Crohn's Disease in which the Patient Developed Aortitis during Treatment with Adalimumab

Vasculitis induced by biological agents used in rheumatology practice: A systematic review

Objectives: Biological medications have been used with an increasing frequency to treat rheumatological diseases. Autoimmune events can be induced by these drugs, such as psoriasiform lesions, alopecia, lupus and, vasculitis, which more often affects the skin (small-sized vessels) and eventually other organs. In this review, we describe the clinical profile of patients with vasculitis induced by the main biological agents used in rheumatology.

Patients and methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The PubMed database was used for searching eligible articles. We included case reports, case series, and letter to the editor of patients on anti-tumor necrosis factor-alpha (anti-TNF-a) molecules, as well as tocilizumab, ustekinumab, secukinumab, rituximab, and abatacept, who had vasculitis induced by these agents.

Results: Eighty-one articles were included for final analysis (n=89). Twenty-seven patients were using infliximab, 20 adalimumab, 18 etanercept, seven secukinumab, four certolizumab, four rituximab, three golimumab, three ustekinumab, two abatacept, and one tocilizumab. Unspecific leukocytoclastic vasculitis (LCV) was the most common type of vasculitis (n=37), followed by anti-neutrophil cytoplasmic antibody (ANCA)- associated vasculitis (n=16). The medication was replaced with another biological molecule in 23 cases, with only four relapses. In six cases, the biological was maintained, but vasculitis worsened/persisted in one case, being necessary drug removal.

Conclusion: Infections, infusion reaction, cancer, and autoimmune events are well-known side effects of biological therapy. This review demonstrates that vasculitis is another adverse effect of this type of therapy, particularly the anti-TNF-a molecules, and LCV the most reported type of vasculitis.

Periaortitis induced by epirubicin and cyclophosphamide for a patient with advanced breast cancer

Aortitis is an extremely rare condition, and it may mimic febrile neutropenia during cancer chemotherapy. A 55-year-old female diagnosed with T2N1M1 stage IV breast carcinoma received chemotherapy with EC (epirubicin 90 mg/m² and cyclophosphamide 600 mg/m² every 3 weeks). At the eleventh day after the first administration of EC, she developed a high-grade fever of 38 °C and stomatitis. We started the intravenous administration of antibiotics at hospitalization, because the laboratory data showed normal white blood cell values 3800/μl but a severe inflammatory reaction (CRP 25.13 mg/dl). The fever and high CRP value continued, and the WBC rose to 14,500/μl at 20th day. However, her condition was stable. On the 25th day after the administration of EC, she complained of back pain, so we performed computed tomography (CT) again and observed thickening of the rind surrounding the descending aorta and bilateral pleural effusion, indicating acute periaortitis. We performed examinations concerning vasculitis and connective tissue disease, but the values were all within normal ranges showing no relationship with other diseases. We stopped the administration of antibiotics on the 20th day, and while we did not administer corticosteroids, however, the fever was resolved and her WBC decreased. She was discharged on day 33, and the other chemotherapy was restarted with pertuzumab, trastuzumab and docetaxel. The patient has remained well without inflammatory reactions. CT at 90 days after EC therapy showed the resolution of the thickened rind of the descending aorta and no aneurysmic changes.

Two Subsets of Large Vessel Vasculitis Characterized by the Absence or Presence of Spondyloarthritis or its Associated Diseases

Background:

Whilst large vessel vasculitis (LVV) predominantly occurs in isolation, associations with other infectious and non-infectious diseases have been reported. Limited data describing associations with various autoimmune diseases (AI), including spondyloarthritis exists. The aim of this study was to characterize the association of LVV and spondyloarthritis or its associated diseases (SpAD).

Methods:

A single centre, retrospective study of patients ≥50yrs with first presentation LVV between 01.06.2008-01.06.2015 was performed. Patients were categorized according to SpA or associated disease, other AI or idiopathic LVV (iLVV). Clinical, laboratory and imaging findings were compared. Kaplan-Meyer survival analysis, with relapse taken as the primary end-point, was performed.

Results:

LVV was confirmed in 62 pts, of who 16/62 (26%) had SpA or associated disease. In these patients, LVV presented earlier (59.2 SpAD vs. 68.1 AI and 70.3yrs iLVV; p=0.01) and occurred predominantly in spring compared to autumn and winter in non-SpA patients, was associated with more centralised pattern of distribution (p=0.05) and was more likely to exhibit a refractory course (p=0.05). Overall relapse rates were similar across groups. Smoking-status influenced age of onset in all groups, being associated with earlier onset.

Conclusion:

A clear association between LVV and SpAD exists. LVV associated with SpAD has a particular phenotype characterised by earlier onset, thorax-limited disease and increased risk of a refractory course. Given on-going LVV treatment trials further genetic and pathophysiological characterization appears warranted, to evaluate potential variation in treatment response and optimize future care.