2009 Southern Regional Meeting Abstracts

Case Report: We report a 34-year old female with a history of ulcerative colitis and primary sclerosing cholangitis who became anti-nuclear antibody (ANA) positive and developed lupus nephritis (LN) after receiving infliximab, a TNF-α inhibitor. The purpose of this report is to describe her presentation and present a review of the literature on TNF-α inhibitor-induced lupus nephritis.

A literature search was conducted and these cases were compared and contrasted to our patients.

Early 2008, the patient was found to be ANA negative during evaluation for a liver transplant. She subsequently received two infusions of infliximab for active ulcerative colitis. Three months following her last infusion, she presented to the ER with weakness and fever secondary to pneumonia and sepsis. She was found to have 1.4 g protein/day of proteinuria and active urinary sediment. Lab tests revealed positive serologies for ANA, dsDNA and histone ab and low complements. Kidney biopsy revealed class III LN and acute tubular necrosis.
In the 7 case studies previously reported, all but one patient had their TNF-α inhibitor discontinued and they were subsequently treated with alternative immunosuppressants. The one patient that was continued on the TNF-α inhibitor eventually developed severe pulmonary disease and died. One patient required short-term hemodialysis. The remainder of the patients had resolution of their symptoms after the TNF-α agent was discontinued and treatment with the alternative immunosuppressive agent began. After our patient was diagnosed with drug-induced LN, she received solumedrol 1g for 3 days followed by oral medrol 48mg with clinical improvement of her symptoms. She was discharged home on prednisone 40mg and scheduled to follow up in the Rheumatology clinic.

Literature teaches us that drug-induced lupus does not involve the kidneys. Our case adds to the 7 published cases of TNF-α induced LN. In 6 of the 7 published cases, resolution of symptoms occurred after the TNF-α agent was discontinued. It was 4 months after our patient’s last infliximab infusion when she was found to have LN. Continued follow-up is needed to confirm the clinical improvement of her lupus-like syndrome.