Calcific Constrictive Pericarditis following TNF-Alpha inhibition

Abstract Background Tumor necrosis factor (TNF) alpha inhibition is a core therapeutic avenue for a broad range of inflammatory and autoimmune disorders including Rheumatoid Arthritis and inflammatory bowel disease, as well as dermatological conditions such as Hidradenitis Suppurativa. Adalimumab has become one of the most common TNF alpha inhibiting agents used for many of these conditions. Treatment with Adalimumab and similar agents is associated with numerous systemic side effects, though cardiac complications remain relatively rare. These include reports of pericarditis and pericardial effusions(1) (2) (3). Case Summary A 63-year-old lady was referred to the outpatient respiratory clinic with a one-year history of increasing breathlessness, on a background of four years of treatment with Adalimumab for stage III Hidradenitis Suppurativa. A high-resolution CT thorax revealed evidence of pericardial calcification. Subsequent left and right heart catheterisation study revealed equalisation of intraventricular pressures, consistent with constrictive pericarditis. A QuantiFERON test was negative and rheumatological serology unremarkable. The patient was initially managed conservatively with close follow up, before undergoing surgical pericardectomy when she developed signs of cardiac failure. Discussion Adalimumab is associated with a range of systemic side effects, though cardiac complications are relatively rare. This case highlights a potentially novel complication associated with prolonged Adalimumab therapy. Given that there are reports in the literature of pericarditis and pericardial effusions associated with Adalimumab and similar agents(1), it is reasonable to hypothesize that the calcific constrictive pericarditis seen in this case may demonstrate a novel cardiac phenomenon associated with this therapy, given the lack of any traditional aetiological factors.