title: New onset sarcoid-like granulomatosis developing during  anti-TNF therapy: an under-recognised complication.
abstract: Tumour necrosis factor-alpha (TNF-a) antagonists have advanced the treatment of inflammatory arthropathies, and are even considered for use in refractory sarcoidosis with some success. Paradoxically, cases of new onset sarcoidosis-like diseases are increasingly reported in patients receiving TNF-a antagonists. Here, we report three cases of sarcoid-like granulomatosis that developed during treatment with TNF-a antagonists. Review of the Biologics clinic data base at Westmead, Sydney, Australia identified three patients whom, during anti-TNF therapy, developed non-caseating granulomas consistent with sarcoidosis. These three cases are described with review of the literature from 2000 to 2009 using PubMed. One hundred and sixty-nine patients within our data base were reviewed for the period 2003–2009. Sarcoidosis-like granulomas developed in three patients within a period of 3 to 36 months of treatment with etanercept and/or adalimumab. All cases demonstrated non-infective, non-caseating granulomas on renal or lymph node biopsy. Improvement was seen in two cases upon cessation of TNF-a antagonist and steroid therapy. Interestingly, clinical deterioration was noted upon re-challenge with the same TNF-a antagonist in one patient. To date, a total of 37 cases of sarcoid-like granuloma development after anti-TNF therapy have been reported in the literature. Development of sarcoidosis-like granulomatosis in patients treated with TNF-a antagonists is a phenomenon previously under-recognised. All three anti-TNF agents have been observed to cause this phenomenon, suggesting a ‘class effect’ rather than being drug specific.
authors.affiliation: Department of Rheumatology, Westmead Hospital, Sydney, New South Wales, Australia. dwytong@yahoo.com.au
authors.forename: D
authors.initials: D
authors.lastname: Tong
authors.forename: N
authors.initials: N
authors.lastname: Manolios
authors.forename: G
authors.initials: G
authors.lastname: Howe
authors.forename: D
authors.initials: D
authors.lastname: Spencer
mesh_terms: D000068879:Adalimumab; D000328:Adult; D061067:Antibodies, Monoclonal, Humanized / Q000009:adverse effects*; D018501:Antirheumatic Agents / Q000009:adverse effects*; D015535:Arthritis, Psoriatic / Q000150:complications / Q000188:drug therapy; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000188:drug therapy; D001315:Australia / Q000453:epidemiology; D000068800:Etanercept; D005260:Female; D006099:Granuloma / Q000139:chemically induced* / Q000473:pathology; D006801:Humans; D007074:Immunoglobulin G / Q000009:adverse effects*; D007668:Kidney / Q000473:pathology; D008198:Lymph Nodes / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009395:Nephritis, Interstitial / Q000139:chemically induced* / Q000473:pathology; D018124:Receptors, Tumor Necrosis Factor; D012008:Recurrence; D012507:Sarcoidosis / Q000139:chemically induced* / Q000473:pathology; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D044465:White People
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D007074:Immunoglobulin G; D018124:Receptors, Tumor Necrosis Factor; D014409:Tumor Necrosis Factor-alpha; D000068879:Adalimumab; D000068800:Etanercept