Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 39

Bilateral diaphragmatic paralysis associated with the use of
the tumor necrosis factor-alpha inhibitor adalimumab
Mina Mecheal Benjamin, MD, Alan William Martin, MD, and Randall Lee Rosenblatt, MD

A 51-year-old woman was referred for evaluation of progressive dyspnea
of 3 months’ duration. She had received 3 doses of adalimumab for
treatment of rheumatoid arthritis prior to the onset of her dyspnea. Her
chest examination revealed absent diaphragmatic movement with inspiration. Spirometry showed a severe restrictive defect. Radiologic studies
confirmed the diagnosis of bilateral diaphragmatic paralysis. Laboratory
and radiologic workup excluded other possible causes of the diagnosis.
Adalimumab was discontinued, and she was treated with bilevel positive airway pressure ventilation and intravenous immunoglobulin. Three
months later, the diaphragmatic paralysis persisted. This is the second
reported case of bilateral diaphragmatic paralysis occurring in a patient
who had received adalimumab. Acute neuropathies are rare side effects
of tumor necrosis factor-alpha inhibitors.

umor necrosis factor alpha (TNF-α) inhibitors currently
play a major role in the management of several autoimmune diseases. Infliximab was the first agent to be approved by the Food and Drug Administration (FDA)
in 1998. TNF-α blockers are approved for the management of
moderate to severely active rheumatoid arthritis or psoriatic arthritis, active ankylosing spondylitis, moderate to severely active
Crohn’s disease, and active ulcerative colitis in patients with an
inadequate response to conventional therapy (1). Five anti-TNF
agents have been approved by the FDA: infliximab, adalimumab,
etanercept, golimumab, and certolizumab. These agents have
demonstrated acceptable safety and tolerability profiles. A 2v