What are the management steps for a patient on Inflectra (Infliximab) presenting with bilateral conjunctivitis, photophobia, and mouth sores?

Management of Bilateral Conjunctivitis, Photophobia, and Mouth Sores in a Patient on Inflectra (Infliximab)

The patient on Inflectra (infliximab) presenting with bilateral conjunctivitis, photophobia, and mouth sores should be immediately evaluated for immune-mediated ocular toxicity and treatment should include temporary discontinuation of infliximab, urgent ophthalmology referral, and initiation of topical corticosteroids.

Initial Assessment

Clinical Presentation Evaluation

• Ocular symptoms: Bilateral conjunctivitis, photophobia
• Oral symptoms: Mouth sores
• Medication history: Currently on Inflectra (infliximab)

Differential Diagnosis

1. Infliximab-induced immune-related adverse event (irAE)

   • Ocular toxicities occur in approximately 1% of patients on immune checkpoint inhibitors 1
   • Can manifest as uveitis, iritis, episcleritis, or conjunctivitis

2. Ocular mucous membrane pemphigoid (OMMP)

   • Can be medication-induced
   • Characterized by subepithelial fibrosis with remissions and exacerbations 1

3. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

   • Severe mucocutaneous reaction that can affect eyes and oral mucosa
   • Can be triggered by medications including biologics

4. Viral conjunctivitis with concurrent oral lesions

   • Herpes simplex virus can cause both conjunctivitis and oral lesions
   • Adenovirus can cause conjunctivitis with systemic symptoms

Immediate Management Steps

1. Medication Management

• Temporarily hold infliximab until evaluation is complete and severity is determined
• Infliximab has been associated with infusion reactions and immune-mediated adverse events 2

2. Urgent Ophthalmology Consultation

• Same-day ophthalmology referral for slit-lamp examination
• Comprehensive eye examination including:
  • Visual acuity measurement
  • External examination
  • Slit-lamp biomicroscopy 1
  • Assessment for conjunctival scarring or membrane formation

3. Initial Symptomatic Treatment

• Topical corticosteroids (preferably with poor ocular penetration like fluorometholone or loteprednol)
  • Start with frequent dosing (e.g., every 2-4 hours) 1
• Artificial tears for lubrication
• Cold compresses for symptomatic relief

Specific Management Based on Severity

Mild to Moderate Presentation

• Continue topical corticosteroids with gradual taper based on response
• Consider cycloplegic agents if anterior chamber involvement is present
• Monitor closely for development of corneal subepithelial infiltrates 1
• Consider resuming infliximab at lower dose once symptoms resolve

Severe Presentation

• Systemic corticosteroids (e.g., prednisone 0.5-1 mg/kg/day)
• Consider switching to alternative immunosuppressive therapy:
  • Mycophenolate mofetil
  • Azathioprine
  • Methotrexate 1
• Permanently discontinue infliximab if vision is severely compromised (vision 20/200 or worse) 1

Follow-up and Monitoring

Short-term Follow-up

• Re-evaluation within 1 week for patients with severe inflammation
• Monitor for:
  • Resolution of conjunctival inflammation
  • Improvement in photophobia
  • Healing of oral lesions
  • Development of complications (corneal involvement, scarring)

Long-term Considerations

• Regular monitoring of intraocular pressure if on prolonged topical corticosteroids
• Assessment for development of dry eye syndrome as a sequela
• Evaluation for recurrence if infliximab is restarted

Special Considerations

If Ocular Mucous Membrane Pemphigoid is Suspected

• Consider conjunctival biopsy for direct immunofluorescence
• More aggressive immunosuppression may be needed
• Aggressive lubrication for associated dry eye 1

If Viral Etiology is Suspected

• Consider antiviral therapy if herpes simplex virus is suspected
• Topical ganciclovir 0.15% gel or trifluridine 1% solution for HSV conjunctivitis 1

Pitfalls and Caveats

1. Don't miss sight-threatening complications:

   • Corneal involvement can lead to permanent vision loss
   • Early recognition and treatment are essential

2. Avoid restarting infliximab prematurely:

   • Ensure complete resolution of symptoms before considering rechallenge
   • Consider alternative biologics if ocular toxicity was severe

3. Don't undertreat:

   • Immune-mediated ocular inflammation can progress rapidly
   • Aggressive initial therapy may prevent long-term complications

4. Monitor for systemic manifestations:

   • The combination of ocular and oral symptoms may indicate a systemic immune-mediated process
   • Consider evaluation for other organ involvement

By following this structured approach, you can effectively manage the patient's symptoms while minimizing the risk of permanent ocular damage and optimizing long-term outcomes.