Developing of granulomatous thyroiditis during etanercept therapy

New Onset Isolated Granulomatous Dacryoadenitis During Etanercept Therapy

Anti-tumor necrosis factor alpha (TNF- α) biological agents can rarely cause sarcoid-like granulomatosis. A 20-year-old woman presented with a 1-month history of painful left upper eyelid swelling. She was on subcutaneous etanercept and methotrexate for 1 year for juvenile idiopathic arthritis. Imaging showed diffuse enlargement of the left and minimal enlargement of the right lacrimal gland. There was no finding in favor of sarcoidosis on systemic evaluation. Incisional biopsy of the left lacrimal gland revealed non-caseating granulomatous dacryoadenitis. The findings showed significant regression 1 month after cessation of Etanercept therapy. To the best of our knowledge, this report illustrates the first case of an isolated granulomatous dacryoadenitis during TNF-α antagonist therapy.

Methotrexate is associated with decreased total thyroxine in patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease characterized by joint swelling, pain, and deformation. RA patients have an increased risk of thyroid dysfunction, and drugs of RA treatment may have potential effects on thyroid function.

METHODS

This is a single-center cross-sectional study including 281 inpatients with RA in the First Affiliated Hospital of Guangzhou University of Chinese Medicine. The purpose of this study is to explore the correlation between RA therapeutic drugs and thyroid function. The medical records of 281 inpatients with RA were collected, including general data, laboratory examination, complications, and RA treatment. Spearman correlation analysis was used to explore the association of independent variables with thyroid function and antibodies in RA patients. Multinomial logistics and binary logistic regression were used for multivariate analysis. The statistically significance level was set as P < 0.05. SPSS 22.0 was used for statistical analysis.

RESULTS

Patients taking methotrexate (OR = 0.067, 95%CI: 0.008-0.588, P = 0.015) had lower levels of total thyroxine (TT4) (TT4 < 78.38 nmol/L). There was a negative correlation between glucocorticoids (r = - 0.153, P = 0.010) and total triiodothyronine (TT3) level (TT3 ≥ 1.34 nmol/L), but it was not significant in the multivariate regression model of TT3, although the regression model was statistically significant (P = 0.001).

CONCLUSION

Methotrexate is associated with decreased TT4 levels in RA patients, and glucocorticoids is associated with decreased TT3 levels. Drugs of RA treatment may affect the thyroid function of patients while treating RA, which may be one of the causes of secondary thyroid diseases in RA patients.

The Old and the New in Subacute Thyroiditis: An Integrative Review

Subacute thyroiditis (SAT) is the most common cause of neck pain and thyrotoxicosis. Although this disease was recognized already by the end of the 18th century, new concepts regarding pathogenesis have emerged in recent years. Moreover, in the last two years, literature on SAT has increased significantly due to articles describing the possible connection with coronavirus disease 2019 (COVID-19). This integrative review depicts old and new concepts of this disease, proposing a detailed overview of pathogenesis, a practical approach to diagnosis and treatment, and a thorough description of the latest discoveries regarding the association of SAT with COVID-19.

Subacute thyroiditis in a patient with psoriatic arthritis switched from secukinumab to adalimumab: a case report and literature review

A 71-year-old Japanese female with psoriatic arthritis (PsA) was admitted for fever and neck pain. Her medication had been switched from secukinumab, an interleukin (IL)-17A inhibitor, to adalimumab, a tumour necrosis factor (TNF)-α inhibitor, due to secondary failure for PsA. She was diagnosed with subacute thyroiditis (SAT) on the basis of thyroid hormone levels and thyroid ultrasound findings. Her SAT symptoms improved with prednisolone administration (15 mg/day). Following the administration of ixekizumab, an IL-17A inhibitor, her PsA improved without SAT relapse. SAT mechanism associated with TNF inhibitors remains unknown, but cytokine imbalance may be involved.

Early instauration granulomatous pneumonitis associated with use of etanercept in seronegative spondyloarthropathy: Case report

Spondyloarthropathies are a group of chronic inflammatory disorders that involve the joints of the axial skeleton, peripheral joints and have extra-articular manifestations. Treatment includes inhibitors of tumor necrosis factor α. Currently there are five approved inhibitors: a soluble receptor, Etanercept and four monoclonal. Etanercept has very low toxicity with pulmonary adverse reactions being very rare. We present the case of a patient who developed respiratory symptoms and pulmonary infiltrates of rapid evolution after the third dose of treatment with Etanercept.

A rare case showing subacute thyroiditis-like symptoms with amyloid goiter after anti-tumor necrosis factor therapy

Anti-tumor necrosis factor (TNF)-α therapy is established as a new standard for the treatment of various autoimmune inflammatory diseases. We report the first case showing subacute thyroiditis-like symptoms with an amyloid goiter after anti-TNF-α therapy. A 56-year-old man with Crohn's disease presented with fever and a diffuse, tender goiter. To control the diarrhea, anti-TNF therapy (infliximab) was administered 4 weeks before the thyroid symptoms emerged. The patient reported a swollen neck with tenderness on the right side and fever 4 days after the second infliximab injection. An elevated serum C-reactive protein (CRP) and serum thyroid hormone level with suppressed serum thyrotropin were observed. The thyroid-stimulating antibody was not elevated. An ultrasonograph of the thyroid revealed an enlarged goiter with posterior echogenicity attenuation and a low echoic region that was tender. The thyroid uptake value on technetium-99m scintigraphy was near the lower limit of the normal range. The patient was initially diagnosed with thyrotoxicosis resulting from subacute thyroiditis. Administration of oral prednisolone improved the fever, thyroid pain, and thyroid function, but his thyroid remained swollen. The patient developed diarrhea after prednisolone withdrawal; therefore, adalimumab, another TNF inhibitor, was administered. After three injections, his abdominal symptoms were alleviated, but the thyroid pain and fever recurred. Elevated serum CRP levels in the absence of thyroid dysfunction were observed. The patient's symptoms resolved after prednisolone retreatment, but an elastic, firm goiter persisted. A fine-needle biopsy revealed amyloid deposition in the thyroid.

Developing of Granulomatosis with Polyangiitis during Etanercept Therapy

We describe a 67-year-old woman who developed c-ANCA positive vasculitis with involvement in eyes, skin, kidney, peripheral nerves, and upper and lower airway during treatment with etanercept therapy for rheumatoid arthritis. A diagnosis of Granulomatosis with Polyangiitis was done. Thus, anti-TNF therapy may be associated with the development of ANCA positive vasculitis.

Subacute thyroiditis in a patient with juvenile idiopathic arthritis undergoing etanercept treatment: a case report and review of the literature

We report on a 24-year-old woman with juvenile idiopathic arthritis (JIA) who developed subacute thyroiditis (SAT) while being treated with etanercept. She had suffered from JIA for 12 years, and her arthritis proved refractory to treatment with ibuprofen, prednisolone, and methotrexate. For the past 5 years, the patient had been treated successfully with etanercept at 25 mg/week. The patient more recently complained of high fever and lassitude, and presented with anterior neck swelling and tenderness. Palpation of the thyroid gland revealed it to be warm, erythematous, tender, and diffusely swollen. Laboratory tests revealed an increased erythrocyte sedimentation rate and C-reactive protein level. Thyroid function tests revealed decreased levels of thyrotropin-stimulating hormone, increased levels of free triiodothyronine, free thyroxine, and thyroglobulin, and an absence of thyroid autoantibodies. Sonography showed a diffusely reduced predominantly hypoechoic thyroid gland. Unenhanced computed tomography of the neck showed a homogeneously and mildly reduced thyroid gland. Serum titers of several viruses were not significant and so were considered unlikely to be the pathogens. On the basis of these presented findings, we diagnosed SAT, and etanercept therapy was withdrawn. The patient was treated with antibiotics and an increased prednisolone dose was initiated. She became symptom free and showed improved laboratory test results within 2 weeks, and was euthyroid by 3 months. Three months later, the patient developed hypothyroidism, although 6 months further on, the patient was asymptomatic on prednisolone, methotrexate, and levothyroxine therapy. In conclusion, whether SAT is a specific adverse event in this case in response to etanercept remains unclear. Nevertheless, the possibility of SAT should be considered in such patients on etanercept treatment.

Autoimmune thyroid disease

PURPOSE OF REVIEW

Autoimmune thyroid disorders (AITDs) are the most common organ-specific autoimmune disorders. The genetics as well as clinical and laboratory manifestations of AITDs are reviewed.

RECENT FINDINGS

We discuss the association between specific rheumatologic disorders and AITDs and manifestations of AITDs that mimic rheumatologic disorders. The recently discovered common molecular pathways involved in these processes are discussed.

SUMMARY

AITDs and rheumatologic disorders have significant commonalities both clinically and etiologically. This information is important for rheumatologists and primary care physicians who care for patients with these disorders.

A20 suppresses inflammatory responses and bone destruction in human fibroblast-like synoviocytes and in mice with collagen-induced arthritis

OBJECTIVE

Nuclear factor-kappaB (NF-kappaB) has been implicated as a therapeutic target for the treatment of rheumatoid arthritis (RA). The purpose of this study was to determine whether A20, a universal inhibitor of NF-kappaB, might have antiarthritic effects.

METHODS

An adenovirus containing A20 complementary DNA (AdA20) was used to deliver A20 to human rheumatoid fibroblast-like synoviocytes (FLS) in vitro as well as to mice with collagen-induced arthritis (CIA) in vivo via intraarticular injection into the ankle joints bilaterally.

RESULTS

In vitro experiments demonstrated that AdA20 suppressed NF-kappaB activation, chemokine production, and matrix metalloproteinase secretion induced by tumor necrosis factor alpha in FLS. Mice with CIA that were treated with AdA20 had a lower cumulative disease incidence and severity of arthritis, based on hind paw thickness, radiologic and histopathologic findings, and inflammatory cytokine levels, than did control virus-injected mice. The protective effects of AdA20 were mediated by the inhibition of the NF-kappaB signaling pathway. The severity of arthritis was also significantly decreased in the untreated front paws, indicating a beneficial systemic effect of local suppression of NF-kappaB. Surprisingly, mice treated with AdA20 after the onset of CIA had significantly decreased arthritis severity from the onset of clinical signs to the end of the study.

CONCLUSION

These results suggest that using A20 to block the NF-kappaB pathway in rheumatoid joints reduces both the inflammatory response and the tissue destruction. The development of an immunoregulatory strategy based on A20 may therefore have therapeutic potential in the treatment of RA.