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Diagnosis and Management
Although the pathogenic mechanism of anti-TNF-induced demyelinating diseases
is not yet clearly delineated, all patients should be counseled on this rare potential
complication of anti-TNF agents prior to initiation of therapy. Given the variability
of onset of these symptoms, patients who are on anti-TNF therapy should be moni-
tored regularly. If demyelinating disease is suspected during treatment with an anti-
TNF, the offending agent should be discontinued immediately [ 82 ].
A thorough history, physical exam, and neurological exam including a fundus
examination for papilledema and optic neuritis, together with a neurology consulta-
tion, are warranted for evaluation of patients with suspected demyelinating disease
[ 82 ]. These patients should also get an MRI of the brain with and without gadolin-
ium; a lumbar puncture to assess for oligoclonal bands and IgG level should be
considered in patients with equivocal MRI findings [ 82 ]. Multiple periventricular
white matter lesions on brain MRI (see Fig. 14.5), elevated IgG level, and positive
oligoclonal bands in CSF are characteristics of MS [ 86 ]. Nevertheless, other causes
of neurological symptoms including Lyme disease, HIV, syphilis, and West Nile
virus should be ruled out [ 83 ]. As demonstrated in the prospective study by
Kaltsonoudis et al., prescreening with brain MRI does not prevent onset of demye-
linating disease during anti-TNF therapy [ 88 ].
Therapies used in MS including glucocorticoids, IFN-beta, or intravenous immu-
noglobulin should be considered in anti-TNF therapy-associated demyelinating dis-
Fig. 14.5 Multifocal T2
hyperintensity in
periventricular and deep
white matter of both
cerebral hemispheres seen
on MRI consistent with
multiple sclerosis. Photo
courtesy of Fauzia
Vandermeer, MD
U. Wong and R.K. Cross