Case Presentation:
An 80 year old female with medical history of hypertension, diabetes mellitus, chronic atrial fibrillation presented with four weeks of lower extremity edema and dyspnea. Notably, she had also been taking Golimumab for 6 months for Rheumatoid Arthritis (RA). Vital signs on presentations were: Temp:99 F, HR: 140bpm, BP: 105/64, oxygen saturation of 88% on room air. Physical exam revealed crackles at the mid lower lung fields bilaterally and 2+ lower extremity edema. EKG showed new ST inversions in lead 1, avF and V2. Troponin T was elevated to 0.11 ng/ml and proBNP was 21,246 pg/ml. Chest X Ray showed cardiomegaly with diffuse alveolar opacities. Transthoracic echocardiogram (TTE) revealed severely reduced left ventricular systolic function with LVEF of 25-29%, left ventricular regional wall hypokinesis and mildly reduced right ventricular systolic function. All findings were new compared to her last TTE 3 months prior, which showed preserved biventricular systolic function. Coronary angiography revealed no coronary artery disease. The patient was started on intravenous furosemide, and her home beta blocker and ARB were resumed. The patient’s Golimumab was discontinued given prior reports of TNF alpha inhibitor induced cardiomyopathy. Over the ensuing days, she was aggressively diuresed with improvement in oxygenation and ultimately discharged home. Three months after discontinuation of Golimumab, repeat TTE showed normalization of biventricular systolic function.
Discussion:
TNF alpha inhibitors have revolutionized the treatment of chronic immune mediated inflammatory diseases. Several TNF alpha inhibitors have been associated with cardiomyopathy, however there remains a paucity of evidence regarding cardiotoxicity with Golimumab. We now present, to our knowledge, the first reported case of reversible heart failure due to Golimumab in an 80 year old woman with RA. Golimumab, like other TNF alpha inhibitors, represents a historic advancement in the treatment of immune mediated inflammatory diseases. However, our case implicates this innovative drug in cardiotoxicity similar to other TNF alpha inhibitors. Further prospective studies are needed to establish a stronger correlation between Golimumab and cardiotoxicity.
Effects of Intermittent Pneumatic Compression on Reduction of Postoperative Lower Extremity Edema and Normalization of Foot Microcirculation Flow in Patients Undergoing Arterial Revascularization
