Acute lymphoid leukemia in a Crohn's disease patient during treatment with adalimumab after a prolonged treatment with azathioprine and steroids

Adalimumab-associated Philadelphia chromosome positive acute lymphoblastic leukaemia in a patient with Crohn's disease

The US Food and Drug Administration has approved TNF(Tumor necrosis factor) alpha inhibitors to manage a range of inflammatory conditions, including Crohn's disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and other inflammatory disorders. However, these inhibitors can potentially increase the risk of secondary blood malignancies due to TNF alpha's role in various cellular processes such as angiogenesis, cell cycle proliferation, apoptosis and differentiation. In this article, we present a unique case study of a patient who developed Philadelphia-positive acute lymphoblastic leukaemia (ALL) while receiving adalimumab, a potent monoclonal antibody that specifically binds to TNF-alpha. We describe the patient's successful treatment using standard-of-care chemotherapy and tyrosine kinase inhibitors, resulting in complete remission with no measurable residual disease. Furthermore, we conducted a literature review on this subject and identified five similar cases of ALL associated with TNF alpha inhibitors.

Ulcerative Colitis Concomitant with Cytomegalovirus Infection, Bullous Sweet's Syndrome, and Acute Myeloid Leukemia: A Case Report and Literature Review

Background

Ulcerative colitis (UC) is a chronic, relapsing progressive inflammatory immune disease. There is still no cure for it. Even worse, UC may predispose patients to opportunistic infections, and several extra-intestinal manifestations (EIMs) and comorbidities may antedate, occur with, or postdate the onset of UC, which may increase the mortality risk. But case reports of UC patients simultaneously concomitant with opportunistic infection, EIM, and comorbidity are extremely rare.

Case Presentation

We report a case of 51-year-old male patient with incipient UC accompanied by cytomegalovirus (CMV) infection and bullous Sweet's syndrome (bSS, a cutaneous EIM of UC) after treatment with oral mesalazine and prednisolone for 3 weeks. After clearance of the CMV infection by using ganciclovir, the patient was administered two cycles of infliximab to cure UC and bSS; however, he developed acute myeloid leukemia (AML) a month later and died after two cycles of chemotherapy.

Conclusion

Based on this rare case of UC concomitant with CMV infection, bSS and AML, we recommend that it is important to distinguish between an acute UC flare and opportunistic infections, especially in patients receiving immunosuppressive therapy, and monitor EIMs and comorbidities timely. Particular attention should be paid to cancer surveillance. Clinicians should be mindful of these facts to adopt optimal therapeutic options to address all aspects of UC. Early initiation of biological therapy may be of benefit to patients with newly diagnosed severe UC.

Adalimumab-induced acute myeloid leukaemia in a patient with Crohn's disease

We present a patient with Crohn's disease under treatment with adalimumab who developed acute myeloid leukaemia (AML) with core-binding factor beta gene rearrangement. This case report emphasises the importance of long-term close follow-up of patients receiving adalimumab because of the increased risk of developing AML and other malignancies.

Acute Myeloid Leukemia with Myelodysplasia-Related Changes in a Patient with Crohn’s Disease Treated with Immunosuppressive Therapy

We report a case of acute myeloid leukemia with myelodysplasia-related changes in a patient with Crohn's disease. The patient was diagnosed with Crohn's disease at the age of 47 years and was treated with the tumor necrosis factor α inhibitors adalimumab and infliximab, and a short course of azathioprine. Four years later, the patient developed acute myeloid leukemia with myelodysplasia that involved mainly erythropoiesis. Crohn's disease is associated with an increased risk of cancers including hematological malignancies. Cancer surveillance including hematology assessment is warranted to monitor the patients on immunosuppressive therapy.

Etanercept-induced leukemia: could increased mean corpuscular volume be a predictor of hematologic malignancy?

In rheumatology practice, anti-tumor necrosis factor (TNF) alpha agents are frequently used medications, more so in ankylosing spondylitis (AS). There are case reports, besides their adverse effects, such as infection and injection site reaction, suggesting these agents may cause solid or hematologic malignancies. Acute leukemia secondary to anti-TNF alpha agents has been rarely reported in patients with AS. In this case report, based on a patient who developed acute leukemia while on the treatment with etanercept, we will discuss whether it is possible to predict acute leukemia by monitoring the mean corpuscular volume in light of the literature.

Thyroid cancer and T lymphoblastic leukemia in Crohn disease: a case report and literature review

The effectiveness of the tumor necrosis-α (TNF-α) blockade has changed the treatment of several chronic inflammatory diseases, including inflammatory bowel disease; however, this treatment also has disadvantages. The use of immunosuppressants in combination with infliximab has been associated with greater risk of developing malignant neoplasms. Herein, we report the case of a 33-year-old ethnic Korean man with Crohn disease (CD) who developed papillary thyroid carcinoma (PTC) and, subsequently, T-cell acute lymphoblastic leukemia (ALL) after approximately 16.0 years of immunosuppressant therapy and 5.5 years of infliximab therapy. To our knowledge, this is the first case described in the literature of 2 different malignant neoplasms, 1 of hematologic origin and the other involving the solid organs, in a patient with CD. Through a systematic literature review, we found 28 cases of acute leukemia in adult patients with CD, of whom 22 had myeloid leukemia and 6 had lymphoid leukemia. Half of the patients with ALL underwent TNF-α-blocker therapy in combination with thiopurines.

TNF alpha antagonist therapy and safety monitoring

OBJECTIVES

To develop and/or update fact sheets about TNFα antagonists treatments, in order to assist physicians in the management of patients with inflammatory joint disease.

METHODS

1. selection by a committee of rheumatology experts of the main topics of interest for which fact sheets were desirable; 2. identification and review of publications relevant to each topic; 3. development and/or update of fact sheets based on three levels of evidence: evidence-based medicine, official recommendations, and expert opinion. The experts were rheumatologists and invited specialists in other fields, and they had extensive experience with the management of chronic inflammatory diseases, such as rheumatoid. They were members of the CRI (Club Rhumatismes et Inflammation), a section of the Société Francaise de Rhumatologie. Each fact sheet was revised by several experts and the overall process was coordinated by three experts.

RESULTS

Several topics of major interest were selected: contraindications of TNFα antagonists treatments, the management of adverse effects and concomitant diseases that may develop during these therapies, and the management of everyday situations such as pregnancy, surgery, and immunizations. After a review of the literature and discussions among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: 1. in RA and SpA, initiation and monitoring of TNFα antagonists treatments, management of patients with specific past histories, and specific clinical situations such as pregnancy; 2. diseases other than RA, such as juvenile idiopathic arthritis; 3. models of letters for informing the rheumatologist and general practitioner; 4. and patient information.

CONCLUSION

These TNFα antagonists treatments fact sheets built on evidence-based medicine and expert opinion will serve as a practical tool for assisting physicians who manage patients on these therapies. They will be available continuously at www.cri-net.com and updated at appropriate intervals.