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Ann Rheum Dis 2004;63:1344-1346 doi:10.1136/ard.2003.014878
  • Concise report

True infliximab resistance in rheumatoid arthritis: a role for lymphotoxin α?

  1. M H Buch,
  2. P G Conaghan,
  3. M A Quinn,
  4. S J Bingham,
  5. D Veale,
  6. P Emery
  1. Academic Unit of Musculoskeletal Disease, University of Leeds, UK
  1. Correspondence to:
    Professor P Emery
    Academic Unit of Musculoskeletal Disease, 1st Floor, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK; p.emeryleeds.ac.uk
  • Accepted 25 November 2003
  • Published Online First 19 March 2004

Abstract

Background: The combination of methotrexate and the anti-tumour necrosis factor α (TNFα) antibody infliximab is a very effective treatment for rheumatoid arthritis (RA). However, a proportion of patients are not responsive to this treatment. Inefficacy may represent a TNFα independent disease or insufficient drug at the site of action.

Case report: A patient with RA resistant to repeated high dose infliximab infusions and intra-articular infliximab into an inflamed knee is described. No beneficial clinical effect was observed. Pre-injection arthroscopic biopsy of the study knee demonstrated TNFα staining but also confirmed the presence of lymphotoxin α (LTα or TNFβ) on immunohistochemistry. Subsequent treatment with etanercept (which blocks LTα as well as TNFα) resulted in clinical remission of disease.

Conclusion: This case suggests that resistance to TNF blockade may occur when TNFα is not the dominant inflammatory cytokine and suggests that LTα may have a pathogenic role in RA.

Footnotes

  • Published online first 19 March 2004

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