Adalimumab-induced Anti-neutrophilic Cytoplasmic Antibody Vasculitis: A Rare Complication of an Increasingly Common Treatment

Tumor necrosis factor (TNF) inhibitors are used for treatment of different autoimmune diseases. Interestingly they are also being noted to cause autoimmune side effects such as vasculitis, systemic lupus erythematosus, interstitial lung disease, etc. We describe one such case of granuloma annulare being treated with Adalimumab, who then developed pulmonary-renal syndrome form anti-neutrophilic cytoplasmic antibody (ANCA)-induced vasculitis. This was treated with steroids and immunosuppression, as well as discontinuation of the TNF inhibitor. However, he remains dependant on dialysis and immunosuppression. In this article, we review the existing literature on clinical presentation and course of TNF inhibitors-induced ANCA vasculitis. We also discuss the underlying mechanisms thought to be responsible for this.


Introduction
Tumor necrosis factor (TNF) inhibitors are utilized for the treatment of a variety of autoimmune diseases, but have also been associated with the paradoxical emergence of autoimmune phenomena, including cutaneous vasculitis. There have also been several reported cases of systemic vasculitis following treatment with Adalimumab without mention of specific patient details or circumstances [1]. Anti-neutrophilic cytoplasmic antibody (ANCA) vasculitis has been rarely described.

Case Presentation
We present the case of a 57-year-old male with past medical history significant for coronary artery disease, hypertension and granuloma annulare (GA) who was admitted with rapid decline in renal function and shortness of breath. GA was being treated with adalimumab for the last two years. Eight months prior to admission, he was noted to have an asymptomatic elevation in his blood urea nitrogen and creatinine ( Table 1) which worsened five months later. Renal ultrasound was performed which showed bilateral echogenic kidneys. He was lost to follow up and represented to his primary care provider three months later with a one-week history of epistaxis, hemoptysis, anorexia and weight loss. He was asked to report to the emergency room.

During hospitalization
Three months prior Eight months prior Blood urea nitrogen (7-  CT chest showed bilateral pulmonary consolidation and ground glass opacities (Figures 1,  2). Renal biopsy performed revealed pauci-immune, rapidly progressive glomerulonephritis with some fibrosis (Figure 3). ANCA with perinuclear staining and myeloperoxidase antibody were positive. He was started on hemodialysis immediately. He also received intravenous methylprednisolone 500 mg daily for three days followed by oral prednisone 60 mg daily, oral cyclophosphamide 125 mg daily (which was eventually transitioned to intravenous monthly pulses of cyclophosphamide) and trimethoprim-sulfamethoxazole for pneumocystis prophylaxis. Adalimumab was discontinued.

glomerulonephritis
Two months after his hospitalization, pulmonary infiltrates have resolved, but there has been no recovery of renal function.

Discussion
To our knowledge, there have only been nine previously reported cases of vasculitis and positive ANCA that were thought to be induced by TNF inhibitors [2][3][4][5][6][7][8][9]. See Table 2 for clinical presentation and treatment of each patient. One patient had atypical ANCA and lupus nephritis (Patient 8) and one patient had aortitis (Patient 9) which are not consistent with true ANCA-associated vasculitis. Of the remaining seven patients, four patients were females and six were being treated for rheumatoid arthritis. The mean age for patients was 51.4 years. Time of onset of symptoms after starting a TNF inhibitor varied from three months to four years. Four of these patients had positive c-ANCA, three had a positive p-ANCA. Six of seven patients had renal biopsies showing pauci-immune glomerulonephritis. Six patients were treated with intravenous methylprednisolone followed by oral prednisone. The TNF inhibitor was discontinued in all cases except patient 7. The most commonly used immunosuppressant was cyclophosphamide in six of seven patients. Four patients had persistent renal dysfunction and one patient died within nine months of presentation. Given the temporal sequence of events, a causal relationship might be present. One proposed mechanism is that anti-TNF drugs form immune complexes, activate complement and promote switching from a T-helper type 1 response (mediated by interleukin (IL)-1, TNF and interferon (IFN)-Y) to a T-helper type 2 response (IL-4, IL-5, IL-6, IL-10 and IL-13) leading to the production of autoantibodies [10].

Conclusions
TNF-induced ANCA vasculitis is exceedingly rare. These cases in conjunction with ours suggest a possible relationship between anti-TNF use and induction of ANCA vasculitis. To the best of our knowledge, our case is the 4th to describe TNF-induced pulmonary renal syndrome as a manifestation of ANCA-vasculitis. It is difficult to conclusively prove that it is not just a spontaneous emergence of ANCA in a patient predisposed to autoimmunity. However, the biological plausibility of shifting towards a T-helper 2 type response in a susceptible individual leading to the emergence of these antibodies among others, remains. Additionally, this subset of patients appears to have a predilection for rapidly progressive kidney injury with long-term impairment despite discontinuation of the anti-TNF agent. This highlights the need for further studies looking into recognizing risk factors for the development of this rare but significant complication.

Additional Information Disclosures
Human subjects: Consent was obtained by all participants in this study.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.