Demyelinating central nervous system lesions, following the use of tumor necrosis factor alpha antagonist

Abstract

Tumor necrosis factor alpha (TNFalpha) antagonists have been a valuable tool in treating patients with rheumatoid arthritis (RA), but reports and case series of neurological adverse events due to TNFalpha antagonists have been reported. Furthermore, central nervous system (CNS) lymphoma always remains a remote, yet a worrisome complication in RA patients, especially in those under treatment with methotrexate (MTX). We present a female patient with RA with tumor-like active demyelinating lesions attributed to TNFalpha antagonist, confirmed by an FNA biopsy, otherwise clinically and radiologically challenging to distinguish from CNS lymphoma. A 72-year-old female patient with RA under TNFalpha antagonist and MTX treatment was presented with neurological symptoms and signs. The brain MRI revealed four tumor-like contrast-enhancing lesions bilaterally, the demyelinating nature of which was delineated by the FNA biopsy. A full clinical and radiological recovery was achieved after the TNFalpha antagonist was permanently withdrawn. Patients with RA under anti-TNF agents and MTX are predisposed to complications such as CNS lymphoma and CNS demyelination. This case uniquely highlights the physicians' vigilance in pursuing these complications and the usage of the FNA when tumor-like appearances on the brain MRI convolute the final diagnosis.Copyright © The Author(s) 2018.