Dados do Trabalho

Title

Arterial thrombosis in Ankylosing Spondylitis and the use of Anti-TNF: cause or consequence?

Background

The use of Anti-TNF in inflammatory rheumatic diseases, especially in Rheumatoid Arthritis and Ankylosing Spondylitis, has shown sedimented clinical efficacy. The most common adverse effects described above them include anaphylactic reactions, tuberculosis's reactivation, infections. Thromboembolic conditions related to anti-TNF therapy are rarely described in the literature and are related to venous occlusion more than the arterial disease. We report a case involving an arterial thrombosis in the subclavian artery in a patient with ankylosing spondylitis in the use of Infliximab.

Case report

A 45-year-old female patient, diagnosed ankylosing spondylitis for ten years ago. Since 9 years in treatment, initially Methotrexate for two years, and after, has been changed for Infliximab, loading dose and maintenance dose every 8 weeks. The patient progressed with adequate control of articular clinical. After an extended period using the immunobiological, about six years, the patient presented a sudden pain, intense (Visual Analog Scale: 9), in weight, in the left upper limb. In one month, there was a worsening of the clinical picture, with the progression of pain, and reduction of strength in the arm, worst after repetitive activities, with pallor and coldness in that arm. The patient was admitted for investigation and didn't report any comorbidity or other medications related to thromboembolism risk. The physical examination evidenced absent arterial pulse at brachial and radial arteries. A Doppler ultrasonography showed arterial occlusion of the subclavian-axillary-brachial segment, with the presence of distal collateral circulation. A angiotomography showed arterial narrowing with irregularities in the left subclavian and brachial arteries, with stenosis greater than 70%. Arteriography was performed and evidenced thrombi in the distal region of the subclavian artery with the chronical and recanalization aspect.

Conclusion

Thrombotic phenomena in autoimmune diseases are always a diagnostic challenge, by the various associated possibilities like Antiphospholipid Syndrome and vasculitis. The use of Anti-TNF, having a strong association with these events, must be a possibility to be excluded in these patients.