Examkin

Question

Difficulty: HardRheumatology and Immunology

A 62-year-old man presents to the emergency department with a 5-day history of progressively worsening shortness of breath, orthopnea, and lower extremity swelling. He has a 30-pack-year smoking history but quit 5 years ago. He also has a 10-year history of erosive rheumatoid arthritis. His joint symptoms were poorly controlled with methotrexate alone, so etanercept was added 4 months ago, resulting in significant improvement in his joint pain. His other medical conditions include mild depression, for which he takes fluoxetine. Temperature is 37.1∘C37.1^\circ\text{C} (98.8∘F98.8^\circ\text{F}), blood pressure is 154/92 mm Hg154/92 \text{ mm Hg}, pulse is 108 min−1108 \text{ min}^{-1}, and respirations are 24 min−124 \text{ min}^{-1}. Pulse oximetry on room air shows an oxygen saturation of 91%91\%. Physical examination reveals jugular venous distention. Lung auscultation demonstrates bilateral bibasilar crackles and scattered expiratory wheezes. Cardiac examination reveals tachycardia with a prominent S3 gallop. There is 2+2+ bilateral pitting edema of the lower extremities. Joint examination shows no active synovitis. Laboratory studies show:

Brain natriuretic peptide: 850 pg/mL850 \text{ pg/mL}

Arterial blood gas on room air:
pH:7.49\text{pH}: 7.49
PaCO2:28 mm Hg\text{PaCO}_2: 28 \text{ mm Hg}
PaO2:64 mm Hg\text{PaO}_2: 64 \text{ mm Hg}
HCO3−:21 mEq/L\text{HCO}_3^-: 21 \text{ mEq/L}

Chest radiography reveals cardiomegaly, bilateral alveolar infiltrates, and small bilateral pleural effusions.

Which of the following is the most appropriate next step in the management of this patient?

  1. Discontinue etanercept and administer intravenous furosemideAnswer
  2. B
    Administer systemic corticosteroids and nebulized albuterol
  3. C
    Obtain blood cultures, continue current medications, and initiate intravenous vancomycin and piperacillin-tazobactam
  4. D
    Administer intravenous sodium bicarbonate and prepare for endotracheal intubation
  5. E
    Discontinue fluoxetine and administer cyproheptadine

Answer

The most appropriate next step is to discontinue etanercept and administer intravenous furosemide.
This patient with rheumatoid arthritis presents with acute decompensated heart failure, characterized by orthopnea, elevated brain natriuretic peptide, an S3 gallop, jugular venous distention, and pulmonary edema on chest radiography. His heart failure was likely induced by etanercept, a tumor necrosis factor (TNF)-alpha inhibitor. TNF-alpha inhibitors are highly effective disease-modifying antirheumatic drugs (DMARDs) but carry a significant risk of causing new-onset heart failure or exacerbating pre-existing cardiac dysfunction. They are absolutely contraindicated in patients with moderate to severe heart failure. The most appropriate next step in management is to immediately discontinue the offending agent and treat the volume overload with intravenous loop diuretics such as furosemide.

Step-by-Step Solution

1
Analyze the clinical presentation and physical examination findings.
The patient has orthopnea, jugular venous distention, an S3 gallop, and bilateral crackles with wheezing (cardiac asthma).
To differentiate between cardiac, pulmonary, and systemic causes of acute dyspnea.
2
Interpret the diagnostic studies.
Elevated BNP, primary respiratory alkalosis on ABG, and cardiomegaly with pulmonary edema on chest x-ray confirm acute decompensated heart failure.
To confirm the clinical diagnosis and rule out primary pulmonary pathology like a COPD exacerbation or infectious pneumonia.
3
Review the patient's pharmacotherapy history for potential triggers.
The patient was started on etanercept, a tumor necrosis factor (TNF)-alpha inhibitor, 4 months ago.
TNF-alpha inhibitors are a well-documented cause of new-onset heart failure or exacerbation of underlying cardiac dysfunction.
4
Determine the appropriate management.
Discontinue the offending agent (etanercept) and administer loop diuretics (furosemide).
Removal of the trigger and acute diuresis are the mainstays of therapy for biologic-induced acute decompensated heart failure.

Key Concept

Tumor necrosis factor (TNF)-alpha inhibitors (e.g., etanercept, infliximab, adalimumab) can cause new-onset heart failure or exacerbate underlying cardiac dysfunction; they must be discontinued immediately if heart failure develops.
Rate this question

Topics

Rheumatology and Immunology

More questions from this topic