TNF Inhibitor-Induced Sarcoidosis-Like Lesions in Inflammatory Bowel Disease

While tumor necrosis factor (TNF) inhibitors can induce paradoxical reactions, sarcoidosis-like disease has hardly been reported so far. This study aimed to describe the epidemiological, diagnostic and therapeutic features of TNF inhibitor-induced sarcoidosis-like lesions in patients with inflammatory bowel disease.

We conducted a case series across 59 institutions affiliated with the Groupe d'Etude Therapeutique des Affections Inflammatoires du Tube Digestif. Diagnosis of TNF inhibitor-induced sarcoidosis was based on typical clinical and radiological signs, histological evidence of non-necrotizing granuloma, exclusion of alternative diagnoses, and a timeline consistent with drug exposure. A pharmacovigilance expert reviewed each case to confirm drug causality.

We identified 14 cases of sarcoidosis-like lesions, including 9 patients with Crohn's disease, 4 ulcerative colitis, and 1 with unclassified inflammatory bowel disease. The implicated medications were infliximab (8), adalimumab (5), and golimumab (1), predominantly in first-time biotherapy users (71%). The median time from treatment initiation to sarcoidosis diagnosis was 27.5 months (range 3-91). Common clinical manifestations included dyspnea (71%), coughing (50%) and fever (50%). Ten patients discontinued TNF inhibitor therapy and started oral steroids, leading to complete symptom resolution in seven cases and improvement in two. Median time from steroid initiation to clinical remission of sarcoidosis was 84 days (range 11-134). After a median follow-up of 40 months, while no relapses occurred in 13 patients, one showed persistent sarcoidosis activity.

TNF inhibitor-induced sarcoidosis should be considered in inflammatory bowel disease patients with chronic respiratory symptoms or fever after exclusion of mycobacterial infection. Management involves discontinuation of TNF inhibitors and a course of steroids.