Ewha Med J.  2016 Jan;39(1):23-27. 10.12771/emj.2016.39.1.23.

Tocilizumab-induced Transaminitis in a Seropositive Rheumatoid Arthritis Patient with Macrophage Activation Syndrome

• Yoo BW
• Park CK
• Yun HR
• Kim D
• Lee SK
• Lee SW

• KMID: 2152754
• DOI: http://doi.org/10.12771/emj.2016.39.1.23

Abstract

As a new humanized monoclonal antibody against the interleukin-6 receptor, tocilizumab is currently used for the treatment of rheumatoid arthritis (RA) patients. Tocilizumab was reported to provoke drug-related liver toxicity, although there have been no reports on significant liver toxicity from tocilizumab in Korean patients with RA to date. Here, we describe the first case of tocilizumab-related liver toxicity in a patient with complicated RA, accompanied with macrophage activation syndrome, who had received tacrolimus and prednisolone and in whom both conventional disease modifying anti-rheumatic drugs, including methotrexate, leflunomide and sulfasalazine or tumor necrotizing factor-alpha blockades, were contraindicated due to drug eruption and a history of lung cancer.

Keyword

Rheumatoid arthritis; Tocilizumab; Liver toxicity

MeSH Terms

Antirheumatic Agents
Arthritis, Rheumatoid*
Drug Eruptions
Humans
Interleukin-6
Liver
Lung Neoplasms
Macrophage Activation Syndrome*
Macrophage Activation*
Macrophages*
Methotrexate
Prednisolone
Sulfasalazine
Tacrolimus
Tranexamic Acid*
Antirheumatic Agents
Interleukin-6
Methotrexate
Prednisolone
Sulfasalazine
Tacrolimus
Tranexamic Acid

Figure

• 

  Fig. 1 Whole body bone scan. It reveals increased uptake in the bilateral wrists, hands, and left tarsal bone, areas of arthritis.

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  Fig. 2 Bone marrow biopsy pathology and immunohistochemical staining of macrophage. It demonstrates areas of fat necrosis surrounded by macrophages (A), which shows CD68 positivity on immunohistochemical staining (B, arrow) (A: H&E, ×200; B: CD68 immunohistochemical stain, ×200).

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  Fig. 3 The graph of the trend of changes in liver enzyme, WBC, and ferritin during tocilizumab treatment. While ferritin and WBC decreases after tocilizumab administration, there is an increase in the liver enzyme. AST, aspartate aminotransferase; ALT, alanine aminotransferase; HD, hospital day; WBC, white blood cell.

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