BMJ Case Reports 2017; doi:10.1136/bcr-2017-219883
  • Unexpected outcome (positive or negative) including adverse drug reactions

Tumour necrosis factor (TNF) inhibitor-induced isolated pleural granulomas: a rare adverse effect

  1. Nagarjun Rao3
  1. 1Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
  2. 2Colorado Springs Pulmonary Consultants, Colorado Springs, Colorado, USA
  3. 3Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA
  1. Correspondence to Dr Rose Franco, rfranco{at}
  • Accepted 30 May 2017
  • Published 18 June 2017


A 53-year-old man with a history of Crohn’s disease on infliximab, presented with several weeks of cough and dyspnoea. He had a right-sided pleural effusion, found to be exudative with lymphocytic predominance. He underwent right-sided video-assisted thoracic surgery (VATS) with biopsies and pleurodesis. Histopathology showed pleural-based non-caseating granulomas with unremarkable lung parenchyma. Cultures were only positive for Propionibacterium acnes. 8 months later, he was found to have a left-sided exudative, lymphocytic predominant pleural effusion. Left-sided VATS and biopsies again showed pleural-based non-caseating granulomas with normal lung parenchyma. Having ruled out an active infection and malignant lesions, we diagnosed infliximab-induced pleural granulomas. Infliximab was stopped. The patient continues to do well at 6 years of follow-up. We believe this is the first report of tumour necrosis factor (TNF) inhibitor-induced isolated pleural granulomas. P. acnes and cytokine imbalance might be responsible for the pathogenesis of TNF inhibitor-induced granulomas.


  • Contributors MSA, RF and DD were involved in the planning, conception and design of this project. MSA and DD collected the history. MSA and RF did the literature search. NR evaluated and provided description regarding the histopathology.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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