Ann Dermatol.  2015 Oct;27(5):605-607. 10.5021/ad.2015.27.5.605.

Nodular Vasculitis That Developed during Etanercept (Enbrel) Treatment in a Patient with Psoriasis

• Park SB
• Chang IK
• Im M
• Lee Y
• Kim CD
• Seo YJ
• Lee JH

• KMID: 2171462
• DOI: http://doi.org/10.5021/ad.2015.27.5.605

Abstract

Nodular vasculitis was introduced by Montgomery for cases of erythema induratum-like lesions that were not associated with tuberculosis. Nodular vasculitis has been associated with both nontuberculous infections and noninfectious conditions. However, there has been no report on the development of nodular vasculitis during tumor necrosis factor-alpha inhibitor treatment. A 28-year-old man visited our clinic for the treatment of severe psoriasis with a 20-year history. Subcutaneous injection of etanercept (25 mg, twice weekly) was started. One year later, erythematous nodules developed on his lower leg. A skin biopsy showed lobular panniculitis with extensive necrosis and vasculitis. To exclude latent tuberculosis, an assay specific for Mycobacterium tuberculosis antigens was performed, with a negative result. After stopping etanercept under the diagnosis of nodular vasculitis associated with etanercept, the lesions gradually disappeared, leaving depressed scars in 3 months. There has been no recurrence after 6 months of follow-up.

Keyword

Etanercept; Psoriasis; Vasculitis

MeSH Terms

Adult
Biopsy
Cicatrix
Diagnosis
Erythema
Follow-Up Studies
Humans
Injections, Subcutaneous
Latent Tuberculosis
Leg
Mycobacterium tuberculosis
Necrosis
Panniculitis
Psoriasis*
Recurrence
Skin
Tuberculosis
Tumor Necrosis Factor-alpha
Vasculitis*
Etanercept
Tumor Necrosis Factor-alpha

Figure

• 

  Fig. 1 (A) Erythematous tender nodule with crust on both lower legs. (B) Close-up view. (C) Three months later, the skin lesions gradually improved, leaving depressed scars.

• 

  Fig. 2 Skin biopsy specimen showing (A) septal and lobular panniculitis with extended necrosis (H&E, ×40) and (B) leukocytoclastic vasculitis and infiltration of inflammatory cells consisting of neutrophils and lymphocytes (H&E, ×100).

Reference

1. Montgomery RM. A case for diagnosis; dermatophytosis; nodular vasculitis? Arch Derm Syphilol. 1948; 57:580.

2. Patterson JW, Brown PC, Broecker AH. Infection-induced panniculitis. J Cutan Pathol. 1989; 16:183–193.

3. Sakuma H, Niiyama S, Amoh Y, Katsuoka K. Chlamydophila pneumoniae infection induced nodular vasculitis. Case Rep Dermatol. 2011; 3:263–267.

4. Segura S, Pujol RM, Trindade F, Requena L. Vasculitis in erythema induratum of Bazin: a histopathologic study of 101 biopsy specimens from 86 patients. J Am Acad Dermatol. 2008; 59:839–851.

5. Ural I, Erel A, Ozenirler S, Tekin NS, Gurert MA. Nodular vasculitis associated with chronic hepatitis C. J Eur Acad Dermatol Venereol. 2002; 16:298–299.

6. Westers-Attema A, van Tubergen A, Plasschaert H, van Marion AM, Frank J, Poblete-Gutiérrez P. Nodular vasculitis in systemic lupus erythematosus. Int J Dermatol. 2008; 47:Suppl 1. 3–6.

7. Wolf D, Ben-Yehuda A, Okon E, Naparstek Y. Nodular vasculitis associated with propylthiouracil therapy. Cutis. 1992; 49:253–255.

8. Kerensky TA, Gottlieb AB, Yaniv S, Au SC. Etanercept: efficacy and safety for approved indications. Expert Opin Drug Saf. 2012; 11:121–139.

9. Sokumbi O, Wetter DA, Makol A, Warrington KJ. Vasculitis associated with tumor necrosis factor-α inhibitors. Mayo Clin Proc. 2012; 87:739–745.

10. Moustou AE, Matekovits A, Dessinioti C, Antoniou C, Sfikakis PP, Stratigos AJ. Cutaneous side effects of anti-tumor necrosis factor biologic therapy: a clinical review. J Am Acad Dermatol. 2009; 61:486–504.

11. Fiorentino DF. The Yin and Yang of TNF-α inhibition. Arch Dermatol. 2007; 143:233–236.

12. Ramos-Casals M, Brito-Zerón P, Muñoz S, Soria N, Galiana D, Bertolaccini L, et al. Autoimmune diseases induced by TNF-targeted therapies: analysis of 233 cases. Medicine (Baltimore). 2007; 86:242–251.

13. Wong SS, Marks R. Cutaneous vasculitis in psoriasis. Acta Derm Venereol. 1994; 74:57–60.