CHEST Guidelines-A-67-Year-Old-Man-With-Psoriatic-Arthritis-and-New

A-67-Year-Old-Man-With-Psoriatic-Arthritis-and-New

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A 67-year-old retired air force officer with a history of psoriatic arthritis presented with six months of nonproductive cough, progressive exertional dyspnea, and weight loss. He could only walk 100 meters, far less than his previous unlimited capability. Following a polyarthritis flare a year earlier, he had been treated with adalimumab and showed good response. The patient had a significant smoking history but no occupational or environmental exposure to known lung irritants. Examination showed respiratory symptoms, including widespread fine inspiratory crackles. Chest radiography indicated worsening from mild atelectasis to significant lung volume loss and reticulations.<br /><br />High-resolution CT scans showed bilateral changes in the lungs, suggesting interstitial lung disease (ILD). Blood tests revealed elevated autoantibodies, but tests for specific conditions like rheumatoid arthritis were negative. Bronchoalveolar lavage highlighted a predominance of lymphocytes, and lung biopsies showed an inflammatory process consistent with nonspecific interstitial pneumonia.<br /><br />The diagnosis was adalimumab-induced interstitial lung disease. Adalimumab is an anti-TNF biologic drug used for autoimmune diseases; however, it can rarely lead to adverse effects like ILD. This condition tends to manifest around 26 weeks after beginning treatment, often presenting with symptoms similar to those seen in this patient.<br /><br />Medical management involved discontinuation of adalimumab along with steroid and immunosuppressive treatment, resulting in symptomatic improvement. This case underlines the necessity of careful drug monitoring, especially with newer agents, and the importance of a multidisciplinary approach in diagnosis and management, given the complexities of distinguishing drug-induced ILD from other life-threatening conditions.

Keywords

adalimumab-induced interstitial lung disease

psoriatic arthritis

nonspecific interstitial pneumonia

anti-TNF biologic

exertional dyspnea

autoantibodies

bronchoalveolar lavage

steroid treatment

multidisciplinary approach

drug monitoring