Lupus-like syndrome attributable to anti-tumor necrosis factor alpha therapy in 14 patients during an 8-year period at Mayo Clinic

Molecular consideration relevant to the mechanism of the comorbidity between psoriasis and systemic lupus erythematosus (Review)

Systemic lupus erythematosus (SLE), a common autoimmune disease with a global incidence and newly diagnosed population estimated at 5.14 (range, 1.4-15.13) per 100,000 person-years and 0.40 million people annually, respectively, affects multiple tissues and organs; for example, skin, blood system, heart and kidneys. Accumulating data has also demonstrated that psoriasis (PS) can be a systemic inflammatory disease, which can affect organs other than the skin and occur alongside other autoimmune diseases, such as inflammatory bowel disease, multiple sclerosis, rheumatoid arthritis and SLE. The current explanations for the possible comorbidity of PS and SLE include: i) The two diseases share susceptible gene loci; ii) they share a common IL-23/T helper 17 (Th17) axis inflammatory pathway; and iii) the immunopathogenesis of the two conditions is a consequence of the interactions between IL-17 cytokines with effector Th17 cells, T regulatory cells, as well as B cells. In addition, the therapeutic efficacy of IL-17 or TNF-α inhibitors has been demonstrated in PS, and has also become evident in SLE. However, the mechanisms have not been investigated. To the best of our knowledge, there remains a lack of substantial studies on the correlation between PS and SLE. In the present review, the literature, with regards to the epidemiology, genetic predisposition, inflammatory mechanisms and treatment of the patients with both PS and SLE, has been reviewed. Further investigations into the molecular pathogenic mechanism may provide drug targets that could benefit the patients with concomitant PS and SLE.

Anti-TNFα induced lupus due to infliximab therapy in a patient with concurrent Crohn's disease

Anti-TNFα inhibitor-induced Lupus (ATIL) is a rare syndrome characterized by a wide array of symptoms ranging from skin manifestations to organ-specific symptoms such as pleural effusions, pericardial effusions, hepatotoxicity, etc. Infliximab is implicated in most cases, and ATIL usually develops between the first month and 4 years of infliximab application. In this report, we present an interesting case of ATIL that developed rather gradually upon anti-TNFa used to treat Crohn's disease. The patient presented with oral ulcers, photosensitive rash, diffuse alopecia, inflammation of the hands, and pleuritic chest pain. Comprehensive serological testing revealed the presence of antinuclear antibodies and anti-DNA antibodies. During the evaluation, the patient developed headaches, followed by a brain MRI that suggested nonspecific white matter lesions. Given the chronic development of symptoms, invasive examinations such as an arteriogram were performed to exclude CNS vasculitis, which showed no evidence of the vasculitis. Therefore, in the absence of any clear radiographical signs of vasculitis, patients should not undergo invasive studies, including an angiogram. The CNS angiogram can be associated with several side effects, including damage to the blood vessel, bruising or bleeding at the puncture site, and infection, which can further aggravate ATIL. Although rare, ATIL should always be considered while evaluating a patient with suggestive symptoms on infliximab therapy. Further research on identifying the variety of clinical presentations of ATIL and the underlying pathophysiology can help improve health policy and clinical practice by reducing unnecessary examination and allowing early management and better-quality care.

Adalimumab-Induced Lupus Serositis: A Case Report and Review of the Literature

Tumor necrosis factor-alpha (TNF-alpha) antagonist use is prevalent for the treatment of autoimmune diseases, including psoriasis, ankylosing spondylitis, and rheumatoid arthritis. Since the onset of its use over the last couple of decades, there have been increasing reports of drug-induced antibodies and antitumor necrosis factor-alpha-induced lupus (ATIL). Herein, we present a case of pericarditis induced by tumor necrosis factor-alpha antagonist, adalimumab. A 61-year-old male with psoriatic arthritis treated with adalimumab injections for five years presented with dyspnea, chest tightness, and three-pillow orthopnea. Echocardiogram showed moderate pericardial effusion with early signs of tamponade. Adalimumab was discontinued. He was started on colchicine and steroids for a high suspicion of drug-induced serositis. With the increased use of tumor necrosis factor-alpha antagonists, adverse reactions such as ATIL will become more common. Such cases need to be reported to spread awareness of this possible complication and avoid any delay in treatment and care.

LAight® Therapy Is an Effective Treatment Option to Maintain Long-Term Remission of Hurley I and II Hidradenitis Suppurativa: Results from Period B of RELIEVE, a Multicenter Randomized, Controlled Trial

BACKGROUND

Hidradenitis suppurativa is a chronic, inflammatory, burdensome skin disease where current first-line treatments are limited to topical and/or systemic antibiotics which cannot be applied for long-term disease management. Period B of the RELIEVE study analyzes whether LAight® therapy can sustain or even increase remission after a first topical antibiotic treatment cycle.

METHODS

The RELIEVE study was performed as a two-period multicenter randomized controlled trial with blinded assessment. For period A from week 0 to week 16, the 88 participating Hurley I and II patients were randomized to either a group receiving topical clindamycin 1% solution combined with 8 additional bi-weekly treatments with LAight® therapy (group TC + L) or a group which was treated with topical clindamycin 1% solution only (group TC). After 16 weeks, patients entered open-label period B and both groups were treated exclusively with LAight® therapy for an additional 16 weeks (8 sessions, group TC + L/L and group TC/L).

RESULTS

In total, 88 patients were enrolled in RELIEVE. Seventy-eight patients entered period B; 39 belonged to group TC + L/L and 39 to group TC/L. The IHS4-response at the start of period B was 62% (group TC + L/L) and 33% (group TC + L). During the 16 weeks of additional monotherapy with LAight, in both groups >90% of patients who responded to therapy in period A maintained their IHS4-response at week 32. IHS4 response rates continued to rise up to 79% of the TC + L/L group and up to 71% of the TC/L group during period B at week 32. Achievement of HiSCR and certain patient reported outcomes confirmed primary endpoint results.

CONCLUSION

LAight® therapy is an effective approved therapy option for Hurley I and II HS that can be used continuously to maintain treatment success. During 16 weeks of follow-up in period B, over 90% of patients with response after period A maintained their treatment outcome, while more than 60% of prior nonresponders gained response. The fact that LAight® therapy can be applied continuously, is very effective and is well tolerated makes it a valuable treatment tool in the design of HS long-term treatment modalities.

Anti-TNF-alpha-induced lupus in patients with non-infectious uveitis

PURPOSE

Anti-TNF-α-induced lupus (ATIL) is a rare condition considered as a drug-induced lupus (DIL) in patients under anti-TNF-α therapies. Nowadays it is still unclear if ATIL is a classical DIL or represent a distinct syndrome. Some characteristics of DIL have been described specifically associated with patients with lupus-like syndrome receiving anti-TNF-α therapy: the severity of the disease, incidence/prevalence of dsDNA antibodies (anti-dsDNA) and hypocomplementaemia. The objective of this study is to describe the development of ATIL in patients with non-infectious uveitis in a single tertiary center.

METHODS

Retrospective description of a case series.

RESULTS

We describe three patients with noninfectious uveitis (NIU) of different etiologies who developed antinuclear antibody (ANA) and anti-dsDNA antibody positivity, arthritis and, in one case, skin lesions under adalimumab treatment. The condition resolved in all of them after adalimumab withdrawal. Corticosteroids were required in one patient, non-steroidal anti-inflammatory drugs in two patients, and hydroxychloroquine in one of them. None required another immunosuppressive drug. A subsequent control of the NIU could continue to be carried out without anti-TNF-α therapy in two patients and in the remaining a switch was made to another anti-TNF-α (golimumab).

CONCLUSION

The current report describes three cases of ATIL in patients with different types of NIU which share some common features: ANA positivity, articular symptoms, and a temporal relationship between symptoms onset and anti-TNF-α treatment. A review of the literature and comparison with the few previous reported ATIL cases was conducted as well.

Case report of severe constrictive perimyocarditis and ischemic hepatitis in a Crohn's disease patient upon infliximab-induced lupus-like syndrome

Anti-tumor necrosis factor (TNF) antibodies have become an indispensable part in the therapeutic landscape of treating inflammatory bowel disease (IBD) patients. Nevertheless, they can be associated with the occurrence of severe systemic side effects. Here, we report the case of a 23-year-old patient with ileocolonic Crohn's disease in endoscopic remission under ongoing anti-TNF infliximab therapy with occurrence of novel generalized arthralgia, pleuritic chest pain, and dyspnea. Clinical, laboratory, and imaging diagnostic workup in an extended clinical routine setting at the University Hospital of Erlangen, Germany, was used by a multidisciplinary team consisting of gastroenterologists, radiologists, cardiologists, and rheumatologists to investigate the underlying cause of the clinical symptoms in the patient. The results received using the aforementioned diagnostic setup led to the diagnosis of severe constrictive perimyocarditis due to infliximab-induced lupus-like syndrome with distinct ANA reactivity and elevated anti-dsDNA levels. Furthermore, pronounced ischemic hepatitis was diagnosed. Infliximab treatment was immediately stopped, and initiated corticosteroid pulse therapy only led to partial response as it had to be reduced due to pronounced psychiatric side effects. Persistent signs of pericarditis required additional ibuprofen therapy, which led to subsequent resolution of cardial symptoms. Formerly elevated liver enzymes returned to normal, and there were no clinical signs of recurrence of Crohn's disease activity over 18 months of follow-up. The patient was subsequently switched to ustekinumab therapy for further treatment of underlying Crohn's disease. This case report describes for the first time severe infliximab-induced lupus-like syndrome in an IBD patient, concurrently mimicking ST-elevation myocardial infarction with MRI visualization of pericarditis, occurrence of ischemic hepatitis, and pronounced signs of systemic inflammation.

Anti-tumor necrosis factor-induced lupus in patients with inflammatory bowel disease: a hospital-based cohort study from Korea

BACKGROUND

Anti-tumor necrosis factor (TNF) agents are increasingly used for rheumatic diseases and inflammatory bowel disease (IBD), but are associated with the development of anti-TNF-induced lupus (ATIL). Nonetheless, few ATIL studies on non-Caucasian IBD patients exist. Here, we investigated the incidence, clinical features, and risk factors of ATIL in Korea.

METHODS

We retrospectively reviewed the medical records of IBD patients undergoing anti-TNF therapy at our tertiary IBD center between 2008 and 2020. ATIL was diagnosed as a temporal association between symptoms and anti-TNF agents, and the presence of at least one serologic and non-serologic American College of Rheumatology criterion. The risk factors for ATIL occurrence were assessed using multivariate Cox regression analysis.

RESULTS

Of 1362 IBD patients treated with anti-TNF agents, 50 (3.7%) ATIL cases were suspected, of which 14 (1.0%) received a definitive diagnosis. Arthritis and mucocutaneous symptoms were observed in 13 and 4 patients, respectively. All ATIL cases were positive for anti-nuclear and anti-dsDNA antibodies. Four patients (30.8%) improved while continuing anti-TNF therapy. At the final follow up, the ATIL group (n = 14) had a lower IBD remission rate (30.8% versus 68.8%, p = 0.019) than the non-ATIL group (n = 36). Ulcerative colitis and longer disease duration were associated with ATIL occurrence, with hazard ratios of 7.017 (p = 0.005) and 1.118 (p = 0.002), respectively.

CONCLUSION

Although rare, ATIL is associated with poor treatment response to IBD in Korean patients. ATIL should be considered if arthritis and mucocutaneous symptoms develop during anti-TNF therapy for IBD.

The Effect of Biological Agents on Antinuclear Antibody Status in Patients with Psoriasis: A Single-Center Study

Background and Aims:

Biological agents are being used as treatment of psoriasis for years. However, autoimmunity can develop after the using of these agents. Antinuclear antibody (ANA) status changes during biological therapy can be affected by certain factors including the presence of immunosuppression. We aimed to evaluate the effect of antitumor necrosis factor agents and ustekinumab on ANA status, as well as other factors leading to change in ANA status such as history of phototherapy and methotrexate combination therapy.

Methods:

In this study, the laboratory findings of thirty-one patients with psoriasis who received biological agents including infliximab, etanercept, adalimumab, and ustekinumab from 2016 to 2018 managed at the department of dermatology were reviewed. The ANA status of the patients was evaluated every 2–3 months.

Results:

Twelve (38.7%) out of the thirty-one patients developed ANA positivity during treatment. Nine patients receiving infliximab, two patients receiving etanercept, and one patient receiving adalimumab developed ANA positivity. The nuclear homogeneous, nuclear fine speckled, and nuclear large/coarse speckled were the most common patterns of ANA. A patient receiving infliximab also developed anti-dsDNA positivity. None of the patients developed drug-induced lupus erythematosus or any autoimmune diseases. Concomitant methotrexate use and phototherapy history had no effect on ANA status statistically (P = 0.240 and 0.717, respectively).

Conclusion:

The emergence of ANA positivity during infliximab therapy among all biological agents was more common. ANA positivity during biologic agents does not cause any signs and symptoms of autoimmune diseases in patients with psoriasis; thus, it can be suggested that biological agents are not major risk factors for autoimmunity.

Presence of anti-nuclear antibodies is a risk factor for the appearance of anti-drug antibodies during infliximab or adalimumab therapy in patients with rheumatoid arthritis

This study aimed to directly analyze the potential relationship of anti-nuclear antibodies (ANA) before and after the administration of TNF-α inhibitors (TNFi) with the appearance of anti-drug antibodies (ADrA) in patients with rheumatoid arthritis (RA). A total of 121 cases, viz., 38, 53, and 30 cases treated with infliximab (IFX), adalimumab (ADA), and etanercept (ETN), respectively, were enrolled. The ANA titers were measured using indirect immunefluorescence assay (IF-ANA) and multiplex flow immunoassay (ANA Screen) before and serially during the therapy. The anti-IFX antibodies (HACA) and anti-ADA antibodies (AAA) were measured with a radioimmunoassay. ADrA turned positive in 14 (36.8%) among 38 patients treated with IFX, and 16 (30.2%) among 53 treated with ADA. All of them were positive for IF-ANA before TNFi administration, while ADrA never appeared in any of the 15 patients negative for IF-ANA (< 40). IF-ANA of high titers (≥ 320 and ≥ 640) before IFX treatment showed a significant association with the appearance of HACA 52 weeks after IFX (P = 0.040 and 0.017, respectively), whereas AAA appearance was not related to IF-ANA titers before treatment. Moreover, IF-ANA of high titers before IFX treatment was significantly associated with inefficacy and discontinuation of the treatment. The positivity of anti-SS-A antibodies before therapy might be a risk factor for ADrA appearance in patients treated with IFX or ADA. The percentage of patients whose IF-ANA titers increased was significantly higher with IFX than with ADA or ETN treatments (P = 0.026 and 0.022, respectively). High ANA titers and positive ANA Screen after IFX therapy showed a significant association with HACA appearance and possibly led to treatment failure. Among the three TNFi, only IFX showed a close relationship with IF-ANA and ADrA appearance, suggesting the interaction of immunogenicity with autoimmunity as well as the advantage of ANA measurement before TNFi therapy.

[Secukinumab-induced subacute-cutaneous lupus erythematosus]

We report about a 52-year-old woman with onset of drug-induced lupus erythematosus (DILE) in sun-exposed areas, under therapy with secukinumab. Topical therapy with a steroid class 3 for 4 weeks showed substantial improvement. The systemic therapy was switched to ustekinumab. DILE is a rare but notable side effect of biologicals in 0.5-1% of the patients and also possible under therapy with IL-17 inhibition. Switch of the biological agent is necessary in most cases.

Personalization of biologic therapy in patients with rheumatoid arthritis: less frequently accounted choice-driving variables

Objective

To propose appropriate statements that drive the choice of biologic therapies in patients with rheumatoid arthritis (RA), factoring in their impact on the following issues: anti-drug antibody (ADAb) formation, suspicion and management of infections, lupus-like syndrome (LLS), effects on bone mass and sexual sphere, and relationship between RA and periodontal disease (PD).

Methods

An overview of existing evidence was undertaken by an expert panel on behalf of the Italian board for the TAilored BIOlogic therapy (ITABIO). Data were extracted from controlled trials, national registries, national health care databases, post-marketing surveys, and, when required by the paucity of controlled studies, from open-label clinical series. Anti-tumor necrosis factor (anti-TNF) and non-anti-TNF-targeted biologics approved for RA were investigated.

Results

ADAb formation is chiefly associated with anti-TNFs, and it is reduced by combination therapy with methotrexate. To date, ADAb titration is not advisable for clinical practice, and, in case of anti-TNF secondary failure, a non-anti-TNF biologic is indicated. LLS is observed in anti-TNF receivers and, in most cases, resolves without anti-TNF withdrawal. A non-anti-TNF biologic is advisable in patients experiencing LLS. Non-anti-TNFs demonstrated a low or absent infection risk and are preferable in patients with comorbidities. Due to their positive effects on bone mass, anti-TNFs are indicated in women at osteoporosis risk, whereas non-anti-TNF have been poorly investigated. The emerging evidence of the relationship between RA and PD and the effects on anti-TNF efficacy should lead clinicians to consider the periodontal status in RA patients. Anti-TNFs may exert a positive effect on fertility and sexuality, and clinicians should explore these aspects in RA patients.

Conclusion

The optimization of biologic therapies by taking into proper account the above issues would improve patient outcomes.

Drug-induced lupus erythematosus: an update on drugs and mechanisms

PURPOSE OF REVIEW

Rapid introduction of newly developed drugs in the absence of clear understanding of the pathophysiologic mechanisms behind drug-induced lupus erythematosus (DILE) can sometimes make DILE difficult to recognize in clinical practice. The purpose of this review is to summarize drugs most recently reported to be involved in DILE and discuss the current landscape of diverse mechanisms involved.

RECENT FINDINGS

A large number of proton pump inhibitor (PPI)-induced subacute cutaneous lupus erythematosus cases have been reported, suggesting a shift over time in the spectrum of drugs implicated in DILE. Twenty-two articles comprising 29 DILE case reports published within the last 2 years are summarized in this review, including 12 (41.4%) systemic DILE. Antitumor necrosis factor (anti-TNF) drugs were the most frequently (41.7%) reported to introduce systemic DILE in these cases. Chemotherapeutic drugs were the most common drug class (54.5%) involved in subacute cutaneous lupus erythematosus, with an observed higher incidence in female patients. Enhanced neutrophil extracellular trap (NET) formation induced by procainamide and hydralazine could be a new mechanism contributing to the pathogenesis of DILE.

SUMMARY

The list of drugs implicated in triggering DILE is expanding as new drugs with novel mechanisms of action are being developed. It is important to recognize culprit drugs that may induce lupus erythematosus, as discontinuation usually results in improvement of drug-induced manifestations. Characterizing the mechanisms involved might help better understand the cause of idiopathic autoimmunity.

Stevens-Johnsons syndrome or drug-induced lupus - a clinical dilemma: A case report and review of the literature

Tumor necrosis factor inhibitors are the first biological agents used in the treatment of rheumatoid arthritis (RA) to have yielded satisfactory results in terms of clinical improvement and radiologic progression, but they are also associated with the possibility of occurrence of a number of autoimmune systemic events [drug-induced lupus (DIL), vasculitis, sarcoidosis] and localized adverse events [uveitis, psoriasis, interstitial lung disease, erythema multiforme including the major form Stevens-Johnson syndrome (SJS)]. During treatment with TNF inhibitors, many patients develop positivity for antinuclear, antihistone and anti-double stranded DNA antibodies, though only a minority of patients will develop clinical manifestations and approximately less than 1% will fulfill the classification criteria for systemic lupus erythematosus. Mucocutaneous manifestations are the most frequent manifestations of DIL following treatment with TNF inhibitors, and can be severe and occasionally difficult to differentiate from erythema multiforme/SJS. Stopping the causative drug (the TNF inhibitor) and general supportive measures are usually sufficient in mild forms, but in moderate to severe forms, systemic glucocorticoids and sometimes immunosuppressive drugs are required. The present report presents the case of a patient with rheumatoid arthritis who developed severe recurrent cutaneous reactions and positive autoantibodies during TNF inhibitor treatment, with difficulties in differential diagnosis and treatment. A review of the literature is also presented.

Anti-TNF therapy-induced lupus erythematosus-like syndrome in a patient treated with adalimumab for cutaneous psoriasis

A 44-year-old woman with cutaneous psoriasis and no history of joint involvement recently treated with adalimumab was admitted to the inpatient Internal Medicine service for uncontrolled, severe joint pain so debilitating that it limited her activities of daily living and prevented her from working as a medical technologist. She had stopped taking adalimumab 3 weeks prior to presentation after receiving approximately 2.5 months of therapy for cutaneous psoriasis unresponsive to trials of topical steroids and methotrexate. Antinuclear antibody and anti-double-stranded DNA antibodies were positive at high titres. She received a course of oral corticosteroids with improvement in her symptoms.

Serious Adverse Events Associated with Anti-Tumor Necrosis Factor Alpha Agents in Pediatric-Onset Inflammatory Bowel Disease and Juvenile Idiopathic Arthritis in A Real-Life Setting

OBJECTIVES

Anti-tumor necrosis factor alpha (anti-TNF-α) agents are generally well tolerated, yet they can be associated with serious adverse events (SAEs) in a minority of patients. We examined the incidence of SAEs in a pediatric referral center for chronic rheumatologic and gastroenterological inflammatory disorders.

METHODS

Retrospective analysis of SAEs occurring during treatment with anti-TNF-α agents in patients with juvenile idiopathic arthritis (JIA) (n = 78)  or pediatric-onset inflammatory bowel disease (IBD) (n = 105) seen at the Institute for Maternal and Child Health IRCCS "Burlo Garofolo" in Trieste, Italy, between June 2001 and February 2016. Only SAEs grade 3-5 according to the Common Terminology Criteria for Adverse Events version 4.03 and/or requiring definitive therapy discontinuation were reported.

RESULTS

Total anti-TNF-α exposure was 390.5 patient-years (PYs). The overall incidence rate of SAEs for etanercept was 4.14/100 PYs. Four patients developed uveitis, two had anxiety disorders, one had a serious zoster infection, and one developed TNF-α antagonist-induced lupus-like syndrome (TAILS). The overall incidence rate of SAEs for infliximab was 22.49/100 PYs. The most common SAEs were anaphylactoid reactions (n = 18), followed by infectious events (n = 9) and TAILS (n = 3). The overall incidence rate of SAEs for adalimumab was 4.71/100 PYs (two infectious SAEs). No malignancies or deaths were observed. A greater incidence rate of infectious SAEs was observed in IBD patients receiving infliximab compared to JIA patients receiving etanercept (8.11 vs 0.52 per 100 PYs).

CONCLUSIONS

Anti-TNF-α therapy was generally well tolerated. SAEs leading to anti-TNF-α discontinuation were rare and non-fatal. Infliximab was associated with the highest incidence of SAEs. Infectious SAEs were more frequently observed in IBD patients treated with infliximab than in JIA patients receiving etanercept.

Infliximab-Induced Lupus: A Case Report

We report the case of a 48-year-old, leukodermic female diagnosed with ulcerative proctitis for 4 years and latent tuberculosis. She was allergic to salicylates and had a minor allergic reaction to infliximab (rash, vertigo, and headache). Thereafter, she started azathioprine (2.5 mg/kg/day). She maintained intravenous infliximab, together with prophylaxis with clemastine and hydrocortisone, due to the steroid-dependent proctitis. The therapy was continued every 8 weeks with anti-tumor necrosis factor for about 3 years. The analytical evaluation when she was diagnosed with ulcerative proctitis (February 2011) showed negative antinuclear antibodies (ANA), double-stranded-DNA antibodies (anti-dsDNA), antineutrophil cytoplasmic antibodies and anti-Saccharomyces cerevisiae antibodies, and a positive outer membrane protein antibody. About 2 years and 6 months after starting infliximab (November 2013), the patient complained of inflammatory symmetrical polyarthralgia (knee, shoulder, elbow, and wrist) without synovitis, which started every week before the administration of infliximab. Resolution of symptoms was observed after each infliximab infusion. In July 2014, the autoantibody re-evaluation showed positive ANA with a homogeneous pattern with a titer of 1:640, weak positive anti-dsDNA (30.2), and positive anti-histone with C3 decreased (80.3). She was then diagnosed with lupus induced by infliximab and initiated hydroxychloroquine 400 mg. Infliximab was suspended. On re-evaluation, the erythrocyte sedimentation rate was 25 mm/h (1st hour), C-reactive protein 0.5 mg/dL (previously erythrocyte sedimentation rate 15 mm/h and C-reactive protein 1.2 mg/dL), and endoscopically, the mucosa was scarred, with some atrophy and scarce mucus in the lower rectum. About 10 months after discontinuation of infliximab, repeated autoantibodies proved all negative, keeping only low C3 (87). The patient also reported complete resolution of the arthralgia.

Anti-TNF-α and hydralazine drug-induced lupus

Drug-induced lupus is a rare drug reaction featuring the same symptoms as idiopathic lupus erythematosus. Recently, with the introduction of new medicines in clinical practice, an increase in the number of illness-triggering implicated drugs has been reported, with special emphasis on anti-TNF-α drugs. In the up-to-date list, almost one hundred medications have been associated with the occurrence of drug-induced lupus. The authors present two case reports of the illness induced respectively by hydralazine and infliximab, addressing the clinical and laboratorial characteristics, diagnosis, and treatment.

Cumulative incidence of, risk factors for, and outcome of dermatological complications of anti-TNF therapy in inflammatory bowel disease: a 14-year experience

OBJECTIVES

The broader and prolonged use of anti-tumor necrosis factor (TNF) agents in inflammatory bowel disease (IBD) could expose patients to an increased risk of adverse reactions, including dermatological complications. We assessed the cumulative incidence of anti-TNF-induced cutaneous adverse reactions in IBD patients, their risk factors, their dermatological management, and their outcome in a large cohort of IBD patients.

METHODS

In a single-center observational retrospective study, including all consecutive adult IBD patients treated with an anti-TNF agent between 2001 and 2014, all patients with dermatological complications under anti-TNF therapy were identified in a well-defined cohort of IBD patients. We conducted a survival analysis to determine the cumulative incidence of dermatological complications and risk factors for developing any dermatological complications, cutaneous infections, and psoriasiform lesions. Survival curves were estimated by the Kaplan-Meier method, and we used a Cox proportional hazards model to test the association between parameters and time to each event: any dermatological complication, cutaneous infections, and psoriasis lesions.

RESULTS

Among 583 IBD patients, 176 dermatological complications occurred, involving 20.5% of patients. Median duration of follow-up was 38.2 months (range: 1-179). Psoriasiform lesions (10.1%; 59/583) and cutaneous infections (11.6%, 68/583) were the most frequently observed, with a cumulative incidence of, respectively, 28.9% and 17.6% at 10 years. They led to anti-TNF discontinuation, respectively, in 18.6% and 2.9% of patients. In case of switching to another anti-TNF agent for psoriasiform lesions, recurrence occurred in 57% of patients. Ulcerative colitis was associated with a lower risk of developing cutaneous infections than Crohn's disease (hazard ratio (HR)=0.25; 95% confidence interval (CI)=0.09-0.68; P=0.007). Higher dosing of anti-TNF agent was associated with a higher risk of developing cutaneous infections (HR=1.99; 95% CI=1.09-3.64; P=0.025). A younger age at time of anti-TNF initiation was associated with a higher risk of dermatological complications (HR=2.25; 95% CI=1.39-3.62; P<0.001).

CONCLUSIONS

Dermatological complications involve one of five patients treated with anti-TNF therapy after a 14-year follow-up. Association of cutaneous infections with higher anti-TNF dosing suggests a dose-dependent effect. Discontinuation of anti-TNF therapy due to dermatological complications is required in one out of five patients with psoriasiform lesions, but specific dermatological treatment allows to continue anti-TNF therapy in half of them.

Mechanisms of tumor necrosis factor α antagonist-induced lupus in a murine model

OBJECTIVE

Tumor necrosis factor α (TNFα) antagonists are effective for treating rheumatoid arthritis and other inflammatory diseases, but their use can be complicated by the development of lupus-like phenomena. This study was undertaken to investigate the role of TNFα in a murine model of lupus.

METHODS

Toll-like receptor 7 (TLR-7) ligand-driven lupus was induced by injection of pristane into C57BL/6 (B6) mice deficient in TNFα (TNFα(-/-) ) or TNFα-intact B6 mice as wild-type controls. Autoantibody and type I interferon (IFN) production was measured in each group of mice, and the effects of the presence or absence of TNFα on type I IFN-producing plasmacytoid dendritic cells (PDCs), Ly-6C(high) monocytes, and TNFα-producing neutrophils were determined.

RESULTS

TNFα(-/-) mice did not spontaneously develop autoantibodies or clinical manifestations of lupus, suggesting that TNFα deficiency alone is insufficient to cause lupus. Although the levels of type I IFN were comparable between untreated TNFα(-/-) and wild-type control mice, untreated TNFα(-/-) mice had increased circulating levels of PDCs and PDC-like cells, which enhanced the potential for production of type I IFN. When treated with pristane, TNFα(-/-) mice developed more severe lupus compared to pristane-treated controls, characterized by increased levels of anti-Sm/RNP autoantibodies, type I IFN, PDCs, and peritoneal inflammatory (Ly-6C(high) ) monocytes. In pristane-treated TNFα(-/-) mice, the numbers of neutrophils, a cell type that promotes resolution of inflammation, were decreased considerably, whereas the responses of inflammatory monocytes and PDCs and the production of type I IFN were increased and prolonged.

CONCLUSION

Low levels of TNFα will increase the number of circulating PDCs in mice, thereby enhancing the potential to produce type I IFN. However, this does not necessarily lead to type I IFN production or autoimmunity unless there is concomitant exposure to endogenous TLR-7 ligands, which are released from dead cells following pristane treatment. In humans, the rate of clearance of dead cells, along with the levels of TNFα, may influence who will develop lupus following treatment with TNFα inhibitors.

Systemic lupus erythematosus in Crohn's disease: drug-induced or idiopathic?

Coexistence of Crohn's disease (CD) and idiopathic systemic lupus erythematosus (SLE) is very rare. On the other hand, drug-induced lupus erythematosus (DILE) due to anti-tumor necrosis factor (TNF) agents is a relatively more common entity. DILE due to anti-TNF agents and idiopathic SLE share common serologic and epidemiologic characteristics making the differentiation between those two entities difficult. We present a case of a 35-year-old woman with CD who developed SLE after treatment with adalimumab and denosumab and persisting symptoms eight months after discontinuation of those agents.

Adverse events in IBD: to stop or continue immune suppressant and biologic treatment

Crohn's disease and ulcerative colitis affect an increasing number of patients. A variety of medical options exist for the treatment of these diseases including immune suppressants and biologic therapies. Unfortunately, these agents are associated with adverse events ranging from mild nuisance symptoms to potentially life-threatening complications including infections and malignancies. This review discusses adverse events associated with azathioprine, mercaptopurine, and methotrexate as well as anti-TNF-α and anti-integrin antibodies. In addition, adverse events associated with combination therapy are discussed as are clinical scenarios in which it may be reasonable to discontinue or de-escalate drug therapy. It is the responsibility of the treating gastroenterologist to effectively communicate the benefits and risks of therapy with patients; this review offers strategies that may assist providers in communicating risk with patients in addition to offering our perspective on whether modification or cessation of therapy can be considered.

TNFα inhibitor induced lupus-like syndrome (TAILS) in a patient with IBD

BACKGROUND

In patients with autoimmune diseases like inflammatory bowel diseases there has been reported a drug-induced lupus like syndrome secondary to TNFα inhibitors.

OBJECTIVE

clinical case presentation and literature review of patients who develop lupus-like syndrome in relation to TNFα antagonists and their future therapeutic options.

MATERIALS AND METHODS

we report the case of a 27-year old woman with colonic Crohn's disease on combo-therapy (infliximab+azathioprine) for nearly two years who developed peripheral arthritis and malar rash in the context of TAILS.

RESULTS

our patient had positive anti-nuclear antibody, arthritis, malar rash, anemia and leukopenia. Her symptomes remited after discontinuation of infliximab and subsequently she started adalimumab for her Crohn's colitis; more than a year after switching between TNFα inhibitor molecules and stopping azathioprine she is feeling very well. TAILS is a rare condition described in the literature that can affect 0.5-1% of individuals, more often in association with etanercept and infliximab. Several pathogenic routes have been incriminated in the apparition of this syndrome there is still no definite mechanism up to date. Management options include discontinuation of the drug, corticosteroids, hydroxycloroquine sulfate and switching for other immunosupressives.

CONCLUSIONS

TAILS can appear even a long time after first exposure to TNFα antagonists. In our case, the association with azathioprine was not a primary prophylactic solution.

Hepatitis and Lupus-Like Syndrome during Infliximab Therapy for Psoriasis

Biologics are very useful medications that changed the lives of many patients in the last decade. However, we still do not know about the long-term side effects of these drugs. Infliximab is an anti-TNF chimeric antibody widely used and approved for the treatment of many diseases. Lupus-like syndrome and hepatitis are among the uncommon side effects of infliximab. Most of the written literature was published for cases of rheumatology and gastroenterology. We report here a case of both hepatitis and lupus-like syndrome that occurred sequentially in the same patient and compare our finding with two case reports of the same side effects, drug and disease.

Juvenile spondyloarthropathies

Spondyloarthropathy (or spondyloarthritis) can begin in childhood (defined as individuals less than 16 years of age). These diseases are distinct in childhood, when compared with adult-onset disease. Because of overlapping features, especially sacroiliac joint involvement, diagnostic difficulty may arise from Behcet's disease, as well as familial Mediterranean fever. Despite advances in diagnostic techniques such as magnetic resonance imaging, the diagnosis of juvenile spondyloarthropathy may still be delayed many years from the onset of symptoms. Treatment of juvenile spondyloarthropathy has advanced rapidly in the last several years, with increasing evidence that agents targeting tumor necrosis factor are effective. These agents also have serious complications, including induction of other autoimmune diseases.

Anti-Tumor Necrosis Factor-α Induced Systemic Lupus Erythematosus()

Anti-tumor necrosis factor-alpha induced lupus (ATIL) represents a major diagnostic and therapeutic challenge. Most cases of ATIL are caused by infliximab, followed by etanercept and adalimumab. Symptoms can range from common, mild cutaneous lesions to rare, serious pleural or pericardial effusions, deep venous thrombosis, life-threatening pneumonitis, and neuritis. Constitutional symptoms often present in association with positive autoantibody serology. Diagnosis can be considered if there is a temporal relationship between symptoms and anti-tumor necrosis factor-α (TNF- α) therapy and at least one serologic and one non-serologic American College of Rheumatology criteria. Since it is contraindicated to use anti-TNF-α drugs in patients with systemic lupus erythematosus, it is recommended to perform a thorough immunological screening in any patient with polyarthritis to assure accurate diagnosis. In addition, prior to anti- TNF therapy, baseline immunological investigations (including antinuclear antibodies) should be performed, and there should be close follow up to assess the development of lupus manifestations. The main approach in the treatment of ATIL is withdrawal of the offending drug. Traditional therapy with corticosteroids and immunosuppressive agents may be required to achieve full resolution of lupus symptoms. In this review, we discuss the pathogenesis, clinical manifestations, and management of ATIL.

Suppression of mycobacterium tuberculosis induced reactive oxygen species and tumor necrosis factor-alpha activity in human monocytes of systemic lupus erythematosus patients by reduced glutathione

OBJECTIVES

The etiology and pathogenesis of systemic lupus erythematosus remains unknown, evidence exists for the involvement of mycobacterial antigen. This study is aimed to determine the effect of Mycobacterium tuberculosis on clinical course of SLE patients and the role of ROS and TNF-α in the pathogenesis of tuberculosis associated SLE patients.

METHODS

This study was done on 100 patients divided into SLE group (n=30), TB group (n=30), SLE-TB group (n=30) and control group (n=10). All patients underwent clinical, biochemical and immunological evaluation by employing techniques such as SDS-PAGE, direct binding and competition ELISA, PBMC and cell culture.

RESULTS

Fever, arthritis, skin rash, photosensitivity were more common in both SLE and SLE-TB group. Reduced glutathione showed amelioration of ROS and TNF-α induced action, which in turn, subsequently suppressed the immune-bindings observed in monocytes of TB and SLE patients cultured without glutathione.

CONCLUSION

Data shows that SLE patients are more susceptible to developing Mycobacterium tuberculosis, as ROS and TNF-α in SLE patients could activate the replication of mycobacterial Ag85B (30 kDa) after bacilli infection.

Vasculitis associated with tumor necrosis factor-α inhibitors

OBJECTIVE

To describe the clinical characteristics, histopathologic features, and outcomes of patients in whom vasculitis developed in association with use of tumor necrosis factor-α (TNF-α) inhibitors.

PATIENTS AND METHODS

This is a retrospective review of patients evaluated at Mayo Clinic, Rochester, Minnesota, from January 1, 1998, through March 31, 2011, with a diagnosis of vasculitis induced by anti-TNF-α therapy.

RESULTS

Of 8 patients with vasculitis associated with anti-TNF-α therapy (mean age, 48.5 years), 6 (75%) were female. Four (50%) had rheumatoid arthritis, 1 (13%) had Crohn disease, and 3 (38%) had ulcerative colitis. Five (63%) were treated with infliximab, 2 (25%) with etanercept, and 1 (13%) with adalimumab. The mean duration of treatment before development of vasculitis was 34.5 months. The skin was the predominant organ affected (5 patients [63%]), with the most common cutaneous lesion being palpable purpura (4 of 5 [80%]). Two organs involved in systemic vasculitis were the peripheral nervous system (4 patients [50%]) and kidney (1 patient [13%]). All cases of vasculitis were histopathologically confirmed. Seven of 8 patients improved with discontinuation of therapy (mean time to resolution, 6.9 months) and adjuvant treatment (all 8 received prednisone; another agent was also used in 7); rechallenge with anti-TNF-α therapy was not attempted in any patient. At last follow-up, no patients had experienced a recurrence of vasculitis after therapy discontinuation.

CONCLUSION

Cutaneous small-vessel vasculitis was the most common finding, but systemic vasculitis, including peripheral nerve and renal vasculitis, was also frequently observed.

A Patient with Psoriatic Arthritis Imaged with FDG-PET/CT Demonstrated an Unusual Imaging Pattern with Muscle and Fascia Involvement: A Case Report

We describe the case of a patient with known history of psoriasis that presented with 1 year of unexplained fever, muscle weakness and marked weight loss, suspicious for B symptoms of a malignant origin. [(18)F]-Fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) scans demonstrated an unusual serpiginous pattern of uptake in the fascia and muscles as well as lymph node activity. Multiple histological samples, including a final PET-probe guided lymph node surgical resection, excluded malignancy and confirmed the diagnosis of reactive inflammatory changes, with a plausible diagnosis of autoimmune lymphoproliferative syndrome with associated lymphadenitis, fasciitis and myositis, possibly mediated by tumor necrosis factor (TNF) inhibitor. To our knowledge, there is no evidence of a previously reported FDG uptake pattern of fascia and muscle involvement in psoriatic arthritis.

Roles of pro- and anti-inflammatory cytokines in the pathogenesis of SLE

SLE is an autoimmune inflammatory disease in which various pro- and anti-inflammatory cytokines, including TGF-β, IL-10, BAFF, IL-6, IFN-α, IFN-γ, IL-17, and IL-23, play crucial pathogenic roles. Virtually, all these cytokines can be generated by both innate and adaptive immune cells and exert different effects depending on specific local microenvironment. They can also interact with each other, forming a complex network to maintain delicate immune homeostasis. In this paper, we elaborate on the abnormal secretion and functions of these cytokines in SLE, analyze their potential pathogenic roles, and probe into the possibility of them being utilized as targets for therapy.

TNF alpha antagonist-induced lupus-like syndrome: report and review of the literature with implications for treatment with alternative TNF alpha antagonists

BACKGROUND

  In patients with various autoimmune and rheumatic diseases, a drug-induced lupus-like syndrome (DILS) has been reported with the use of adalimumab, cerrolizumab pegol, etanercept, and infliximab.

OBJECTIVE

  To review clinical characteristics of patients who develop tumor necrosis factor (TNF) alpha antagonist-induced lupus-like syndrome (TAILS) and review implications for further TNF alpha antagonist therapy.

MATERIALS AND METHODS

 We describe a 62-year-old woman with rheumatoid arthritis who developed a pruritic photo-distributed rash two months after the initiation of etanercept therapy. Her skin biopsy showed lupus erythematosus, and she had positive serum ANA, anti-Sjogren's syndrome A (SSA)/Ro, and anti-Sjogren's syndrome B (SSB)/La antibodies. Her symptoms resolved after discontinuation of the drug, topical and systemic corticosteroids, and hydroxychloroquine sulfate. Subsequently, her rheumatoid arthritis was treated with golimumab for six months without recurrence of skin lesions. Published reports of individuals who have developed TAILS and those who have continued treatment with alternative TNF alpha antagonists are reviewed.

RESULTS

  TAILS is most commonly associated with the use of etanercept and infliximab. It occurs most often in women in the fifth decade of life. Onset of symptoms ranges from less than one month to more than four years. Syndrome-associated cutaneous lesions and induction of autoantibodies are common. There is no definitively established mechanism of pathogenesis. Treatment can include discontinuation of the drug, corticosteroids, immunosuppressives, and hydroxychloroquine sulfate. To date, 10 patients with TAILS have continued therapy with an alternative TNF alpha antagonist without recurrence of lupus symptoms.

CONCLUSIONS

Development of a DILS after one TNF alpha antagonist does not preclude continued treatment with an alternative TNF alpha antagonist.

Pulmonary manifestations of rheumatoid arthritis

Pulmonary disease is a major source of morbidity and mortality in rheumatoid arthritis, manifesting most commonly as interstitial lung disease, airways disease, rheumatoid nodules, and pleural effusions. The diagnostic assessment of respiratory abnormalities is complicated by underlying risk for infection, the use of drugs with known pulmonary toxicity, and the frequency of lung disease related to rheumatoid arthritis itself. Evaluation and management of rheumatoid arthritis-associated pulmonary disease frequently necessitates a multidisciplinary approach.

Tumor necrosis factor-alpha as a potential therapeutic target in idiopathic inflammatory myopathies

The cytokine, tumor necrosis factor alpha (TNFα), has been implicated in many aspects of immune system development, immune response regulation, and T cell-mediated tissue injury. TNFα plays a less well-defined role in the pathogenesis of the idiopathic inflammatory myopathy (IIM) group of disorders, and has been considered a potential therapeutic target. Observational studies of TNFα-blockade in (mostly refractory) IIM have yielded inconsistent beneficial results so that administration of these biological agents is presently deemed an unreliable alternative treatment strategy. Moreover, anti-TNFα therapy has the rare potential to trigger myositis in patients with rheumatoid arthritis, hinting at a pre-existing "overlap disorder". The full potential of TNFα-antagonism will be realized only if randomized controlled trials ascertain appropriate treatment regimens and identify patient subgroups most likely to benefit from such therapy.

Tumor necrosis factor-alpha antagonist etanercept decreases blood pressure and protects the kidney in a mouse model of systemic lupus erythematosus

Chronic inflammation has been implicated in the pathology of hypertension; however, the role for specific cytokines remains unclear. We tested whether tumor necrosis factor-α blockade with etanercept (Etan) reduces mean arterial pressure in a female mouse model of systemic lupus erythematosus (SLE). SLE is a chronic inflammatory disorder with prevalent hypertension. Thirty-week-old SLE (NZBWF1) and control mice (NZW/LacJ) received Etan (0.8 mg/kg SC weekly) for 4 weeks or vehicle. Mean arterial pressure (in millimeters of mercury) was increased in SLE mice (150±5 versus 113±5 in controls; P<0.05) and was lower in Etan-treated SLE mice (132±3) but not controls (117±5). Albuminuria (in micrograms per milligram of creatinine) was elevated in SLE mice (28 742±9032 versus 1075±883; P<0.05) and was lower in Etan-treated SLE mice (8154±3899) but not control animals (783±226). Glomerulosclerosis (in percentage of glomeruli) was evident in SLE mice (2.5±1.6 versus 0.0±0.0 in controls; P<0.05) and was ameliorated in Etan-treated SLE mice (0.1±0.1). Renal cortex CD68(+) cell staining (in percentage of area) was elevated in SLE mice (4.75±0.80 versus 0.79±0.12 in controls; P<0.05) and was lower in Etan-treated SLE mice (2.28±0.32) but not controls (1.43±0.25). Renal cortex NADPH oxidase activity (relative light units per milligram of protein) was higher in SLE mice compared with controls (10 718±1276 versus 7584±229; P<0.05) and lowered in Etan-treated SLE mice (6645±490). Renal cortex nuclear factor κB (phosphorylated and nonphosphorylated) was increased in SLE mice compared with controls and lower in Etan-treated SLE mice. These data suggest that TNF-α mechanistically contributes to the development of hypertension in a chronic inflammatory disease through increased renal nuclear factor κB, oxidative stress, and inflammation.

Neurological adverse events associated with anti-tumor necrosis factor α treatment

Anti-tumor necrosis factor alpha (TNF-alpha) drugs have been successfully used for the treatment of rheumatic autoimmune diseases including rheumatoid arthritis (RA), psoriatic arthritis, psoriasis, ankylosing spondylitis (AS), juvenile chronic arthritis, and Crohn's disease. However, they have been associated with different neurological disorders, including alterations of peripheral nerves, multiple sclerosis (MS), optic neuritis (ON) and acute transverse myelitis (ATM). This article reviews the most current aspect regarding neurological adverse events associated with anti-TNF-alpha drugs with emphasis on the possible explanations for this relation and the pathogenic mechanism of TNF-alpha in neurological disorders.

Safety and immunotoxicity assessment of immunomodulatory monoclonal antibodies

Most therapeutic monoclonal antibodies (mAbs) licensed for human use or in clinical development are indicated for treatment of patients with cancer and inflammatory/autoimmune disease and as such, are designed to directly interact with the immune system. A major hurdle for the development and early clinical investigation of many of these immunomodulatory mAbs is their inherent risk for adverse immune-mediated drug reactions in humans such as infusion reactions, cytokine storms, immunosuppression and autoimmunity. A thorough understanding of the immunopharmacology of a mAb in humans and animals is required to both anticipate the clinical risk of adverse immunotoxicological events and to select a safe starting dose for first-in-human (FIH) clinical studies. This review summarizes the most common adverse immunotoxicological events occurring in humans with immunomodulatory mAbs and outlines non-clinical strategies to define their immunopharmacology and assess their immunotoxic potential, as well as reduce the risk of immunotoxicity through rational mAb design. Tests to assess the relative risk of mAb candidates for cytokine release syndrome, innate immune system (dendritic cell) activation and immunogenicity in humans are also described. The importance of selecting a relevant and sensitive toxicity species for human safety assessment in which the immunopharmacology of the mAb is similar to that expected in humans is highlighted, as is the importance of understanding the limitations of the species selected for human safety assessment and supplementation of in vivo safety assessment with appropriate in vitro human assays. A tiered approach to assess effects on immune status, immune function and risk of infection and cancer, governed by the mechanism of action and structural features of the mAb, is described. Finally, the use of immunopharmacology and immunotoxicity data in determining a minimum anticipated biologic effect Level (MABEL) and in the selection of safe human starting dose is discussed.