Dados do Trabalho

Title

SPONDYLOARTHRITIS EVOLVING WITH GRANULOMATOSIS WITH POLYANGIITIS AFTER ANTI-TNF SUSPENSION

Background

Anti-TNFs represented a revolution in the treatment of rheumatological diseases, presenting levels of control of disease activity never before obtained. However, with current knowledge we still have not mastered the best way to managed medication suspension, as well its consequences.
Spondyloarthritis are among the diseases with a good response to Anti-TNF treatment. And with this case report, we illustrate an unexpected evolution of a patient whose anti-TNF treatment were suspended, after a very good control of the disease.

Case report

A 42-year-old male patient were diagnosed with ankylosing spondylitis, due to the following criteria: inflammatory low back pain, good anti-inflammatory response, and bilateral grade IV sacroiliitis. Infliximab was started to control the disease after previous treatment failure. He used the medication over 10 years, and as the disease control was obtained, the applications were spaced until the suspension.
One year after the last intake, the patient returns in an outpatient clinic, reporting that he had hospital admission in the last month due to paresthesia and motor deficit in lower limbs, with the appearance of hemorrhagic suffusions, in addition to dyspnea. In the initial investigation, pulmonary cavitations were evidenced. In this way, the first hypotesis were community-acquired pneumonia, after exclusion of tuberculosis and antibiotic treatment was initiated. The cultures were negative, and there was improvement only of the dyspnea and maintaining the paresthesia. In this way, they amplify the investigation excluding vascular complications, and finding a C-anca positive in the title of 1:80. Corticosteroid was increased and sent to our outpatient clinic.
With this data, a new chest CT scan was requested for comparison, without alterations in relation to the previous one, electroneuromiography that evidenced multiple mononeuritis, new Anca dosage demonstrating titration increase to 1:120. So, patient was diagnosed with granulomatose with polyangiitis, initiated with methylprednisolone pulse therapy, followed by cyclophosphamide for 6 months according to the SBR protocol. Patient evolved with complete lung and neurological resolution.

Conclusion

We report this case of a patient with a diagnosis of spondyloarthritis who had been treated with biological medication and who after its suspension evolved with a totally new autoimmunity. We report this case due to rarity and unexpected evolution and also in the intention to discussing the hypothesis of this evolution to be associated to the previous use of immunobiological.