A Case of Third Nerve Palsy following Infliximab Treatment

Infliximab, a monoclonal anti-TNF α antibody prescribed for treatment of inflammatory and autoimmune diseases (1), may cause neurological adverse reactions, including demyelinating conditions such as multiple sclerosis, optic neuritis, mononeuritis multiplex, Guillain Barré and Miller Fisher syndromes (2, 1, 3, 4, 5). Third nerve palsy with cisternal enhancement with gadolinium on MRI has been reported (6). Whether anti-TNF α blockers unmask preexisting or induces de novo demyelination was addressed by a prospective study. New demyelinating events, which improved with cessation of TNF alfa antagonists and re-emerged with reintroduction of them, supports anti-TNF alfa evoked pathophysiology. Incidence is controversial, some authors conclude it isn ́t clear if TNF alfa antagonists increase demyelinating diseases, while others found 30% increased risk. MRI findings without typical demyelination symptoms is recognized as radiologically isolated syndrome (RIS) (2). If demyelination emerges during treatment, discontinuation of anti TNF alfa is mandatory, with close clinical and MRI follow-up (1) .