A Rare Side Effect due to TNF-Alpha Blocking Agent: Acute Pleuropericarditis with Adalimumab

Tumor necrosis factor-alpha antagonism is an important treatment strategy in patients with rheumatoid arthritis, psoriatic arthritis, vasculitis, and ankylosing spondylitis. Adalimumab is one of the well-known tumor necrosis factor-alpha blocking agents. There are several side effects reported in patients with adalimumab therapy. Cardiac side effects of adalimumab are rare. Only a few cardiac side effects were reported. A 61-year-old man treated with adalimumab for the last 6 months due to psoriatic arthritis presented with typically acute pleuropericarditis. Chest X-ray and echocardiography demonstrated marked pericardial effusion. Patient was successfully evaluated for the etiology of acute pleuro-pericarditis. Every etiology was excluded except the usage of adalimumab. Adalimumab was discontinued, and patient was treated with 1200？mg of ibuprofen daily. Control chest X-ray and echocardiography after three weeks demonstrated complete resolution of both pleural and pericardial effusions. This case clearly demonstrated the acute onset of pericarditis with adalimumab usage. Acute pericarditis and pericardial effusion should be kept in mind in patients with adalimumab treatment. 1. Introduction Tumor necrosis factor-alpha (TNF ) antagonism is an important treatment strategy in patients with rheumatoid arthritis, psoriatic arthritis, vasculitis, and ankylosing spondylitis [1, 2]. Infliximab, etanercept, and adalimumab are indicated in immune-mediated inflammatory diseases. Several side effects including congestive heart failure, skin disorders, tuberculosis, and malignancy could be seen during the treatment [3]. 2. Case A 61-year-old man treated with adalimumab for the last 6 months due to psoriatic arthritis presented with sudden onset of chest pain, shortness of breath, palpitation, cough, and signs of right heart failure. Physical examination revealed bilaterally bibasilar fine crackles with ortopnea and tachypnea. Heart sounds were markedly decreased with pericardial frotman. Chest X-ray showed significant cardiomegaly and bilateral pleural effusion (Figure 1). The patient underwent to transthoracic echocardiography. Echocardiographic examination showed moderate to large pericardial effusion without cardiac tamponade (Figures 2 and 3). Etiology causing acute pleuropericarditis was carefully evaluated. Figure 1: Chest X-ray demonstrating cardiomegaly with pericardial effusion. Figure 2: Parasternal long axis view with transthoracic echocardiography demonstrating pericardial effusion (PE: pericardial effusion, RV: right ventricle, LV: left ventricle, and