Tocilizumab-induced psoriatic eruption : a case report and a case-based review

BACKGROUND

Cases of psoriasis associated with Tocilizumab (TCZ) are scarce.

OBJECTIVE

To describe a new case of TCZ-associated psoriasis and to perform a case-based review of similar cases.

METHODS

We searched Medline/Pubmed, Embase, Scopus, Web of Science, and Directory of Open Access Journals databases using the terms « Tocilizumab » and « Psoriasis » in the French and English literature.

RESULTS

We report a 70-year-old woman with a history of Rheumatoid Arthritis who developed Infliximab-induced plaque psoriatic eruption of the soles and palms, that resolved after Infliximab interruption, then relapsed after TCZ relay, and eventually resolved after TCZ interruption. Including our case, we identified 16 cases of TCZ-induced psoriatic eruption. Three (21%) out of 14 patients had a history of cutaneous psoriasis - data were not available for 2 patients. Eight (50%) patients had previously received TNFα antagonists. TCZ was stopped for 10 patients and continued for 4 patients. For the 2 remaining patients, the interval between two injections of TCZ was shortened. All the patients with available follow-up data had an improvement of the eruption within 4 weeks.

CONCLUSION

To conclude, in case of TCZ-induced psoriatic eruption and in light of the published cases, we suggest using topical steroids and reassessing the patient 4 weeks later. If no healing is obtained, we suggest stopping TCZ, and treating the underlying disease with another drug. When no other drug is available, while waiting for more data regarding the value of IL-6 levels, it can be discussed to increase TCZ regimen, as it has been successful for 2 authors. Efficacy assessment of the chosen attitude should not take place before 4 weeks.

Prevalence of cardiovascular risk factors in patients with psoriasis

OBJECTIVES

The main goal of the study was to describe the demographic, epidemiological, clinical and laboratory characteristics of a monitored group of patients with psoriasis to assess the prevalence of cardiovascular comorbidities and to define the cardiovascular risk profile.

METHODS

One hundred and ninety outpatients aged over 18 were included in the prospective observational cross-sectional study. Demographic and clinical data were obtained from patients. The severity of psoriasis was evaluated using the Psoriasis Area and Severity Index (PASI) and the Dermatology Life Quality Index (DLQI). The results of laboratory testing were identified based on patient health records.

RESULTS

Based on an evaluation of psoriasis phenotypes, 150 patients (78.95%) suffered from plaque psoriasis, 18 (9.5%) from palmoplantar psoriasis, 11 (5.8%) from guttate psoriasis, 6 (3.2%) from generalized pustular psoriasis, and 5 (2.6%) from erythrodermic psoriasis. The personal medical history discovered the occurrence of arterial hypertension in 83 patients (43.7%), the occurrence of depression in 49 patients (25.8%), type 2 diabetes in 29 patients (15.3%), and dyslipidaemia in 48 patients (25.3%).

CONCLUSION

It is noteworthy that psoriasis may be demonstrated as a multi-system disease which does not only affect the skin and its adnexa. The association of psoriasis with comorbidities may significantly increase morbidity and total mortality as well as the demands for health care provision.

[Which taxonomy for inflammatory diseases in rheumatology? The concept of Psout]

Clinical practice needs the identification of the patient disease. The physician has to rationalize symptoms allowing the recognition of a realistic entity and its classification in a reference nosology. Unlike other practices, the biomedical model uses scientific census methodology, from a tabular perspective to the definition of diseases. Due to its simplification process, it therefore neglects transitional or complex cases. In Rheumatology, this reasoning is challenged by the lack of objectivity and specificity of the items supporting the clinician when he builds the diagnosis, but also by the physiopathological complexity. Sometimes, diseases may be confused or superposed, possibly leading to the description of novel entities. The authors describe herein the difficulties encountered in practical clinical medicine. They show, from a concrete and real personal situation, how it can possibly lead to the justification of a new entity.

Cyclin-Dependent Kinase 7 Promotes Th17/Th1 Cell Differentiation in Psoriasis by Modulating Glycolytic Metabolism

Excessive activation of CD4⁺ T cells and T helper type (Th) 17/Th1 cell differentiation are critical events in psoriasis pathogenesis, but the associated molecular mechanism is still unclear. Here, using quantitative proteomics analysis, we found that cyclin-dependent kinase 7 (CDK7) expression was markedly increased in CD4⁺ T cells from patients with psoriasis compared with healthy controls and was positively correlated with psoriasis severity. Meanwhile, genetic or pharmacological inhibition of CDK7 ameliorated the severity of psoriasis in the imiquimod-induced psoriasis-like mouse model and suppressed CD4⁺ T-cell activation as well as Th17/Th1 cell differentiation in vivo and in vitro. Furthermore, the CDK7 inhibitor also reduced the enhanced glycolysis of CD4⁺ T cells from patients with psoriasis. Proinflammatory cytokine IL-23 induced increased CDK7 expression in CD4⁺ T cells and activated the protein kinase B/mTOR/HIF-1α signaling pathway, enhancing glycolytic metabolism. Correspondingly, CDK7 inhibition significantly impaired IL-23-induced glycolysis via the protein kinase B/mTOR/HIF-1α pathway. In summary, this study shows that CDK7 promotes CD4⁺ T-cell activation and Th17/Th1 cell differentiation by regulating glycolysis, thus contributing to the pathogenesis of psoriasis. Targeting CDK7 might be a promising immunosuppressive strategy to control skin inflammation mediated by IL-23.

An IL17RA frameshift variant in a Holstein cattle family with psoriasis-like skin alterations and immunodeficiency

BACKGROUND

Skin lesions and dermatoses in cattle are often associated with infections due to bacteria, fungi or environmental risk factors. Dermatoses with genetic etiology have been described in cattle. Among these rare disorders, there are primary congenital dermatoses that are associated with inherited nutritional deficiencies, such as bovine hereditary zinc deficiency or zinc deficiency-like syndrome. This study presents three cases of Holstein cattle with congenital skin lesions observed on a single farm that resemble zinc deficiency-like syndrome. Close clinical and pathological examinations took place in two cases. Pedigree analysis indicated autosomal recessive inheritance and whole-genome sequencing of both affected calves was performed.

RESULTS

The two calves showed retarded growth and suffered from severe ulcerative dermatitis with hyperkeratosis, alopecia furunculosis and subcutaneous abscess formation. Blood analysis showed correspondent leukocytosis with neutrophilia whereas minerals, macro- and micronutrients were within the reference ranges. Variant calling and filtering against the 1000 Bull Genomes variant catalogue resulted in the detection of a single homozygous protein-changing variant exclusively present in both sequenced genomes. This single-nucleotide deletion in exon 3 of IL17RA on bovine chromosome 5 was predicted to have a deleterious impact on the encoded protein due to a frameshift leading to a truncated gene product. Genotyping of the affected cattle family confirmed recessive inheritance.

CONCLUSIONS

A loss-of-function mutation of the IL17RA transmembrane protein could be identified as most likely pathogenic variant for the psoriasis-like skin alterations observed in the two affected Holstein calves. In man, rare recessive diseases associated with IL17RA include immunodeficiency 51 and chronic mucocutaneous candidiasis. This supports the observed immunodeficiency of the presented cases. This study reports the first naturally occurring IL17RA-associated animal model.

Diversity of KIR/HLA Genotypes and Their Association with Psoriasis Vulgaris in the Western Mexican Population

NK and some T cell functions are regulated by the interaction between KIR and HLA molecules. Several studies have shown an association between activating KIR genes and the development of autoimmune diseases, including psoriasis vulgaris (PsV). Our objective was to determine the association between KIR/HLA genes and genotypes with PsV in the Western mestizo Mexican population. One hundred subjects diagnosed with PsV (SP) and 108 healthy subjects (HS) were genotyped for 14 KIR genes, HLA-Bw4, HLA-C1, and HLA-C2 by PCR-single specific primer (SSP). Positive associations of the KIR3DS1 gene (odds ratio (OR) 1.959, p = 0.021), G11 genotype (OR 19.940, p = 0.008), and KIR3DS1/HLA-ABw4 (OR 2.265, p = 0.009) were found with susceptibility to PsV. In contrast, the G1 genotype (OR 0.448, p = 0.031) and KIR3DL1/HLA-Bw4Ile80 (OR 0.522, p = 0.022) were negatively associated with susceptibility to this disease. These results suggest an implication of the KIR3DS1/HLA-ABw4 genotype in PsV pathology.

Advances in Understanding the Immunological Pathways in Psoriasis

Psoriasis vulgaris is a chronic, immune-mediated, inflammatory, polygenic skin disorder affecting approximately 2% of the population. It has a great impact on quality of life; patients often experience depression, anxiety, stigma as well as suicidal behavior. Even though psoriasis is one of the most studied dermatological conditions, the pathogenesis of the disease is still not completely elucidated. The complex interactions between keratinocytes, dendritic cells, T-lymphocytes, neutrophils and mast cells are responsible for the histopathological changes seen in psoriasis. The pathogenic model leading to the formation of psoriatic plaques has however evolved a lot over the years. There is now enough evidence to support the role of interleukin (IL) -23, IL-17, IL-22, T helper (Th) -17 cells, Th-22 cells, T regulatory cells, transforming growth factor (TGF)-β1 and IL-10 in the pathogenesis of the disease. Moreover, several inflammatory and anti-inflammatory molecules are currently being investigated, some of them showing promising results. The aim of this paper is to look over the most recent advances in the immunological pathways involved in the pathogenesis of psoriasis vulgaris.

A catalog of potential putative functional variants in psoriasis genome-wide association regions

Psoriasis is a common inflammatory skin disease, with considerable genetic contribution. Genome-wide association studies have successfully identified a number of genomic regions for the risk of psoriasis. However, it is challenging to pinpoint the functional causal variants and then further decipher the genetic mechanisms underlying each region. In order to prioritize potential functional causal variants within psoriasis susceptibility regions, we integrated the genetic association findings and functional genomic data publicly available, i.e. histone modifications in relevant immune cells. We characterized a pervasive enrichment pattern of psoriasis variants in five core histone marks across immune cells/tissues. We discovered that genetic alleles within psoriasis association regions might influence gene expression levels through significantly affecting the binding affinities of 17 transcription factors. We established a catalog of 654 potential functional causal variants for psoriasis and suggested that they significantly overlapped with causal variants for autoimmune diseases. We identified potential causal variant rs79824801 overlay with the peaks of five histone marks in primary CD4+ T cells. Its alternative allele affected the binding affinity of transcription factor IKZF1. This study highlights the complex genetic architecture and complicated mechanisms for psoriasis. The findings will inform the functional experiment design for psoriasis.

[Role of fractalkine/CX3CL1 and its receptor CX3CR1 in allergic diseases]

Allergic asthma and atopic dermatitis are diseases mainly resulting from the activation of Th2 cells, that produce cytokines favouring IgE production and eosinophilia but also of Th1 cells, that contribute to inflammation chronicity. Lymphocyte recruitment and retention of Th cells in target organs are 2 key events for asthma and atopic dermatitis pathogenesis. While lymphocyte migration is regulated by chemokines and lipid mediators such as leukotrienes and prostaglandins, factors involved in lymphocyte retention and survival within inflammatory tissues remain poorly understood. Recent works show that, in allergic diseases, there is an increased expression of fractalkine/CX3CL1 and its unique receptor CX3CR1 and that this chemokine does not act as chemoattractant. In allergic asthma, CX3CR1 expression regulates Th2 and Th1 cell survival in the inflammatory lung, while, in atopic dermatitis, it regulate Th2 and Th1 cell retention into the inflammatory site. Use of peptides blocking fractalkine binding to its receptor is currently tested in the treatment of asthma and atopic dermatitis.