Seropositive Neuromyelitis Optica onset after golimumab in a Rheumatoid arthritis patient: a case report

We present the case report of a 43 years old, african descendant woman, with Rheumatoid Arthritis since 2015, previously on methotrexate for 5 years and leflunomide treatment for 1 year, interrupted due to gastrointestinal intolerance and poor effectiveness, respectively. Golimumab was then started and after the 2nd dose she presented a severe longitudinally extensive transverse myelitis, with involvement of C2 to C7 and D2 to D4. Infectious causes were ruled out at this time, and CSF was normal. The patient underwent methylprednisolone (MP) 1g for 5 days, with partial recovery. At this time, the condition was attributed to anti-TNF demyelination, which was prompt discontinued. She didn't receive complementary acute-phase therapy or a disease modifier treatment. After 2 months, she presented with nausea and vomiting and new motor deterioration -now paraplegia-, and MRI revealed worsening of the extent of the lesion (C2 to D5), with signs of acute inflammation. She again received MP 1g for 5 days, and only 2 months later she underwent plasmapheresis - 5 sessions - without expressive clinical improvement. Anti-AQP-4 antibody came up positive 1:160. Maintenance therapy with rituximab was started and she remains with free of new relapses for the last 12 months. Tumor necrosis factor ? (TNF?) long-term use inhibitors is associated with a growing number of paradoxical autoimmune events including demyelinating lesions of the central nervous system (CNS). However, patients with Neuromyelitis Optica Spectrum Disease (NMOSD) tend to have other coexisting autoimmune/connective tissue diseases, and some immunosuppressive treatment for such conditions may mask the onset of the first relapse. A detailed diagnostic evaluation work up is important in a demyelinating event in patients using anti-TNF, as this may be a trigger for the onset of a comorbid primary demyelinating disease of the CNS, such as NMOSD.