Pulmonary sarcoidosis with a cavitary lesion in the lung caused by a TNF‐α inhibitor: A case report

Abstract

A 28‐year‐old man with ankylosing spondylitis (AS) who was treated with a tumour necrosis factor‐alpha (TNF‐α) inhibitor, adalimumab, presented with newly detected multiple bilateral pulmonary nodules on chest computed tomography (CT). We suspected bacterial infection, including those caused by acid‐fast bacilli, or adalimumab‐related condition, such as sarcoidosis. After adalimumab cessation, no resolution of the pulmonary shadows was observed. Moreover, pulmonary cavitation appeared on chest CT at 7 weeks, prompting surgical lung biopsy. Acid‐fast bacteria culture of the lung tissue showed negative results. Pathological examination suggested that confluent granulomas associated with sarcoidosis might have obstructed the blood vessels, causing necrosis and lung cavitation. Consequently, prednisolone was initiated, and these shadows were reduced. After administering anti‐interleukin (IL)‐17A antibody for treatment of AS and prednisolone withdrawal, these shadows were not exacerbated. TNF‐α inhibitor‐induced sarcoidosis could cause cavitary lesions due to vascular invasion of granulomas.

Phenotypes of Sarcoidosis-Associated Pulmonary Hypertension—A Challenging Mystery

“…For example, the same degree of fibrosis is associated with higher PAP in sarcoidosis than in idiopathic pulmonary fibrosis (IPF) and other ILDs [48,49]. The predilection to bronchovascular bundles, septa, and subpleural regions may be associated with a larger direct impact on nearby pulmonary vessels [50].…”

“…Microangiopathy refers to the alterations of endothelial and basement membrane of precapillary, capillary, and postcapillary pulmonary vessels and was found in 35% of transbronchial biopsy specimens from patients with sarcoidosis [101] and 100% of explanted lungs of five patients with SAPH [4]. Both angiitis and microangiopathy caused vessel occlusion and destruction [4,45,50,[100][101][102][103][104]. Plexiform lesions were not typically seen in sarcoidosis-associated vasculopathy [4,100,101]; however, venous involvement with vessel obliteration and subsequent capillary congestion may resemble pulmonary veno-occlusive disease (PVOD) [4,105,106].…”