Eosinophilia during psoriasis treatment with TNF antagonists

Hematologic side effects of biologics and kinase inhibitors used in rheumatologic diseases: a review of the current evidence

Treatment options for various rheumatologic diseases have been limited until the introduction of biologic agents and kinase inhibitor therapy in recent decades. Since their arrival, they have steadily been integrated into routine management. Given their wide use and overall successful outcomes, it becomes increasingly pertinent for clinicians to readily identify their side effects. Their effects can involve multiple organ systems, including hematologic. This review aims to identify and classify the range of hematologic effects associated with individual biologics and kinase inhibitors used for treatment of rheumatologic diseases.

Pathogenesis of Paradoxical Reactions Associated with Targeted Biologic Agents for Inflammatory Skin Diseases

Targeted biologic agents have dramatically changed the therapeutic landscape for immune-mediated inflammatory diseases, particularly in rheumatology and dermatology. Their introduction has resulted in a paradigm shift, i.e., they produce significant clinical improvements in most patients with such diseases. Nevertheless, a variety of adverse reactions associated with these agents have been observed, including so-called paradoxical reactions (PRs), which are a new class of adverse events. PRs involve the de novo development or worsening of immune-mediated inflammatory disease during treatment with a targeted biologic agent that is commonly used to treat the idiopathic counterpart of the drug-induced reaction. In addition, the efficacy of biologic agents targeting individual cytokines and the existence of PRs to them have provided proof that cytokines are key drivers of various immune-mediated inflammatory diseases and helped researchers elucidate the molecular pathways underlying the pathophysiology of these diseases. Here, a comprehensive review of the targeted biologic agents used to treat immune-mediated inflammatory diseases, particularly psoriasis and atopic dermatitis, is provided, with a specific focus on biologic agents that inhibit cytokine signaling involving tumor necrosis factor-α, interleukin (IL)-12/23 (p40), IL-17A (and the IL-17 receptor [R]), IL-23 (p19), and the IL-4Rα, and their associated PRs. The characteristic clinical manifestations and potential immunological mechanisms of the PRs induced by these biologic agents are also reviewed.

Successful prevention of secondary burn progression using infliximab hydrogel: A murine model

INTRODUCTION

Burn injury remains a serious cause of morbidity and mortality worldwide. Severity of burns is determined by the percentage of burned area compared to the body surface area, age of patient, and by the depth of skin and soft tissue involvement; these factors determine management as well as prospective outcomes. The pathophysiology of partial- to full-thickness burn conversion remains poorly understood and is associated with a worse overall prognosis. Recent studies have demonstrated that an altered inflammatory response may play a significant role in this conversion and therefore a reduction in early inflammation is crucial to ultimately decreasing burn severity and morbidity. We hypothesize that the application of a microcapillary gelatin-alginate hydrogel loaded with anti-TNF-α (infliximab) monoclonal antibodies to a partial-thickness burn will reduce inflammation within partially burned skin and prevent further progression to a full-thickness burn.

METHODS

Assembly of the microfluidic hydrogels is achieved by embedding microfibers within a hydrogel scaffold composed of a gelatin-alginate blend, which is then soaked in a solution containing anti-TNF-α antibodies for drug loading. 12 young (2-4 months) and 12 old (>16 months) mice were given partial thickness burns. The treatment cohort received the anti-TNF-α infused hydrogel with an occlusive dressing and the control cohort only received an occlusive dressing. Mice were euthanized at post-burn day 3 and skin samples were taken. Burn depth was evaluated using Vimentin immunostaining.

RESULTS

All mice in the treatment cohort demonstrated decreased conversion of burn from partial to full thickness injury (old = p < 0.01, young = p < 0.001) as compared to the control group. Old mice had greater depth of burn than young mice (p < 0.001). There were greater eosinophils in the treatment cohort for both young and old mice, but it did not reach statistical significance.

CONCLUSION

The application of a novel microcapillary gelatin-alginate hydrogel infused with anti-TNF-α antibody to partial thickness burns in mice showed reduction in partial to full thickness burn secondary progression as compared to controls using this murine model; this promising finding might help decrease the high morbidity and mortality associated with burn injuries.

Eosinophilia during natalizumab treatment: Incidence, risk factors and temporal patterns

Eosinophilia is common during natalizumab treatment for multiple sclerosis but risk factors are unknown. We aimed to identify demographic, clinical and laboratory characteristics predicting eosinophilia. Sustained eosinophilia occurred in 16.8%. Risk factors for sustained eosinophilia included baseline pre-treatment eosinophilia, medical conditions potentially associated with eosinophilia including allergies, and suboptimal compliance. One temporal profile was associated with the highest and most rapidly developing eosinophilia, and was less likely to resolve: in one such case, eosinophilia was symptomatic. Changes in eosinophil and lymphocyte counts were only weakly correlated, suggesting factors other than Very Late Antigen-4 (VLA-4) inhibition drive eosinophilia.

Comorbid Diagnosis of Eosinophilic Esophagitis and Inflammatory Bowel Disease in the Pediatric Population

BACKGROUND AND AIMS

The incidence and prevalence of eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD) are rising with similar patterns. Co-occurrence of both diseases in the same patient has been increasingly reported. We sought to examine the pediatric population with both EoE and IBD to better understand the epidemiology and clinical implications of this overlap.

METHODS

We conducted a retrospective case-control study at 2 tertiary care children's hospitals. Subjects with both EoE and IBD were identified and compared with randomly selected controls with EoE and IBD alone in terms of: demographics, atopic conditions, IBD classification, location and phenotype of Crohn disease (CD), IBD medications, endoscopic findings, and histopathology. Descriptive statistics summarized the data.

RESULTS

Sixty-seven subjects with dual-diagnosis were identified across both institutions. The prevalence of IBD in the EoE population was 2.2% and EoE in IBD was 1.5%. Subjects with both diseases were more likely to have IgE-mediated food allergy compared with IBD alone (36% vs 7%, P < 0.001). Subjects with CD-EoE were less likely to have perianal disease than CD alone (2% vs 20%, P = 0.004). There was no difference in fibrostenotic EoE between the dual-diagnosis group and EoE alone. Treatment with a TNF-alpha inhibitor (anti-TNF) for management of preexisting IBD was protective against development of EoE with a relative risk of 0.314 [95% confidence interval [CI] 0.159-0.619].

CONCLUSIONS

This is a unique population in whom the underlying pathway leading to dual-diagnosis is unclear. Concomitant atopic conditions, especially IgE-mediated food allergy, and medication exposures, particularly anti-TNFs, may help predict likelihood of developing dual-diagnosis.

Eosinophilic Gastroenteritis in an Ulcerative Colitis Patient During Treatment with Tumor Necrosis Factor-alpha Antagonist

A 45-year-old man with steroid-dependent ulcerative pancolitis was hospitalized with frequent diarrhea, abdominal pain and distension 3 months after induction of golimumab, a tumor necrosis factor-alpha antagonist. Computed tomography showed wall thickening from the stomach to the colon and massive ascites. Peripheral blood test revealed eosinophilia. A large number of eosinophils were observed in the ascites fluid. Although esophagogastroduodenoscopy showed no abnormal findings and colonoscopy showed ulcerative colitis with a Mayo endoscopic subscore of 1, eosinophil infiltration was histologically observed. Based on these findings, we diagnosed him with eosinophilic gastroenteritis and started prednisolone. Consequently, his eosinophil counts and abdominal symptoms dramatically improved.

Investigation of the relationship between atopy and psoriasis

Introduction

The relationship between allergic and autoimmune diseases is an important issue, which has recently attracted the researchers’ interest.

Aim

To determine the relationship between atopy and psoriasis.

Material and methods

This case-control study was conducted on 102 patients referred to the Ghaem Hospital, Mashhad, Iran, in 2016. The participants were assigned into two groups: experimental and control groups, including the patients suffering from psoriasis and those with no history of cutaneous or other systemic diseases, respectively. Both groups filled in the ISAAC questionnaire and had skin prick tests. In addition, the serum levels of immunoglobulin E (IgE) and blood eosinophil cell count were measured. The data were analysed using the regression test through SPSS version 16.

Results

According to the results of the ISAAC questionnaire, there was a significant difference between the control and experimental groups in terms of asthma (p = 0.04). The mean serum concentrations of IgE and eosinophil cell count were not significantly different between the experimental (153.93 IU/ml and 187.77 cells/μl, respectively) and control groups (152.19 IU/ml and 187.68 cells/μl, respectively) (p = 0.057 and p = 0.886, respectively). In addition, there was an indirect correlation between the eosinophil cell count and psoriasis severity (p = 0.032, r = –0.297). Furthermore, the comparison of the skin prick test results revealed no significant difference between the two groups regarding the number of positive and negative cases (p = 0.436).

Conclusions

The findings suggested that atopy was not common in the patients with psoriasis and supported the concept that atopy protects against such autoimmune diseases such as psoriasis.

Long-term effects of biologic therapies on peripheral blood eosinophils in patients with psoriasis: a 3-year single-center study

Background: Biologic therapies (BTs), etanercept, infliximab, adalimumab, and ustekinumab, are generally well-tolerated and safe agents in psoriasis management.Objectives: To determine the overall effect of BTs on peripheral blood eosinophil count (PBEc) and percentage (PBEp), peripheral blood basophil count (PBBc) and percentage (PBBp), white blood cell count (WBCc), erythrocyte sedimentation rate (ESR), and serum C-reactive protein (s-CRP) level during a 3-year follow-up in patients with psoriasis.Methods: This retrospective cohort study included 200 patients (116 men; 84 women) treated continuously with BTs for 3 years for plaque-type, pustular, or nail psoriasis. Patient data were reviewed from medical charts. During routine laboratory investigation at baseline and every 3 months thereafter up to 3 years, the PBEp, PBEc, PBBp, PBBc, WBCc, ESR, and s-CRP level were monitored. Generalized estimating equations were used to compare consecutive data.Results: Seventy patients received infliximab (35%); 34 (17%), etanercept; 44 (22%), adalimumab; and 52 (26%), ustekinumab. The mean PBEp and PBEc significantly increased starting from 3 months after BT (both p<.001). The mean PBEp and PBEc significantly increased during follow-up compared with the baseline values (PBEp (%): 1.49 ± 0.1 (1st month) vs. 2.29 ± 0.14 (3rd month), p<.001 and 1.49 ± 0.1 (1st month) vs. 2.17 ± 0.18 (36th month), p=.004; PBEc (×10³/µL): 115.80 ± 6.32 (1st month) vs. 174.9 ± 10.08 (3rd month), p<.001 and 115.80 ± 6.32 (1st month) vs. 162.9 ± 12.86 (36th month), p<.001). However, the mean PBBp, PBBc, WBCc, ESR, and s-CRP level did not change significantly.Conclusions: The PBEc and PBEp increase with BTs up to 3 years in patients with psoriasis. This increase is observed at as early as 3 months of BT and maintained thereafter.

The relationship between blood eosinophil count and disease activity in ankylosing spondylitis patients treated with TNF-α inhibitors

Aim

Anti-tumor necrosis factor-alpha (Anti-TNF-α) therapy has achieved an important position, are widely used for ankylosing spondylitis (AS) patients. TNF-α inhibition improves clinical outcomes and has differential effects on haematopoiesis. Information about effects on eosinophils is limited. The aim of our study is to determine the relationship between blood eosinophil counts in AS patients treated with TNF-α inhibitors.

Methods

Seventy-five patients diagnosed with AS according to modified New York criteria were enrolled in this study. Disease activity was assessed by BASDAI, and erythrocyte sedimentation rate, C-reactive protein of patients were evaluated. All data were analyzed with Spearman’s correlation and Friedman's Two-Way by using SPSS version 19.0 statistical software, and p < 0.05 was considered as statistically significant.

Results

Seventy-five AS (F/M: 27/48, the mean age of 41 ± 10 years) patients were evaluated. On the 3rd month of treatment, there was a correlation between BASDAI and CRP (r = 0.32, p = 0.005), but no correlation between BASDAI and ESR (r = 0.21, p = 0.06). Blood eosinophil count was not correlated with BASDAI, ESR and CRP on pre-, post-therapy (p > 0.05). It counts lower before anti-TNF-α therapy compare with post-treatment (130/mm³, 140/mm³ and 190/mm³, respectively). There was no statistically significant difference between pre- and 3rd month (p > 0.05), while correlation was found between pre- and 6th month, and also 3rd month and 6th month (p < 0.001, p = 0.002, respectively) for blood eosinophil count.

Conclusion

To the best of our knowledge, our study is the first to evaluate blood eosinophil counts and disease activity with anti-TNF-α therapy. Blood eosinophil count may be affected by TNF-α inhibition in patients with AS.

Immune response patterns in non-communicable inflammatory skin diseases

Non-communicable inflammatory skin diseases (ncISD) such as psoriasis or atopic eczema are a major cause of global disease burden. Due to their impact and complexity, ncISD represent a major challenge of modern medicine. Dermatology textbooks describe more than 100 different ncISD based on clinical phenotype and histological architecture. In the last decades, this historical description was complemented by increasing molecular knowledge - and this knowledge is now being translated into specific therapeutics. Combining the enormous advances made in lymphocyte immunology and molecular genetics with clinical and histological phenotyping reveals six immune response patterns of the skin - type I immune cells cause the lichenoid pattern characterized by immune-mediated cell death of keratinocytes; type II immune cells underlie the eczematous pattern with impaired epidermal barrier, infection and eosinophils as well as the bullous pattern with loss of epithelial integrity; Th17 cells and ILC3 mediate the psoriatic pattern characterized by acanthosis, high metabolic activity and neutrophils; dysbalance of regulatory T cells causes either the fibrogenic pattern with rarefication of cells and dermal thickening or the granulomatous pattern defined by formation of granulomas. With more and more specific therapeutic agents approved, classifying ncISD also according to their immune response pattern will become highly relevant. This review defines the six immune response patterns of ncISD and highlights therapeutic strategies targeting key lymphocyte mediators.

Analysis of anti-tumour necrosis factor-induced skin lesions reveals strong T helper 1 activation with some distinct immunological characteristics

BACKGROUND

Psoriasiform and eczematous eruptions are the most common dermatological adverse reactions linked to anti-tumour necrosis factor (TNF)-α therapy. Yet, a detailed characterization of their immune phenotype is lacking.

OBJECTIVES

To characterize anti-TNF-α-induced inflammatory skin lesions at a histopathological, cellular and molecular level, compared with psoriasis, eczema (atopic dermatitis) and healthy control skin.

METHODS

Histopathological evaluation, gene expression (quantitative real-time polymerase chain reaction) and computer-assisted immunohistological studies (TissueFAXS) were performed on 19 skin biopsies from patients with inflammatory bowel disease (n = 17) and rheumatoid arthritis (n = 2) with new-onset inflammatory skin lesions during anti-TNF-α-therapy.

RESULTS

Although most biopsies showed a psoriasiform and/or spongiotic (eczematous) histopathological architecture, these lesions were inconsistent with either psoriasis or eczema on a molecular level using an established chemokine (C-C motif) ligand 27/inducible nitric oxide synthase classifier. Despite some differences in immune skewing depending on the specific histopathological reaction pattern, all anti-TNF-α-induced lesions showed strong interferon (IFN)-γ activation, at higher levels than in psoriasis or eczema. IFN-γ was most likely produced by CD3/CD4/Tbet-positive T helper 1 lymphocytes.

CONCLUSIONS

New-onset anti-TNF-α-induced eruptions previously classified as psoriasis or spongiotic dermatitis (eczema) exhibit a molecular profile that is different from either of these disorders.

Eosinophils from Physiology to Disease: A Comprehensive Review

Despite being the second least represented granulocyte subpopulation in the circulating blood, eosinophils are receiving a growing interest from the scientific community, due to their complex pathophysiological role in a broad range of local and systemic inflammatory diseases as well as in cancer and thrombosis. Eosinophils are crucial for the control of parasitic infections, but increasing evidence suggests that they are also involved in vital defensive tasks against bacterial and viral pathogens including HIV. On the other side of the coin, eosinophil potential to provide a strong defensive response against invading microbes through the release of a large array of compounds can prove toxic to the host tissues and dysregulate haemostasis. Increasing knowledge of eosinophil biological behaviour is leading to major changes in established paradigms for the classification and diagnosis of several allergic and autoimmune diseases and has paved the way to a "golden age" of eosinophil-targeted agents. In this review, we provide a comprehensive update on the pathophysiological role of eosinophils in host defence, inflammation, and cancer and discuss potential clinical implications in light of recent therapeutic advances.

Immunologic, microbial, and epithelial interactions in atopic dermatitis

OBJECTIVE

To provide an overview of studies contributing to the understanding of immunologic, microbial, and epithelial interactions in atopic dermatitis.

DATA SOURCES

PubMed literature review (2000-2017) and meeting abstracts from recent international dermatology conferences.

STUDY SELECTIONS

Articles discussing primarily human disease.

RESULTS

Clinical studies showed that atopic dermatitis is a type 2 immune-centered disease with a systemic inflammatory component but with heterogeneous treatment responses. This suggests that other factors are likely involved in shaping the skin disease phenotype, including microbial dysbiosis and epidermal barrier dysfunction.

CONCLUSION

Recent clinical investigation has significantly expanded our knowledge on disease pathogenesis in atopic dermatitis, and current and future clinical trials will most likely further help to elucidate this complex, heterogeneous skin disease.

Loeffler Endocarditis: A Unique Presentation of Right-Sided Heart Failure Due to Eosinophil-Induced Endomyocardial Fibrosis

Loeffler endocarditis is a rare restrictive cardiomyopathy caused by abnormal endomyocardial infiltration of eosinophils, with subsequent tissue damage from degranulation, eventually leading to fibrosis. Although an uncommon entity, it is still a disease with significant morbidity and mortality. Often identified only at late stages, treatment options are limited once fibrosis occurs, usually requiring heart failure medications or surgical intervention. We present a unique case of a woman with remote history of hypereosinophilic syndrome, attributed to treatment of rheumatoid arthritis with infliximab, who presented with symptoms of heart failure refractory to medical management and was found to have Loeffler endocarditis. The severe progression of the disease required surgical intervention with endocardial stripping to treat the right-sided diastolic heart failure.

Biologic response modifiers: Indications, implications, and insights

The field of biologic immune modulators is currently mushrooming at a dizzying pace. Although most of these biologics are tested and approved for one or a few indications, their unanticipated side effects and off-label use have contributed significantly to our understanding of basic immune mechanisms, the involvement of cytokines in several apparently nonimmunologic diseases, and the importance of compartmentalized immune responses. In this review we attempt to give a bird's-eye view of the major biologics and to highlight insights and implications derived from their secondary effects and adverse reactions.

Successful Switch to Golimumab for Eosinophilia and Skin Symptoms Related to Multiple Biologics in a Patient with Rheumatoid Arthritis

Biologics used in the treatment of rheumatoid arthritis (RA) rarely cause eosinophilia. We herein report a patient with RA being treated with infliximab, adalimumab, and tocilizumab who developed eosinophilia with skin symptoms. Interestingly, the marked eosinophilia and skin symptoms did not reappear after the patient's medication was switched to golimumab. In this case, the presence of biologics-specific antibodies suggested that immunogenicity caused the eosinophilia. Therefore, switching to a biologic with a lower immunogenicity was effective. These findings may be helpful for clinicians treating patients with biologics-induced eosinophilia.

Eosinophilic Drug Allergy

While peripheral or tissue eosinophilia may certainly characterize drug eruptions, this feature is hardly pathognomonic for a medication-induced etiology. While delayed drug hypersensitivity reactions with prominent eosinophilic recruitment have been typically classified as type IVb reactions, their pathophysiology is now known to be more complex. Eosinophilic drug reactions have a diversity of presentations and may be benign and self-limited to severe and life-threatening. The extent of clinical involvement is also heterogeneous, ranging from isolated peripheral eosinophilia or single organ involvement (most often the skin and lung) to systemic disease affecting multiple organs, classically exemplified by drug-reaction with eosinophilia and systemic symptoms (DRESS). The spectrum of implicated medications in the causation of DRESS is ever expanding, and multiple factors including drug metabolites, specific HLA alleles, herpes viruses, and immune system activation have been implicated in pathogenesis. Due to this complex interplay of various factors, diagnostic workup in terms of skin and laboratory testing has not been validated. Similarly, the lack of controlled trials limits treatment options. This review also describes other localized as well as systemic manifestations of eosinophilic disease induced by various medication classes, including their individual pathophysiology, diagnosis, and management. Given the multitude of clinical patterns associated with eosinophilic drug allergy, the diagnosis can be challenging. Considerable deficits in our knowledge of these presentations remain, but the potential for severe reactions should be borne in mind in order to facilitate diagnosis and institute appropriate management.

Eosinophilia--A rare possible adverse reaction during anti-tumor necrosis factor-alpha therapy for psoriasis

The current use of tumor necrosis factor (TNF)-alpha inhibitors in rheumatological, dermatological and gastroenterological diseases has increased considerably in recent years. Different reports have been communicated regarding specific risks and side effects during treatment with TNF-alpha inhibitors. Eosinophilia has been linked to TNF-alpha inhibitors by several recent reports, although it is not listed as a possible adverse reaction in the product information of the drug. The aim of the present study was to evaluate the eosinophil count in patients diagnosed with psoriasis and treated with adalimumab. Based on the results of the present study, eosinophilia remains a rare adverse reaction during psoriasis treatment with TNF-alpha antagonists.

Biologics-induced autoimmune diseases

PURPOSE OF REVIEW

Biological agents are therapies designed to target a specific molecular component of the immune system, and are currently licensed for use in autoimmune rheumatic, digestive, dermatological and systemic diseases. However, their use has been linked with the paradoxical development of autoimmune processes.

RECENT FINDINGS

More than 1500 cases of autoimmune diseases induced by biologics have been reported, including a wide variety of both systemic (lupus, vasculitis, sarcoidosis, antiphospholipid syndrome and inflammatory myopathies) and organ-specific (interstitial lung disease, uveitis, optic neuritis, peripheral neuropathies, multiple sclerosis, psoriasis, inflammatory bowel disease and autoimmune hepatitis) autoimmune processes. Although these processes are overwhelmingly associated with anti-TNF agents, recent cases have been associated with therapies directed against other cytokines, B or T-cells, illustrating that even though targeting a particular immune molecule may be associated with an excellent clinical response in most patients, an unexpected autoimmune response may arise in some cases.

SUMMARY

As the use of biological therapies expands, the number and diversity of induced autoimmune disorders should be expected to increase. Paradoxically, for many of these drug-related processes, current treatment indications include the very biological agent producing the adverse event.