimmune testing revealed elevated nuclear homogenous anti-neutrophilic antibodies (ANA) with negative immunofluorescence assay, anti-histone antibodies, and myositis panel. The patient had no history of recent trauma or radiation exposure. She was discharged but readmitted due to concerns for recurrent pericarditis. Infliximab was subsequently discontinued with resultant symptomatic resolution. Discussion Infliximab is increasingly used to treat various conditions, including inflammatory bowel disease, rheumatoid arthritis, plaque psoriasis. While generally well tolerated, infliximab-induced pericarditis is a rare but recognized adverse reaction, with a reported prevalence of 0.19-0.22% in post-marketing studies. The exact incidence is unknown. The proposed mechanisms include direct cardiac toxicity, an IgE-mediated allergic response, humoral antibody activation, and a delayed cell-mediated hypersensitivity reaction, resembling serum sickness. It may be associated with the production of antinuclear antibodies (79%), double-stranded (ds) DNA antibodies (725), antihistone antibodies (17-57%), and others, developing drug-induced lupus. Onset can range from less than a month to over four years after initiation of therapy. The primary treatment is discontinuation of the drug. Clinicians should maintain a high index of suspicion for pericarditis in patients receiving infliximab and consider drug withdrawal if symptoms arise. Close monitoring for severe complications, such as pericardial effusion and systemic vasculitis, is also advised. References: Thiriveedi M, et al. J Gen Intern Med. 2021;36(7):2134-8. • Fonseca A, et al. Case Rep Pediatr. 2021;9989729. • Dipasquale V, et al. J Clin Pharm Ther. 2018;43(1):107-9. • Devasahayam J, et al. J Crohns Colitis. 2012;6(6):730-1. This abstract is funded by: none
Haque et al. (Fri,) conducted a case report in Acute pericarditis (n=1). Infliximab was evaluated. Discontinuation of infliximab in a 59-year-old female presenting with acute pericarditis and a moderate-to-large pericardial effusion resulted in complete symptomatic resolution.