Demyelinating Disease following Anti-TNFa Treatment: A Causal or Coincidental Association? Report of Four Cases and Review of the Literature

Table 1

Demographical, clinical and imaging data of the four cases.

Cases	1	2	3	4
Gender	Male	Male	Female	Female
Type of rheumatic disease	PA	AS	PA	AS
Duration of anti-TNFa treatment	8 months	3 years	4 years	6 years
Family history	PA (mother), Ps (aunts)	MS (father), Ps (sister)	—	—
Anti-TNFa	Etanercept	Adalimumab	Etanercept	Etanercept
Age at onset of symptoms	17 years	30 years	46 years	57 years
Symptoms	Dysesthesias of left lower limb, T4 level	Right unilateral tinnitus, urinary urgency	Left parietotemporal headache, paresthesias of the left side of the face and head, urinary urgency, diminished libido	Peripheral paresis of right facial nerve, dysarthria, mild surface dysgraphia.
CNS MRI	Hyperintensities (1 Gd+ lesion at C3 level)	Hyperintensities (>5 lesions showed Gd+)	Hyperintensities (no Gd+ lesions)	Hyperintensities (1 Gd+ lesion at left parietal lobe and 1 at C4-C5 level)
OB	Yes	Yes	Yes	Yes
Evolution	MS	MS	Monophasic demyelinating event	MS

PA: psoriatic arthritis, AS: ankylosing spondylitis, Ps: psoriasis, anti-TNFa: tumor necrosis factor alpha antagonist, MRI: magnetic resonance imaging; OB: oligoclonal bands, MS: multiple sclerosis, and Gd+: gadolinium enhancement.