A Cheifetz

CP Anand

DM Knight

IA Alrashid

JF Colombel

Kiran CR Patel

MJ Elliott

MM Diwan

Mukesh Singh

S Sofos

Sood Ajit

SR Targan

Y Sote

English

PubMed

Crossref

A rare case of supraventricular tachycardia induced by Infliximab: a case report

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BioMed CentralCases Journal
ssOpen AcceCase Report
A rare case of supraventricular tachycardia induced by Infliximab: a 
case report
Mukesh Singh*1,2, MM Diwan2 and Kiran CR Patel2
Address: 1Department of Internal Medicine, Rosalind Franklin University of Medicine & Sciences at Chicago Medical School, Chicago, Illinois, 
60064. USA and 2Selly Oak Hospital, University Hospital Birmingham NHS Foundation Trust, Selly Oak, Birmingham, B29 6JD, UK
Email: Mukesh Singh* - drmukeshsingh@yahoo.com; MM Diwan - masroor11@yahoo.com; Kiran CR Patel - kiran.patel@uhb.nhs.uk
* Corresponding author    
Abstract
Background: Infliximab, a chimeric monoclonal immunoglobulin antibody to tumor necrosis
factor-α, has been established as a safe and effective treatment of rheumatoid arthritis, active and
fistulising crohn's disease. Infliximab is generally well tolerated drug. The commonly reported
cardiac side effects of Infliximab include exacerbation of congestive heart failure, hypotension and
syncope. Symptomatic disorders of cardiac rhythm have been reported only rarely in few case
reports and to the best of our knowledge, no tachyarrhythmia has been reported in past.
Case report: We report the case of a supraventricular tachycardia that occurred within three
hours of Infliximab infusion in a patient with rheumatoid arthritis.
Conclusion: It is interesting to note that prior infusions in this patient did not precipitate similar
consequences, thus, emphasising the importance of careful monitoring of patients on Infliximab
therapy for possible reactions, even if prior exposures have been uneventful.
Case presentation
A 60 year old Caucasian gentleman with rheumatoid
arthritis on infliximab therapy for one year presented with
acute onset palpitations. Which started within three hours
after receiving the eight weekly infliximab infusion for his
rheumatoid arthritis. There was no past medical history of
diabtes mellitus, ischemic heart disease, hypertension or
heart failure. He has never smoked cigarettes and there
was no history of alcohol or illicit drug use. He had no
known drug or food allergies. His medical therapy on
admission included azathioprine, prednisolone,
diclofenac, omeprazole, Dihydrocodeine, paracetamol,
salbutamol inhaler and eight weekly Infliximab infusions.
On examination he was tachycardic at 168 beats per
minute. Blood pressure was 110/90 and respiratory rate of
16 per minute; oxygen saturation was 99% on room air.
Systemic examination was unremarkable. The electrocar-
diogram (Figure 1) showed a supraventricular tachycardia
(SVT), which reverted rapidly to sinus rhythm (Figure 2)
with intravenous adenosine therapy (9 milligrams). His
complete blood count, cardiac enzymes, troponinI, serum
electrolytes, renal functions and liver enzymes all were
normal. Chest X-ray did not show any evidence of cardi-
omegaly or pulmonary congestion and 2-D echocardio-
gram revealed normal left ventricular systolic and
diastolic functions.
Discussion
Infliximab is a recombinant immunoglobulin G1 kappa,
human-murine chimeric monoclonal antibody that spe-
cifically and potently binds to and neutralizes the soluble
Published: 5 October 2009
Cases Journal 2009, 2:147 doi:10.1186/1757-1626-2-147
Received: 16 September 2009
Accepted: 5 October 2009
This article is available from: http://www.casesjournal.com/content/2/1/147
© 2009 Singh et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Cases Journal 2009, 2:147 http://www.casesjournal.com/content/2/1/147TNF alpha homotrimer and its membrane-bound precur-
sor [1]. It has been shown to be an effective treatment for
moderate-to-severe active and fistulising Crohn's disease
[2], and for active rheumatoid arthritis that is not
responding adequately to Methotrexate therapy [3].
The safety profile of infliximab is still evolving because of
its rapidly growing use and indications. Infliximab is gen-
erally well tolerated drug. An adverse event that occurs
during or within 24 hours of an infliximab infusion is
considered an acute infusion reaction. These acute reac-
tions most commonly include hypotension/hyperten-
sion, dyspnea, fever, chest pain and urticarial rash [4,5].
The commonly reported cardiac side effects of infliximab
include exacerbation of congestive heart failure, hypoten-
sion and syncope [5]. Symptomatic disorders of cardiac
rhythm have been reported only rarely [6-9] and all these
were bradyarrhythmias. To the best of our knowledge,
there have been no case reports of tachyarrhythmias and
this is the first case of supraventricular tachycardia caused
by infliximab. Alrashid A et al recently reported a case of
Crohn's disease with pulmonary involvement who had
history of paroxysmal supraventricular tachycardia and
this patient was treated with infliximab infusion without
occurrence of cardiac arrhythmia [10].
TNF-α antagonism has been shown to adversely affect the
clinical status in heart failure but the mechanism remains
unknown. So, a caution is required in heart failure
patients before infliximab therapy is started and close
monitoring of left ventricular function during therapy is
advised. In our patient, there were no clinical signs and
previous history to suspect heart failure and echo showed
normal left ventricle. So we can speculate it as a case of
supraventricular tachycardia caused by infliximab ther-
apy. It is interesting to note that prior infusions in this
patient did not precipitate similar consequences. This
underlines the need to carefully monitor patients on inf-
liximab therapy for possible reactions, even if prior expo-
sures have been uneventful.
The issue of whether further therapy with the drug in
question should cease, should be determined by a risk-
benefit evaluation and discussion of alternative therapeu-
tic options with the patient. There is no literature available
as to recurrence of such arrhythmias with further infu-
sions. However, infliximab should be used with caution
ECG 1, The 12 lead electrocardiogram and rhythm strip showing supraventricular tachycardia on presentationFigure 1
ECG 1, The 12 lead electrocardiogram and rhythm strip showing supraventricular tachycardia on presenta-
tion.Page 2 of 4
(page number not for citation purposes)
Cases Journal 2009, 2:147 http://www.casesjournal.com/content/2/1/147in patients with concomitant heart disease, particularly
those with a history of conduction abnormalities and
advanced age.
Abbreviations
SVT: Supraventricular tachycardia; TNF: Tumor necrosis
factor.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
MS and MMD drafted and wrote the manuscript. MS,
MMD and KCRP participated in the care of the patient and
interpretation of the investigations. All authors read and
approved the final manuscript.
Acknowledgements
We would like to thank the patient
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ECG 2, The 12 lead electrocardiogram and rhythm strip after supraventricular tachycardia reverted back to normal sinus rhythm following nin  milligr ms of AdenosineFigure 2
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A rare case of supraventricular tachycardia induced by Infliximab: a case report

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