Multiple Sclerosis Onset during Etanercept Treatment

Case Report A 36-year-old woman with psoriatic arthritis who had received etanercept for 4 months (25 mg s.c. twice weekly) presented with a 1-week history of right eye pain and vision decline. Three weeks previously, she had developed the same symptoms in the left eye that resolved spontaneously. There was no family history of neurological disorders. Two years previously, she received (partially effective) treatment for her articular problem with methotrexate and prednisone for 12 months. A physical examination revealed deformation in both wrists, nail pitting, generalized hyperreflexia, temporary ankle clonus, a paracentral scotoma in her right visual field and left internuclear ophthalmoplegia. Visual acuities were 1 / 3 and 1 / 2 in the right and left eye respectively; funduscopy was normal. The full blood count, erythrocyte sedimentation rate, Creactive protein, and kidney, liver, bone and thyroid function, vitamin B-12, folate levels, antibody screen (antinuclear, antidouble-stranded DNA, antineutrophilic cytoplasmic, antiextractable nuclear antigen, antigliadin, antiphospholipid and antithyroid antibodies) and protein electrophoresis were all within normal limits or negative. No oligoclonal bands were observed in serum. Brucella, Borrelia, human immunodeficiency virus and syphilis serologies were negative. A chest X-ray Dear Sir, Tumor necrosis factor (TNF) is a cytokine of known proinflammatory properties produced by cells of the monocyte-macrophage lineage and lymphocytes in certain infectious or immunological contexts [1] . There is a substantial body of evidence supporting its role as inflammatory mediator in autoimmune diseases. At present, TNFinhibitors constitute an effective treatment against many of these pathologies including psoriasis [2] . In multiple sclerosis (MS) patients, TNFlevels increase in serum and in cerebrospinal fluid to an extent that depends on the phase of activity of the disease [3] . TNFproduction is higher before exacerbations [4] . Furthermore, a higher number of cells express TNFmRNA in active acute and chronic demyelinating lesions than in inactive or remyelinating lesions [5] . Although TNF antagonists have shown promising results in experimental allergic encephalomyelitis [6, 7] , clinical trials with MS patients had to be suspended because of the increased number and severity of relapses [8, 9] . Some cases of demyelinating events have also been noticed in relation to their use [10– 18] . In this article, we describe a patient who presented the first attack of MS during a course of etanercept treatment (a fusion protein composed of the soluble membrane of TNFp75 and the constant fraction of IgG1) for psoriatic arthritis. Received: January 23, 2006 Accepted: April 11, 2007 Published online: October 11, 2007