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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriasis is characterized by the World Health Organization &#40;WHO&#41; as a systemic&#44; non-contagious&#44; inflammatory&#44; and incapacitating disease&#44; for which there is no cure&#46; Systemic treatment is required in 20&#37; to 30&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Being highly stigmatizing&#44; the impact of psoriasis extends far beyond the body surface&#44; affecting the individuals&#8217; social relationships and personality&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">One of the main focal points of psoriasis research has been the development of biological therapies for this disease&#46; Adalimumab is the first anti-human tumor necrosis factor &#40;TNF&#41; monoclonal antibody fully developed for the treatment of psoriasis and other immune-mediated diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; varying adverse effects have been identified in patients treated with biological agents&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Recently&#44; cases have been reported associating the use of TNF-alpha inhibitors infliximab and etanercept to interstitial lung disease&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; the literature is scarce regarding the correlation between the use of adalimumab for the treatment of psoriasis and the subsequent development of interstitial pneumonia and this motivated the present report&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 58-year-old patient&#44; had been undergoing dermatological follow-up for plaque psoriasis for ten years&#46; The patient had been well controlled during the last 5 years with the use of adalimumab &#40;Humira&#8482;&#41;&#44; receiving a dose of 40&#8239;mg every 14 days&#46; Chest X-ray and PPD test were performed for annual screening due to the use of an immunobiological agent&#46; Parietal thickening was observed in the posterior basal segments of the lung on the chest radiography&#44; which prompted the case investigation&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was asymptomatic from the respiratory point of view&#46; On physical examination&#44; there were rales in the pulmonary bases&#44; bilaterally&#44; without any other alterations&#46; A chest computed tomography &#40;CT&#41; was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; with the following results&#58; bilateral pulmonary infiltrate characterized by ground-glass opacities and a thin reticulation with basal predominance&#46; Nodular and ground-glass opacities with sparse lobular center distribution were observed&#44; which were more evident in the middle lobe&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Adalimumab was discontinued due to the hypothesis of drug-induced pulmonary tuberculosis or interstitial pneumopathy&#46; The patient denied having had contact with individuals with respiratory symptoms&#46; A bronchoscopy was performed with bronchial lavage and culture&#44; bacterioscopy&#44; fungoscopy and AFB testing&#44; which were all negative&#46; Then&#44; the hypothesis of infectious etiology was ruled out and a new chest CT was requested &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; three months after the medication was discontinued&#44; which showed sparse reticulonodular opacities in the lung parenchyma bilaterally&#44; more evident in the lower lung fields&#44; with partial resolution in comparison to the previous CT&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Due to the significant reduction in pulmonary infiltration after adalimumab discontinuation and without any other additional therapy&#44; the dermatologists and the pulmonologist concluded that the causal relationship was sufficient for the diagnosis&#46; One year after adalimumab discontinuation&#44; the patient is using ustekinumab&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The use of tumor necrosis factor &#40;TNF&#41; inhibitors in chronic inflammatory diseases has been well reported&#44; showing that they are safe drugs&#44; with pneumonia being observed as an adverse effect in 1&#46;8&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Among the cases of interstitial pneumonia resulting from the use of immunobiological agents&#44; about 97&#37; are related to TNF-alpha inhibitors&#46; In 89&#37; of cases&#44; patients suffered from psoriatic arthritis&#44; and the pulmonary disease appeared approximately 26 weeks after starting the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore&#44; the atypical and late presentation of this adverse effect is evident after 5 years of adalimumab use&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In psoriasis with solely cutaneous involvement&#44; adalimumab has shown no significant difference when compared to placebo&#44; regarding adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In countries such as Japan&#44; the dose indicated for the treatment of psoriasis with adalimumab varies between 40 and 80&#8239;mg a week&#44; with no significant adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The reported case is noteworthy&#44; as the patient had the cutaneous form of psoriasis&#44; did not use the maximum dose&#44; and nevertheless developed interstitial lung disease due to the use of anti-TNF-alpha&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Ustekinumab &#40;Stelara&#8482;&#41;&#44; a human IgG1 monoclonal antibody specific for IL-12&#47;23&#44; is also one of the most widely used drugs for the treatment of paradoxical psoriasis cases&#44; which has been shown to be an effective alternative drug&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This report reinforces the need for special care in relation to the monitoring of immunobiological agent users&#44; whose screening with relevant tests and at the appropriate time is essential for the early diagnosis of potentially severe diseases that may have an asymptomatic presentation&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217; contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">D&#233;bora Dorneles Cunha de Queiroz Tur&#237;bio&#58; Design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Francisco Clitson Sousa Oliveira&#58; Design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Sandra Maria Fonseca Barreto&#58; Design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Tha&#237;s Barros Felippe Jabour&#58; Design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Report
Interstitial lung disease due to anti-TNF use in the treatment of psoriasis
Débora Dorneles Cunha de Queiroz Turíbio
Corresponding author
deboradorneles4@gmail.com

Corresponding author.
, Francisco Clitson Sousa Oliveira, Sandra Maria Fonseca Barreto, Thaís Barros Felippe Jabour
Department of Medicine, Hospital Universitário Onofre Lopes, Natal, RN, Brazil
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Adalimumab is the first anti-human tumor necrosis factor &#40;TNF&#41; monoclonal antibody fully developed for the treatment of psoriasis and other immune-mediated diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; varying adverse effects have been identified in patients treated with biological agents&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Recently&#44; cases have been reported associating the use of TNF-alpha inhibitors infliximab and etanercept to interstitial lung disease&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; the literature is scarce regarding the correlation between the use of adalimumab for the treatment of psoriasis and the subsequent development of interstitial pneumonia and this motivated the present report&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 58-year-old patient&#44; had been undergoing dermatological follow-up for plaque psoriasis for ten years&#46; The patient had been well controlled during the last 5 years with the use of adalimumab &#40;Humira&#8482;&#41;&#44; receiving a dose of 40&#8239;mg every 14 days&#46; Chest X-ray and PPD test were performed for annual screening due to the use of an immunobiological agent&#46; Parietal thickening was observed in the posterior basal segments of the lung on the chest radiography&#44; which prompted the case investigation&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was asymptomatic from the respiratory point of view&#46; On physical examination&#44; there were rales in the pulmonary bases&#44; bilaterally&#44; without any other alterations&#46; A chest computed tomography &#40;CT&#41; was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; with the following results&#58; bilateral pulmonary infiltrate characterized by ground-glass opacities and a thin reticulation with basal predominance&#46; Nodular and ground-glass opacities with sparse lobular center distribution were observed&#44; which were more evident in the middle lobe&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Adalimumab was discontinued due to the hypothesis of drug-induced pulmonary tuberculosis or interstitial pneumopathy&#46; The patient denied having had contact with individuals with respiratory symptoms&#46; A bronchoscopy was performed with bronchial lavage and culture&#44; bacterioscopy&#44; fungoscopy and AFB testing&#44; which were all negative&#46; Then&#44; the hypothesis of infectious etiology was ruled out and a new chest CT was requested &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; three months after the medication was discontinued&#44; which showed sparse reticulonodular opacities in the lung parenchyma bilaterally&#44; more evident in the lower lung fields&#44; with partial resolution in comparison to the previous CT&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Due to the significant reduction in pulmonary infiltration after adalimumab discontinuation and without any other additional therapy&#44; the dermatologists and the pulmonologist concluded that the causal relationship was sufficient for the diagnosis&#46; One year after adalimumab discontinuation&#44; the patient is using ustekinumab&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The use of tumor necrosis factor &#40;TNF&#41; inhibitors in chronic inflammatory diseases has been well reported&#44; showing that they are safe drugs&#44; with pneumonia being observed as an adverse effect in 1&#46;8&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Among the cases of interstitial pneumonia resulting from the use of immunobiological agents&#44; about 97&#37; are related to TNF-alpha inhibitors&#46; In 89&#37; of cases&#44; patients suffered from psoriatic arthritis&#44; and the pulmonary disease appeared approximately 26 weeks after starting the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore&#44; the atypical and late presentation of this adverse effect is evident after 5 years of adalimumab use&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In psoriasis with solely cutaneous involvement&#44; adalimumab has shown no significant difference when compared to placebo&#44; regarding adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In countries such as Japan&#44; the dose indicated for the treatment of psoriasis with adalimumab varies between 40 and 80&#8239;mg a week&#44; with no significant adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The reported case is noteworthy&#44; as the patient had the cutaneous form of psoriasis&#44; did not use the maximum dose&#44; and nevertheless developed interstitial lung disease due to the use of anti-TNF-alpha&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Ustekinumab &#40;Stelara&#8482;&#41;&#44; a human IgG1 monoclonal antibody specific for IL-12&#47;23&#44; is also one of the most widely used drugs for the treatment of paradoxical psoriasis cases&#44; which has been shown to be an effective alternative drug&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This report reinforces the need for special care in relation to the monitoring of immunobiological agent users&#44; whose screening with relevant tests and at the appropriate time is essential for the early diagnosis of potentially severe diseases that may have an asymptomatic presentation&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217; contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">D&#233;bora Dorneles Cunha de Queiroz Tur&#237;bio&#58; Design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Francisco Clitson Sousa Oliveira&#58; Design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Sandra Maria Fonseca Barreto&#58; Design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Tha&#237;s Barros Felippe Jabour&#58; Design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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ISSN: 03650596
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