Acute, non-obstructive, sterile cholecystitis associated with etanercept and infliximab for the treatment of juvenile polyarticular rheumatoid arthritis

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Abstract
A 15 year old white female patient with polyarticular JRA, treated with a combination of 14 mg/m2 methotrexate once a week intramuscularly and 2 g sulfasalazine a day, did not show any remission. Sulfasalazine was stopped, and 0.4 mg/kg etanercept twice a week subcutaneously was added. With this combination treatment the patient was in full remission after 4 weeks, but at 12 weeks her disease flared. Etanercept was increased to 0.5 mg/kg twice a week subcutaneously. Two weeks later she developed upper abdominal pain, nausea, and weight loss; she could not attend school. Gastroscopy showed a minimally active duodenitis and antrum gastritis. Histologically a helicobacter infection was proved. The abdominal sonography showed a thickened gall bladder with a halo sign. The laboratory tests showed normal lipase, aspartate aminotransferase, and alanine aminotransferase, but increased bilirubin (20 μmol/l). Despite eradication treatment against Helicobacter pylori, the symptoms were unchanged. A puncture of the gall bladder did not help to prove any infectious agent. Shortly after stopping etanercept, the abdominal symptoms resolved, and ultrasound showed a decrease of the thickness of the gallbladder wall.