ATS 2021 will feature presentations of original research from accepted abstracts. Mini Symposia and Thematic Poster Sessions are abstract based sessions.
Please use the form below to browse scientific abstracts and case reports accepted for ATS 2021. Abstracts presented at the ATS 2021 will be published in the Online Abstract Issue of the American Journal of Respiratory and Critical Care Medicine, Volume 203, May 3, 2021.
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Adalimumab Induced Eosinophilic Interstitial Pneumonia
Session Title
TP36 - TP036 WHAT DRUG CAUSED THAT? CASE REPORTS IN DRUG-INDUCED LUNG DISEASE
Abstract
A2127 - Adalimumab Induced Eosinophilic Interstitial Pneumonia
Author Block: F. A. Nitol1, S. Chauhan2, L. Ramdhanie3, M. Babury4, D. Shalonov5; 1Internal Medicine, Jamaica Hospital Medical Center, Richmond Hill, NY, United States, 2Pulmonary, Jamaica Hospital Medical Center, Richmond Hills, NY, United States, 3Pulmonary, Jamaica Hospital : Graduate Medical Education, Richmond Hill, NY, United States, 4Pulmonary, Jamaica Hospital Medical Center, Jamaica, NY, United States, 5Stony Brook University, Stony Brook, NY, United States.
Introduction: As the use of immunobiological agents such as tumor necrosis factor inhibitors (TNFi) in the treatment of inflammatory and autoimmune diseases rise, we consider potential drug-induced complications such as lung toxicity. Here we present a case of adalimumab induced eosinophilic pulmonary interstitial pneumonia in an elderly woman, taking Adalimumab (ADA) for rheumatoid arthritis (RA).
Case report: A 77-year-old female with RA on methotrexate (MTX), ADA was presented to the hospital with chronic cough, dyspnea, significant weight loss worsening over 10 months. She reported taking ADA from August 2019 and MTX since 2013. Pulmonary function test was normal. After initiating ADA she was developed eosinophilia with normal Chest X-ray (CXR). On admission, her temperature was 100.6, saturating 96% in room air. Labs showed eosinophilia (15.5) with absolute eosinophil count (21) with elevated inflammatory markers. CXR showed bilateral patchy opacity. CT chest showed extensive peripheral and basilar reticular opacities with honeycombing at the lung bases. She was started on antibiotics and high dose steroids. MTX and ADA were hold due to suspicion of lung injury. She underwent bronchoscopy with BAL revealing pulmonary macrophages, eosinophilia of 15% and monocyte of 49%. Pneumocystis Jiroveci, tuberculosis and bacterial infections were ruled out. She responded to the steroid satisfactorily and discharged with tapered dose and drug holiday of ADA, MTX.
Discussion: TNFi's are used as a targeted strategy in inflammatory conditions such as RA, systemic lupus erythematosus and inflammatory bowel disease leading to various pulmonary complications. A review of 196 cases reported for drug-induced eosinophilic pneumonia found daptomycin to be the most notorious. As the newest member of this group, ADA has the fewest reported cases (prevalence rate is 0.5-3% in RA patients). It has been postulated that eosinophilia occurs due to exaggerated Th2 response to TNFi inducing releases of toxic granule protein causing local inflammation. This is diagnosed by presence of lung infiltrate in CXR, peripheral eosinophilia, parenchymal infiltration by eosinophil. Temporal association between exposure to TNFi, onset of respiratory symptoms and improvement following discontinuation strengthens the diagnosis. Ruling out other causes specifically infectious disease and pre-existing lung disease is crucial. The suggested treatment is withdrawing offending drugs and, in some cases, use of steroids.
References: Bartal et al., Drug-induced eosinophilic pneumonia, Medicine: January 2018 - Volume 97 - Issue 4 - p e9688 DOI: 10.1097/MD.0000000000009688K.
Thavarajah et al., Pulmonary complications of tumor necrosis factor-targeted therapy Respir. Med., 103 (5) (2009), pp. 661-669
Author Block: F. A. Nitol1, S. Chauhan2, L. Ramdhanie3, M. Babury4, D. Shalonov5; 1Internal Medicine, Jamaica Hospital Medical Center, Richmond Hill, NY, United States, 2Pulmonary, Jamaica Hospital Medical Center, Richmond Hills, NY, United States, 3Pulmonary, Jamaica Hospital : Graduate Medical Education, Richmond Hill, NY, United States, 4Pulmonary, Jamaica Hospital Medical Center, Jamaica, NY, United States, 5Stony Brook University, Stony Brook, NY, United States.
Introduction: As the use of immunobiological agents such as tumor necrosis factor inhibitors (TNFi) in the treatment of inflammatory and autoimmune diseases rise, we consider potential drug-induced complications such as lung toxicity. Here we present a case of adalimumab induced eosinophilic pulmonary interstitial pneumonia in an elderly woman, taking Adalimumab (ADA) for rheumatoid arthritis (RA).
Case report: A 77-year-old female with RA on methotrexate (MTX), ADA was presented to the hospital with chronic cough, dyspnea, significant weight loss worsening over 10 months. She reported taking ADA from August 2019 and MTX since 2013. Pulmonary function test was normal. After initiating ADA she was developed eosinophilia with normal Chest X-ray (CXR). On admission, her temperature was 100.6, saturating 96% in room air. Labs showed eosinophilia (15.5) with absolute eosinophil count (21) with elevated inflammatory markers. CXR showed bilateral patchy opacity. CT chest showed extensive peripheral and basilar reticular opacities with honeycombing at the lung bases. She was started on antibiotics and high dose steroids. MTX and ADA were hold due to suspicion of lung injury. She underwent bronchoscopy with BAL revealing pulmonary macrophages, eosinophilia of 15% and monocyte of 49%. Pneumocystis Jiroveci, tuberculosis and bacterial infections were ruled out. She responded to the steroid satisfactorily and discharged with tapered dose and drug holiday of ADA, MTX.
Discussion: TNFi's are used as a targeted strategy in inflammatory conditions such as RA, systemic lupus erythematosus and inflammatory bowel disease leading to various pulmonary complications. A review of 196 cases reported for drug-induced eosinophilic pneumonia found daptomycin to be the most notorious. As the newest member of this group, ADA has the fewest reported cases (prevalence rate is 0.5-3% in RA patients). It has been postulated that eosinophilia occurs due to exaggerated Th2 response to TNFi inducing releases of toxic granule protein causing local inflammation. This is diagnosed by presence of lung infiltrate in CXR, peripheral eosinophilia, parenchymal infiltration by eosinophil. Temporal association between exposure to TNFi, onset of respiratory symptoms and improvement following discontinuation strengthens the diagnosis. Ruling out other causes specifically infectious disease and pre-existing lung disease is crucial. The suggested treatment is withdrawing offending drugs and, in some cases, use of steroids.
References: Bartal et al., Drug-induced eosinophilic pneumonia, Medicine: January 2018 - Volume 97 - Issue 4 - p e9688 DOI: 10.1097/MD.0000000000009688K.
Thavarajah et al., Pulmonary complications of tumor necrosis factor-targeted therapy Respir. Med., 103 (5) (2009), pp. 661-669
