Smoking is bad for your health This is a 64 years old male with a four years history of rheumatoid arthritis. He was a heavy smoker (>1ppd), and suffered from diabetes mellitus and chronic obstructive pulmonary disease. On his first visit, his DAS (ESR) was 5,6 and HAQ 1,6. The laboratory work showed anemia, elevated ESR and CRP. Radiographs of hands revealed narrowing of joint space and marginal erosions. He was initially treated with methotrexate (up to 22,5 mg) weekly and low doses of prednisone. Nine month later, Infiximab was added to the treatment because of lack of response. He improved and went into clinical remission with normalization of blood inflammatory parameters. Three years later, he developed dyspnea and dry cough. His musculo-skeletal exam was within normal limits with no evidence of articular inflammation. The laboratory work demonstrated anemia, and elevation of ESR and CRP. Infection including tuberculosis and “methotrexate lung” disease due to hypersensitivity reaction were excluded. The chest radiograph demonstrated a mass of 36 mm in the anterior segment of left upper lobe and pleural effusion. An open biopsy was obtained, and the pathology examination demonstrated a squamous cell carcinoma. Infliximab was discontinued and chemotherapy initiated.
No all “night sweats” is tuberculosis This is a 55 years old female admitted to the ICU because fever, night sweats, dyspnea, cough, and hypotension. She had a ten years history of rheumatoid arthritis. At starting her articular symptoms, she was treated with methotrexate (up to 22,5 mg) weekly and low doses of prednisone. Due to lack of significant response, infliximab was added to the therapy. One year latter infliximab was discontinued and switched to adalimumab. She remained in clinical remission for eight years. On admission, she was tachycardic, with arterial hypotension, diaphoresis, and low systemic vascular resistance. Her physical examination showed generalized enlarged lymphonodes, and splenomegy. Her joint examination was irrelevant. The laboratory work demonstrated anemia, thrombocytopenia and elevation of ESR and CRP. Extensive investigations (cultures, PCR, and serology) excluded bacterial and viral infections. CT scan showed multiple thoracic and abdominal lymph nodes, and splenomegaly. Patient died in four days, and the postmortem examination revealed a no Hodgkin lymphoma with nodular sclerosis, and pulmonary embolism.
These two cases raise important questions related to the risk of solid tumor and lymphoma in RA patients treated with TNF antagonists; Is the risk of tumors increased in RA patients? Is the overall risk of tumors increased in RA patients exposed to TNF antagonists? Is the risk higher in patients treated with anti-TNF monoclonal antibodies? Does the risk increase with the exposure?
Disclosure of Interest None declared