Antineutrophil Cytoplasmic Antibody Associated Vasculitis In A Patient Treated With Adalimumab For A Rheumatoid Arthritis

Tumor necrosis factor alpha (TNF alpha) plays a central role in the pathogenesis of inflammatory diseases, especially in rheumatoid arthritis, accounting for the increased use of antitumor necrosis factor alpha (anti-TNF alpha) in these disorders. However, these drugs are not devoid of side effects and an increasing number of auto-immune diseases are currently reported. We report an extracapillary and necrotizing glomerulonephritis associated with positive anti-neutrophil cytoplasmic antimyeloperoxydase antibodies in a 58-year-old woman with a long-standing rheumatoid arthritis treated with adalimumab since four years. Despite the instauration of corticotherapy, cyclophosphamide, plasma exchanges and dialysis, she did not recover her impaired renal function. The link between the vasculitis and adalimumab is not proven, but is highly probable. Vasculitis are more and more reported with anti-TNF alpha therapy but severe renal disease remains exceptional. Pathogenesis probably involves modified immune response with production of autoantibodies. Though anti-TNFa treatment is unquestionably indicated in rheumatoid arthritis, we should be aware about the possible link between this treatment and induced vasculitis. Moreover, the use of anti-TNF alpha treatment to manage vasculitis needs to be assessed. (C) 2009 Published by Elsevier Masson SAS on behalf of the Association Societe de nephrologie.