Internet Journal of Rheumatology and Clinical Immunology Page 1 of 3 IJRCI. 2013;1(1):CS7 CASE STUDIES Tumor necrosis factor inhibition may improve autonomic dysfunction in rheumatoid arthritis Ashit Syngle 1 *, Inderjeet Verma 2 , Pawan Krishan 2 , Nidhi Garg 2 1 Director Cardio Rheuma & Healing Touch City Clinic, Chandigarh & Senior Consultant Physician & Rheumatologist Fortis Multi Speciality Hospital, Mohali, India 2 Department of Pharmaceutical Sciences & Drug Research, Punjabi University, Patiala, India Introduction Rheumatoid arthritis (RA), a chronic infammatory disease affecting the synovial tissue, causes irreversible joint damage, chronic pain, stiffness, functional impairment and premature mortality. It affects about 1% of the general population. The extra-articular manifestations of RA are diverse involving many organ systems. 1 The involvement of autonomic nervous system (ANS) has been reported to occur in 24-100% of the patients with RA. 2 Autonomic neuropathy in RA was frst reported by Bennett and Scott in 1965. 3 The study conducted by Toussirot et al. demonstrated that among 50 RA patients, 60% had ANS dysfunction, defned by abnormal results of two of the three cardiovascular refex tests. 4 However, autonomic dysfunction is now well documented in RA. 2-5 Evaluation of sympathetic and parasympathetic nervous system involvement has been done employing sweat response, orthostatic test and combination of cardiovascular refex tests. Recently, autonomic dysfunction has also been reported in psoriatic arthritis. 6 Although the symptoms of autonomic dysfunction may be absent, non-specifc and extremely varied; diagnosis of ANS dysfunction is non-invasive and is warranted in patients to prevent severe consequences including sudden death. Infiximab, a TNF-inhibitor (TNFi), is now widely used in the treatment of RA and other autoimmune diseases due to its effcacy. Infiximab has also been shown to improve the endothelial dysfunction associated with the chronic infammation in RA and ankylosing spondylitis. 7-8 We report here a case of RA with autonomic dysfunction treated with infiximab and its effect on AN. To the best of our knowledge this is the frst reported observation of improvement in AN with infiximab in RA. Methods We here in report a case of 57-year-old woman with 9 months history of severe RA, who was treated with combination of methotrexate 15 mg/week, lefunomide 10 mg/day and hydroxychlorquine 400 mg/day. The patient was investigated for AN. Autonomic function was assessed by a battery of non-invasive tests. Cardiovascular autonomic dysfunction was diagnosed by applying cardiovascular refex tests according to Ewing, and was considered to exist if at least two tests were positive. 6, 9 Peripheral sympathetic autonomic Abstract Autonomic nervous system (ANS) involvement in rheumatoid arthrits (RA) has been well recognized. Symptoms of autonomic dysfuncton are absent and not specifc, but diagnosis of ANS dysfuncton by non-invasive means is warranted to prevent severe consequences. However, there is no study demonstratng therapeutc efcacy on autonomic neuropathy (AN) in RA. This is the frst reported observaton of improvement in AN with the TNF-α inhibitor (TNFi), infiximab in RA. We report here a case of a 57-year-old, seropositve RA female with severe disease actvity, investgated for AN. Non-invasive tests based on peripheral sympathetc and cardiovascular autonomic neuropathy (CAN) functon were used for accurate assessment of autonomic functon. The patent was treated with infiximab 3 mg/kg intravenous infusion at weeks 0, 2, and 6. An improvement in autonomic dysfuncton was noted afer 6 weeks of therapy in both sympathetc and parasympathetc CAN.