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Bogdos et al. Neuroimmunol Neuroinflammation 2018;5:19 Neuroimmunology and
DOI: 10.20517/2347-8659.2018.07 Neuroinflammation

Case Report Open Access

Demyelinating central nervous system lesions,
following the use of tumor necrosis factor alpha
antagonist

Emmanuel Bogdos , Sofia Markoula , Anastasia Zikou , Paraskevi Voulgari , Aleksandros Drosos ,
2
1
1
3
3
Spyridon Konitsiotis 1
1 Department of Neurology, Univeristy Hospital of Ioannnina, Ioannina 45500, Greece.
2 Department of Radiology, Univeristy Hospital of Ioannnina, Ioannina 45500, Greece.
3 Department of Rheumatology, Univeristy Hospital of Ioannnina, Ioannina 45500, Greece.
Correspondence to: Dr. Emmanuel Bogdos, Department of Neurology, Univeristy Hospital of Ioannnina, Ioannina 45500, Greece.
E-mail: manosbogdos@gmail.com

How to cite this article: Bogdos E, Markoula S, Zikou A, Voulgari P, Drosos A, Konitsiotis S. Demyelinating central nervous system
lesions, following the use of tumor necrosis factor alpha antagonist. Neuroimmunol Neuroinflammation 2018;5:19.
http://dx.doi.org/10.20517/2347-8659.2018.07

Received: 26 Feb 2018 First Decision: 7 Mar 2018 Revised: 26 Mar 2018 Accepted: 26 Mar 2018 Published: 22 May 2018

Science Editor: Athanassios P. Kyritsis Copy Editor: Jun-Yao Li Production Editor: Huan-Liang Wu

ABSTRACT
Tumor necrosis factor alpha (TNFα) antagonists have been a valuable tool in treating patients with rheumatoid
arthritis (RA), but reports and case series of neurological adverse events due to TNFα antagonists have been
reported. Furthermore, central nervous system (CNS) lymphoma always remains a remote, yet a worrisome
complication in RA patients, especially in those under treatment with methotrexate (MTX). We present a female
patient with RA with tumor-like active demyelinating lesions attributed to TNFα antagonist, confirmed by an FNA
biopsy, otherwise clinically and radiologically challenging to distinguish from CNS lymphoma. A 72-year-old female
patient with RA under TNFα antagonist and MTX treatment was presented with neurological symptoms and signs.
The brain MRI revealed four tumor-like contrast-enhancing lesions bilaterally, the demyelinating nature of which
was delineated by the FNA biopsy. A full clinical and radiological recovery was achieved after the TNFα antagonist
was permanently withdrawn. Patients with RA under anti-TNF agents and MTX are predisposed to complications
such as CNS lymphoma and CNS demyelination. This case uniquely highlights the physicians’ vigilance in pursuing
these complications and the usage of the FNA when tumor-like appearances on the brain MRI convolute the final
diagnosis.

Keywords: Anti-tumor necrosis factor complications, demyelination, rheumatoid arthritis

© The Author(s) 2018. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made.

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