Acute-severe fatigue after anti-TNFa treatment: An early insidious side effect

Extract

Dear Sir,

Fatigue is considered one of the symptoms of inflammatory bowel disease (IBD). Despite the abundant literature on IBD, controlled experience has not been published on this issue but only patient subjective experience. All available data concerning fatigue are empirical evidences and they represent one of the leading concerns for IBD patients.¹ In 2009 Van Langenberg² reported data on fatigue in quiescent IBD patients (36 and 41% in ulcerative colitis [UC] and Crohn's disease [CD] respectively). These rates significantly increased during the clinical relapse. A lot of factors were evaluated (duration of symptoms, pain, anemia, sleep disturbance) but with conflicting results especially concerning severity of fatigue. Immunosuppressant treatment has been related to fatigue appearance (p = 0.024) but no data were reported on the association between fatigue and 5-ASA, prednisolone and anti-TNFa treatment.³

Case 1: a 24 year-old man, intolerant to azathioprine, with previous history of resected ileo-cecal CD, was evaluated in the outpatient clinic for sub-occlusive symptoms. At colonoscopy the ileo-colonic anastomosis was ulcerated and strictured (Rutgeerts' score i4) and endoscopic balloon dilation was performed. Two weeks later, after the pre-biologic screening, the patient received the first dose of infliximab (5 mg/kg i.v.). No signs or history of neurological disorders was recorded. After 10 h from the end of the infusion the patient referred appearance of progressive fatigue characterized by generalized severe weakness with difficulty in body movement, difficulty with concentration and somnolence. Symptoms were so severe that he was not able to work for 4 days. No drug intake was reported by the patient. Biochemistry was normal (including creatine kinase [CK]) as well as objective findings during examination by neurologist. The fatigue slowly improved and after 7 days he returned to his regular job. On this evidence infliximab treatment was discontinued and until now he is free of neurological or intestinal symptoms.