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Zorluk: OrtaRheumatology and Immunology

A 64-year-old man presents to the emergency department with a 2-day history of progressive shortness of breath, orthopnea, and a dry cough. His medical history is significant for chronic obstructive pulmonary disease (COPD) and severe seropositive rheumatoid arthritis. Four months ago, his rheumatologist added infliximab to his regimen of methotrexate due to persistent joint erosions. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 158/94 mmHg, pulse of 112/min, and respiratory rate of 26/min. Pulse oximetry is 88% on room air. Physical examination reveals elevated jugular venous pressure, a third heart sound (S3) gallop, and bilateral basilar crackles with mild expiratory wheezing. Chest radiography shows an enlarged cardiac silhouette, bilateral interstitial opacities, and blunting of the costophrenic angles. Which of the following is the most appropriate next step in management?

  1. Intravenous furosemideCevap
  2. B
    Inhaled albuterol and ipratropium
  3. C
    Intravenous piperacillin-tazobactam
  4. D
    Intravenous methylprednisolone
  5. E
    Immediate discontinuation of methotrexate and initiation of leucovorin

Cevap

Intravenous furosemide
This patient with severe rheumatoid arthritis recently started on infliximab presents with classic signs of acute decompensated heart failure (ADHF), including orthopnea, elevated jugular venous pressure, an S3 gallop, and pulmonary edema on chest radiograph. Tumor necrosis factor (TNF)-alpha inhibitors (e.g., infliximab, adalimumab, etanercept) are highly effective disease-modifying antirheumatic drugs (DMARDs); however, they are a well-documented cause of new-onset heart failure and can exacerbate existing left ventricular dysfunction. They are absolutely contraindicated in patients with moderate to severe (NYHA Class III/IV) heart failure. The most appropriate immediate management for his acute volume overload and resultant respiratory distress is diuresis using an intravenous loop diuretic such as furosemide.

Adım Adım Çözüm

1
Analyze the physical examination and imaging findings.
The patient has elevated jugular venous pressure, an S3 gallop, cardiomegaly, and pulmonary edema.
These findings are classic for acute decompensated heart failure (ADHF).
2
Correlate the clinical syndrome with the patient's pharmacological history.
The patient recently started infliximab, a TNF-alpha inhibitor.
TNF-alpha inhibitors are known to precipitate new-onset heart failure or exacerbate underlying left ventricular dysfunction.
3
Determine the most appropriate immediate therapy.
Administer an intravenous loop diuretic such as furosemide.
Loop diuretics rapidly reduce volume overload and alleviate pulmonary edema in ADHF.

Anahtar Kavram

Tumor necrosis factor (TNF)-alpha inhibitors (e.g., infliximab, adalimumab, etanercept) can cause new-onset heart failure or worsen existing cardiac dysfunction. Patients presenting with signs of acute decompensated heart failure should be treated promptly with intravenous loop diuretics.
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Rheumatology and Immunology

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