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Wu A, Brown D, Wong U. A Rare Case of Leukocytoclastic Vasculitis Associated With Infliximab. GASTRO HEP ADVANCES 2022; 2:322-324. [PMID: 39132650 PMCID: PMC11307674 DOI: 10.1016/j.gastha.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/02/2022] [Indexed: 08/13/2024]
Abstract
Infliximab is a chimeric monoclonal antibody to tumor necrosis factor-α used commonly in several autoimmune conditions including Crohn's disease. We present a case of a 33-year-old man with inflammatory ileocolonic Crohn's disease who developed biopsy-proven leukocytoclastic vasculitis (LCV) exacerbated by a rechallenged dose of infliximab after years of tolerating the drug. To our knowledge, this is the first reported case of infliximab-associated LCV that occurred years after initiation of the drug. This case highlights that LCV can be a potential adverse reaction of infliximab, and health-care providers should consider a change in therapy.
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Affiliation(s)
- Angela Wu
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Danielle Brown
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Uni Wong
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Medicine, VA Maryland Health Care System, Baltimore, Maryland
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Phillips FM, Verstockt B, Sebastian S, Ribaldone D, Vavricka S, Katsanos K, Slattery E, de Suray N, Flores C, Fries W, Vincenzi F, Capoferro E, Bachmann O, Kopylov U. Inflammatory Cutaneous Lesions in Inflammatory Bowel Disease Treated With Vedolizumab or Ustekinumab: An ECCO CONFER Multicentre Case Series. J Crohns Colitis 2020; 14:1488-1493. [PMID: 32318735 DOI: 10.1093/ecco-jcc/jjaa078] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This was a multicentre case series supported by the European Crohn's and Colitis Organisation [ECCO] and performed as part of the Collaborative Network of Exceptionally Rare case reports [CONFER] project. The aim was to report on whether cutaneous lesions associated with inflammatory bowel disease [IBD] and refractory to standard medical therapy including anti-tumour necrosis factors [anti-TNFs], would respond to the newer biologic agents ustekinumab [UST] or vedolizumab [VDZ]. This report includes 28 patients with cutaneous lesions from 14 centres, all of whom had failed immunomodulator and anti-TNF therapy. Metastatic Crohn's disease [MCD] was diagnosed in 10 patients: UST led to remission in five cases and partial response in four cases, with a single report of VDZ inducing remission. All cases of MCD treated with UST responded after the first or second dose, and the median time for the five cases that attained remission was 5 months. Pyoderma gangrenosum [PG] was diagnosed in four cases: three of these attained remission with UST [median time to remission 4 months] and one case did not respond to VDZ. There were seven cases of erythema nodosum [EN]: UST led to remission in four cases and partial response in 1 case whilst VDZ had partial response in 2 cases and non-response in two cases. There were seven single cases of other inflammatory lesions. In summary, UST appears to be useful for different cutaneous lesions including MCD, PG, and EN, whereas VDZ does not appear to be useful for lesions that are independent of disease activity.
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Affiliation(s)
- Frank M Phillips
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals, Nottingham, UK
| | - Bram Verstockt
- University Hospitals Leuven, Gastroenterology and Hepatology, KU Leuven, Chronic Diseases, Metabolism and Ageing, TARGID-IBD Unit, Leuven, Belgium
| | - Shaji Sebastian
- Hull and East Yorkshire Hospitals NHS Trust, Inflammatory Bowel Disease Unit, University of Hull and York, Hull York Medical School, Hull, UK
| | | | | | - Konstantinos Katsanos
- University of Ioannina School of Medical Sciences, Gastroenterology, Ioannina, Greece
| | - Eoin Slattery
- University Hospital Galway, Gastroenterology, Galway, Ireland
| | - Nicholas de Suray
- Grand Hopital de Charleroi, Gastroenterology and Hepatology, Charleroi, Belgium University Hospital Saint-Luc, Gastroenterology and Hepatology, Bruxelles, Belgium
| | - Cristina Flores
- Hospital de Clinicas de Porto Alegre, Gastroenterology, Rio Grande do Sul, Brazil
| | - Walter Fries
- University Messina, Clinical Unit for Chronic Bowel Disorders, Messina, Italy
| | | | - Elvira Capoferro
- University of Parma, Gastroenterology and Endoscopy Unit, Parma, Italy, Sacro Cuore Don Calabria of Negrar, Negrar, Italy
| | - Oliver Bachmann
- Siloah St. Trudpert Klinikum, Gastroenterology, Pforzheim, Germany
| | - Uri Kopylov
- Sheba Medical Centre, Gastroenterology, Ramat Gan, Israel
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Leukocytoclastic vasculitis as a rare dermatologic manifestation of Crohn's disease mimicking cellulitis: a case report. BMC Gastroenterol 2020; 20:240. [PMID: 32727390 PMCID: PMC7389435 DOI: 10.1186/s12876-020-01371-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 06/09/2020] [Indexed: 12/12/2022] Open
Abstract
Background Leukocytoclastic vasculitis (LCV) is an immune-complex mediated vasculitis characterized by neutrophilic inflammation and nuclear debris in post capillary venules. LCV is a rare dermatologic manifestation of Crohn’s disease (CD) and may occur with the onset of the disease or any time after the diagnosis including the period of exacerbation. Case presentation We present a 70 year old woman with history of psoriasis and treatment refractory CD requiring monoclonal antibody therapy with ustekinumab. One month prior to the current admission, she developed abdominal pain, worsening diarrhea and was diagnosed with CD exacerbation for which she was given ustekinumab. While her abdominal symptoms mildly improved with ustekinumab, she developed new bilateral lower extremity rash initially treated with levofloxacin for presumed cellulitis. The rash consisted of mild erythematous, non-scaling patches with scattered non-palpable petechiae on the lower extremities with subsequent involvement of abdomen, lower back and buttocks. Abdominal exam showed diffuse tenderness without mass, guarding or rebound while reminder of physical exam was unremarkable. Following the failure of antimicrobial therapy, she was diagnosed with LCV by skin biopsy. Complete work up was negative for infectious, malignant and inflammatory etiologies of LCV. Patient improved with increased dose of budesonide and subsequently continued to tolerate ustekinumab without recurrence of LCV. Discussion and conclusion LCV is a rare form of vasculitis and one of the rarest dermatologic manifestations of CD, appearing at any stage of the disease. LCV has been associated with autoimmune diseases, infections, specific drugs (levofloxacin, ustekinumab), and malignancy. Clinical presentation of LCV is variable and frequently mistaken for cellulitis. LCV should be considered in differential diagnosis of bilateral lower extremity rash in patients with CD after infectious, malignant and auto-immune/inflammatory etiologies are excluded. Unlike erythema nodosum (EN) and pyoderma gangrenosum (PG), LCV requires biopsy for diagnosis. Most patients respond well to steroids without scarring.
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Costa-Moreira P, Lopes S, Santos AL, Pedrosa AF, Andrade P, Portugal R, Macedo G. Leukocytoclastic Vasculitis Related to Ustekinumab in a Crohn's Disease Patient: First Case Report and Literature Review. J Crohns Colitis 2020; 14:274-276. [PMID: 31267125 DOI: 10.1093/ecco-jcc/jjz128] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Leukocytoclastic vasculitis is a single-organ, skin-isolated small vessel vasculitis. It can be a side effect of many common drugs, including biological agents. Unlike with other drugs, leukocytoclastic vasculitis induced by biological agents may have a prolonged latency period. We report the first case of ustekinumab-induced leukocytoclastic vasculitis in a patient with inflammatory bowel disease.
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Affiliation(s)
- Pedro Costa-Moreira
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Portugal
| | - Susana Lopes
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Pathology Department, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - Ana Luísa Santos
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Portugal
| | - Ana Filipa Pedrosa
- Dermatology Department, Centro Hospitalar e Universitário São João, Porto Portugal
| | - Patrícia Andrade
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Portugal
| | - Raquel Portugal
- Pathology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Portugal
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Ko JS, Uberti G, Napekoski K, Patil DT, Billings SD. Cutaneous manifestations in inflammatory bowel disease: a single institutional study of non-neoplastic biopsies over 13 years. J Cutan Pathol 2016; 43:946-955. [DOI: 10.1111/cup.12777] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/30/2016] [Accepted: 07/22/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Jennifer S. Ko
- Department of Pathology; Cleveland Clinic Foundation; Cleveland OH USA
| | - Georgina Uberti
- Department of Pathology; Cleveland Clinic Foundation; Cleveland OH USA
| | - Karl Napekoski
- Department of Pathology; Edward Hospital; Naperville IL USA
| | - Deepa T. Patil
- Department of Pathology; Cleveland Clinic Foundation; Cleveland OH USA
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Abstract
Awareness of the extraintestinal manifestations of Crohn disease is increasing in dermatology and gastroenterology, with enhanced identification of entities that range from granulomatous diseases recapitulating the underlying inflammatory bowel disease to reactive conditions and associated dermatoses. In this review, the underlying etiopathology of Crohn disease is discussed, and how this mirrors certain skin manifestations that present in a subset of patients is explored. The array of extraintestinal manifestations that do not share a similar pathology, but which are often seen in association with inflammatory bowel disease, is also discussed. Treatment and pathogenetic mechanisms, where available, are discussed.
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Affiliation(s)
- Joshua W Hagen
- Department of Dermatology, University of Pittsburgh Medical Center, Medical Arts Building, 3708 Fifth Avenue, 5th Floor, Pittsburgh, PA 15213, USA
| | - Jason M Swoger
- Department of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop street, C-Wing, Mezzanine, Pittsburgh, PA 15213, USA
| | - Lisa M Grandinetti
- Department of Dermatology, University of Pittsburgh Medical Center, Medical Arts Building, 3708 Fifth Avenue, 5th Floor, Pittsburgh, PA 15213, USA.
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Cutaneous Vasculitis, Interstitial Pneumonia with Crazy-Paving Appearance, and Positive pANCA in a Patient with Severe Crohn's Disease. Case Rep Gastrointest Med 2014; 2014:485714. [PMID: 25371834 PMCID: PMC4209777 DOI: 10.1155/2014/485714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 07/12/2014] [Accepted: 08/05/2014] [Indexed: 12/27/2022] Open
Abstract
Cutaneous vasculitis, interstitial pneumonia with crazy-paving appearance on high-resolution computed tomography, and repeated positive perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) are rarely found together in patients with inflammatory bowel disease in the existing literature. We report the case of a Chinese patient previously diagnosed with cutaneous vasculitis and interstitial pneumonia, who presented with acute pain and mass in his right lower quadrant a couple of years later. The terminal ileum biopsy and postoperative pathology confirmed Crohn's disease (CD).
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Cutaneous manifestations in patients with inflammatory bowel diseases: pathophysiology, clinical features, and therapy. Inflamm Bowel Dis 2014; 20:213-27. [PMID: 24105394 DOI: 10.1097/01.mib.0000436959.62286.f9] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The skin is one of the most common extraintestinal organ system affected in patients with inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis. The skin manifestations associated with IBD are polymorphic and can be classified into 4 categories according to their pathophysiology: (1) specific, (2) reactive, (3) associated, and (4) induced by IBD treatment. Cutaneous manifestations are regarded as specific if they share with IBD the same granulomatous histopathological pattern: perianal or metastatic Crohn's disease (commonly presenting with abscesses, fistulas or hidradenitis suppurativa-like features) is the prototype of this setting. Reactive cutaneous manifestations are different from IBD in the histopathology but have close physiopathological links: pyoderma gangrenosum, a neutrophil-mediated autoinflammatory skin disease typically manifesting as painful ulcers, is the paradigm of this group. Among the cutaneous diseases associated with IBD, the most commonly seen are erythema nodosum, a form of panniculitis most commonly involving bilateral pretibial areas, and psoriasis, a T helper 1/T helper 17-mediated erythematous squamous inflammatory disease. Finally, the number of cutaneous adverse reactions because of IBD therapies is progressively increasing. The most frequent drug-induced cutaneous manifestations are psoriasis-like, eczema-like, and lichenoid eruptions, as well as cutaneous lupus erythematosus for biologics, and nonmelanoma skin cancer, mainly basal cell and squamous cell carcinomas for thiopurines.
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Huang BL, Chandra S, Shih DQ. Skin manifestations of inflammatory bowel disease. Front Physiol 2012; 3:13. [PMID: 22347192 PMCID: PMC3273725 DOI: 10.3389/fphys.2012.00013] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Accepted: 01/17/2012] [Indexed: 12/13/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a disease that affects the intestinal tract via an inflammatory process. Patients who suffer from IBD often have diseases that affect multiple other organ systems as well. These are called extraintestinal manifestations and can be just as, if not more debilitating than the intestinal inflammation itself. The skin is one of the most commonly affected organ systems in patients who suffer from IBD. The scientific literature suggests that a disturbance of the equilibrium between host defense and tolerance, and the subsequent over-activity of certain immune pathways are responsible for the cutaneous disorders seen so frequently in IBD patients. The purpose of this review article is to give an overview of the types of skin diseases that are typically seen with IBD and their respective pathogenesis, proposed mechanisms, and treatments. These cutaneous disorders can manifest as metastatic lesions, reactive processes to the intestinal inflammation, complications of IBD itself, or side effects from IBD treatments; these can be associated with IBD via genetic linkage, common autoimmune processes, or other mechanisms that will be discussed in this article. Ultimately, it is important for healthcare providers to understand that skin manifestations should always be checked and evaluated for in patients with IBD. Furthermore, skin disorders can predate gastrointestinal symptoms and thus may serve as important clinical indicators leading physicians to earlier diagnosis of IBD.
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Affiliation(s)
- Brian L Huang
- Department of Medicine, Cedars-Sinai Medical Center Los Angeles, CA, USA
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