Rheumatic manifestations among cancer patients treated with immune checkpoint inhibitors

BACKGROUND

The use of immune checkpoint inhibitors (ICI) has grown incessantly since they were first approved in 2014. These monoclonal antibodies inhibit T cell activation, yielding a dramatic tumor response with improved survival. However, immunotherapy is frequently hampered by immune adverse events (iAE) such as hypophysitis, colitis, hepatitis, pneumonitis and rash. Until recently, rheumatic side effects were only infrequently reported.

AIM

To describe the rheumatic manifestations encountered among patients treated with ICIs in a large tertiary cancer center in Israel METHODS: The cancer center's patient registry was screened for patients who had ever been treated with ipilimumab, pembrolizumab and/or nivolumab with relevant data gathered from clinical charts.

RESULTS

Rheumatic manifestations were encountered in 14 of 400 patients (3.5%) who had received immunotherapy between January 1st 2013 and April 30th, 2017. The most common rheumatic manifestation was inflammatory arthritis (85%) for which a third (4/11) had a clear cut predisposing factor such as a personal or family history of psoriasis, a prior episode of uveitis or ACPA positivity. Pulmonary sarcoidosis and biopsy-proven eosinophilic fasciitis were diagnosed in two additional patients. Treatment with NSAIDS was mostly unsuccessful while steroid therapy was beneficial in doses ≥20 mg/d. Methotrexate enabled steroid tapering without an excess of side effects or tumor progression in the short follow-up available. Overall, rheumatic manifestations tended to occur later in the course of immunotherapy as compared to other iAE.

CONCLUSIONS

Our findings underscore that rheumatic iAE are part of the side effect profile of ICIs and require heightened awareness as these therapies are becoming the standard of care for various malignancies. We show that these appear later in the course of iAEs and respond preferentially to high dose steroids. MTX appears effective as a steroid sparing agent.

Eosinophilic Fasciitis Following Checkpoint Inhibitor Therapy: Four Cases and a Review of Literature

BACKGROUND

Checkpoint inhibitor therapy is widely known to cause a number of immune-related adverse events. One rare adverse effect that is emerging is eosinophilic fasciitis, a fibrosing disorder causing inflammatory infiltration of subcutaneous fascia. It is characterized clinically by edema and subsequent induration and tightening of the skin and subcutaneous tissues. The condition is rare, yet at our institutions we have seen four cases in the past 3 years. We describe our 4 cases and review 11 other cases reported in the literature.

CASE PRESENTATION

We present four cases of eosinophilic fasciitis following treatment with programmed cell death protein 1 or programmed cell death-ligand 1 blockade. All patients had extremity involvement with characteristic skin changes ranging from peripheral edema to induration, tightening, and joint limitation. The patients had varying degrees of peripheral eosinophilia. In two of our patients, the diagnosis was made by full-thickness skin biopsy showing lymphocytic infiltration of the subcutaneous fascia, with CD4+ T cells predominating in one case and CD8+ T cells in the other. In the other two cases, the diagnosis was made on the basis of characteristic imaging findings in the context of clinical features consistent with the diagnosis. All four patients were treated with glucocorticoids with varying degrees of success; immunotherapy had to be discontinued in all four. Patients with advanced melanoma who experienced this adverse effect had either a partial response or a complete response to therapy.

CONCLUSION

Eosinophilic fasciitis can occur as a result of checkpoint inhibitor therapy. Although a tissue diagnosis is the gold standard, imaging studies may facilitate the diagnosis in the presence of consistent clinical features, but a degree of suspicion is key to recognizing the condition early. Therapy requires a collaborative approach by oncology, rheumatology, and dermatology; physical therapy is an important adjunct in treatment. For advanced melanoma, it may be a good prognostic indicator.

IMPLICATIONS FOR PRACTICE

It is important for clinicians to recognize that eosinophilic fasciitis is a potential immune-related adverse event (irAE) as a consequence of immune checkpoint inhibitor therapy. The presentation is quite stereotypical; the diagnosis can be made by imaging in the absence of a full-thickness skin biopsy. Early intervention is important to limit morbidity. This irAE may be a good prognostic sign among patients with melanoma.

Eosinophilia in Rheumatologic/Vascular Disorders

Peripheral and tissue eosinophilia can be a prominent feature of several unique rheumatologic and vascular diseases. These diseases span a wide range of clinical features, histologic findings, therapeutic approaches, and outcomes. Despite the rare nature of these entities--which makes large-scale studies challenging--knowledge has continued to grow regarding their epidemiology, pathophysiology, and management. This review compares and contrasts 5 rheumatologic and vascular conditions in which eosinophilia can be seen: eosinophilic granulomatosis with polyangiitis (Churg-Strauss), immunoglobulin G4-related disease, diffuse fasciitis with eosinophilia, eosinophilia-myalgia syndrome, and eosinophilic myositis.

Scleroderma Mimickers

Cutaneous fibrosing disorders encompass a diverse array of diseases united by the presence of varying degrees of dermal sclerosis. The quality and distribution of skin involvement, presence or absence of systemic complications and unique associated laboratory abnormalities often help to distinguish between these diseases. It is imperative that an effort is made to accurately differentiate between scleroderma and its mimics, in order to guide long-term management and facilitate implementation of the appropriate treatment modality where indicated.

Update on the classification and treatment of localized scleroderma

Morphea or localized scleroderma is a distinctive inflammatory disease that leads to sclerosis of the skin and subcutaneous tissues. It comprises a number of subtypes differentiated according to their clinical presentation and the structure of the skin and underlying tissues involved in the fibrotic process. However, classification is difficult because the boundaries between the different types of morphea are blurred and different entities frequently overlap. The main subtypes are plaque morphea, linear scleroderma, generalized morphea, and pansclerotic morphea. With certain exceptions, the disorder does not have serious systemic repercussions, but it can cause considerable morbidity. In the case of lesions affecting the head, neurological and ocular complications may occur. There is no really effective and universal treatment so it is important to make a correct assessment of the extent and severity of the disease before deciding on a treatment approach.

[Eosinophilic fasciitis (Shulman's disease): Diagnostic and therapeutic review]

Eosinophilic fasciitis (EF) is a rare connective tissue disease characterized by symmetrical and painful swelling with a progressive induration and thickening of the skin and soft tissues. The diagnosis of EF is often based on the association of characteristic skin or subcutaneous abnormalities and a thickened fascia with an inflammatory infiltration, mostly composed of lymphocytes and eosinophils. A peripheral eosinophilia is frequently present (60-90%) but is not mandatory for the EF diagnosis. At the onset, the morphological diagnosis might be helped by a muscle magnetic resonance imaging, which typically may evidence an increased signal intensity within the fascia and marked fascia enhancement after gadolinium administration at the acute phase of the disease. Differential diagnoses include eosinophilia-myalgia syndrome after L-tryprophane ingestion, hypereosinophilic syndromes (HES), systemic sclerosis, eosinophilic granulomatosis with polyangeitis, and peripheral T cell lymphomas with cutaneous involvement. There is no consensual therapeutic strategy. However, oral corticosteroids, with or without methylprednisolone pluses, remain the mainstay treatment with a significant improvement for the majority of patients. It might be associated to an immunosuppressive drug, mainly methotrexate, in patients with morphea-like lesions or an unsatisfactory response to corticosteroids alone.

Immune Checkpoint Inhibitor-Associated Scleroderma-Like Syndrome: A Report of a Pembrolizumab-Induced "Eosinophilic Fasciitis-Like" Case and a Review of the Literature

Immune checkpoint inhibitors are a promising new therapeutic strategy in oncology that aims to eliminate cancer cells by enhancing patients' immune response against tumor antigens. Despite their beneficial effects, immune checkpoint inhibitors are also responsible for a plethora of autoimmune manifestations, known as immune-related adverse events. We present a case of eosinophilic fasciitis-like disorder in an 81-year-old patient treated with the programmed death cell protein 1 inhibitor pembrolizumab for non-small-cell lung cancer. The patient developed characteristic indurated skin lesions in his limbs after 1½ years of treatment with pembrolizumab and a typical “groove sign.” Raynaud’s syndrome was absent. A full-thickness biopsy confirmed the clinical diagnosis of an “EF-like” condition. Neither peripheral eosinophilia nor eosinophilic infiltrates in the skin biopsy were found. His symptoms improved after a 2.5-month CPI discontinuation and treatment with 16 mg of methylprednisolone slowly tapered to a dose of 4 mg. Eosinophilic fasciitis is a rare immune-related adverse event of CPI treatment; our literature search identified only 12 cases that fulfill the criteria of EF in patients receiving CPIs.

Two cases of eosinophilic fasciitis

Eosinophic fasciitis (EF) is an uncommon connective tissue disease characterized by scleroderma-like cutaneous changes, peripheral eosinophilia, hypergammaglobulinemia, and an elevated erythrocyte sedimentation rate (ESR). Typical histopathologic findings include chronic inflammatory infiltration affecting the deep fascia with lymphocytes, histiocytes, and occasionally eosinophils. We report two cases of EF, the first of which is a 36-year-old man with a tender brownish induration on both forearms, for 2 months. Histopathologic examination showed fibrotic fascia with a mixed inflammatory cell infiltration. The second case is a 52-year-old woman with a symmetrical painful swelling and skin induration on both forearms, for 4 months. A deep biopsy demonstrated chronic inflammatory cell infiltration and hyaline degeneration in the fascia. Increased signal intensity in the fascia and tendon sheath was shown on magnetic resonance imaging. In laboratory examination, mild eosinophilia was found in both cases. Both patients had a history of physical activity (weight training and excessive housework, respectively) and showed marked improvement with high doses of oral prednisolone for several months.

The use of tocilizumab in the treatment of refractory eosinophilic fasciitis: a case-based review

Eosinophilic fasciitis (EF) is a rare disorder involving chronic inflammation of the fascia and connective tissue of unknown aetiology and poorly understood pathogenesis. We present the case of a 60-year-old man diagnosed with eosinophilic fasciitis with extensive cutaneous involvement and severe functional repercussion, which appeared weeks after suffering from pneumonia due to Legionella pneumophila. The patient did not experience any clinical response with high-dose corticosteroids, subcutaneous methotrexate, and intravenous immunoglobulins. Consequently, tocilizumab was initiated at 8 mg/Kg monthly achieving clinical response measured by a control MRI at the fifth dose. Response in terms of cutaneous thickness has been slower however favourable, therefore, more months of follow-up are necessary to assess the complete remission at skin level. EF treatment still constitutes a challenge, and experience with tocilizumab in the management of the disease is very limited. Through a systematic search of medical literature, we retrieved two cases describing EF treated with tocilizumab and several cases using another monoclonal antibody or Janus kinase inhibitor. We report the third case to our knowledge of the efficacy of tocilizumab in a refractory EF to corticosteroids and other immunosuppressive drugs.

Finger stiffness or edema as presenting symptoms of eosinophilic fasciitis

To investigate the clinical features and finger symptoms of eosinophilic fasciitis (EF), we reviewed five patients with EF. The chief complaint was pain, edema and/or stiffness of the extremities. The distal extremities were affected in all patients, and there was also proximal involvement in one patient. One patient had asymmetrical symptoms. All four patients with upper limb involvement had limited range of motion of the wrist joints, and three of them complained of finger symptoms. Two of these three patients showed slight non-pitting edema of the hands, and the other one had subcutaneous induration of the forearm. All four patients with lower limb symptoms had limited range of motion of the ankle joints, and two showed edema or induration of the legs. Inflammatory changes in the joints were not detected in any of the patients. Two patients displayed neither objective induration nor edema, and two patients had muscle tenderness. In conclusion, finger symptoms of patients with EF might be caused by fasciitis of the forearms, which leads to dysfunction of the long finger flexors and extensors as well as slight edema of hands. Limited range of motion of wrist and/or ankle joints indicates sensitively distal muscle dysfunction caused by fasciitis.

Eosinophilic fasciitis associated with myositis

Eosinophilic fasciitis is clinically characterized by symmetrical scleroderma-like indurations of the skin with pain. The histological features are fascial inflammation with lymphocytes and eosinophils as well as thickened and fibrotic fascia. Lymphocytic infiltration and degeneration of the underlying muscle are rarely observed. We report a 69-year-old Japanese woman who presented with multiple areas of glossy induration and painful peau d'orange-like lesions on the chest and four extremities. T2-weighted magnetic resonance imaging showed significant hyperintense thickening of the fascia of the lower extremities. Histopathological examination of a biopsy specimen from the induration showed marked fibrinoid degeneration of the fascia and the neighboring muscle with mixed cellular infiltration of lymphocytes and eosinophils. The predominant CD8+ lymphocytic infiltrates were observed by immunohistological study. A diagnosis of eosinophilic fasciitis with myositis was made. Oral administration of prednisolone and discontinuation of exercise significantly improved the lesions and pain.

Eosinophilic fasciitis (Shulman syndrome) - recognition of the histological spectrum allows for new insights into possible pathomechanisms

OBJECTIVES

Eosinophilic fasciitis (EF) is a rare disease characterized by fibrosis and inflammation of the fascia, scleroderma-like skin indurations, and optional blood eosinophilia. We aimed to expand the knowledge about its aetiology and pathogenesis.

METHODS

Biopsy specimens from 16 EF patients were assessed by histology, immunohistochemistry, and qRT-PCR in comparison to anti-Mi-2+ dermatomyositis (DM) patients and non-disease controls.

RESULTS

Histologically, EF shows mild to severe inflammation at the muscle-fascia interface, with frequent involvement of the underlying muscle tissue, though varying in degree. CD206+ macrophages predominate and eosinophils are detected within the fascia in the majority of cases, however, in quite small numbers, and seen infrequently within the muscle. Activators of the so-called Th2-M2 pathway like STAT6 and interleukin (IL)-4 are upregulated leading to high expression levels of CD206. Activators of the so-called Th1-M1 pathway like STAT1 and interferon-γ (IFNG) are also upregulated, though not translating into a significant upregulation of the effector molecule COX2. Interestingly, activators or chemoattractants of eosinophils show no significant upregulation in EF compared with DM. EF shows features of perifascicular pathology comparable to DM, with upregulation of MHC class I and II, however, this is not accompanied by perifascicular atrophy or any signs of a type I interferon response or hypoxia-mediated processes.

CONCLUSIONS

Our findings highlight a specific immune phenotype of leucocyte infiltrates in EF along features of perifascicular pathology similar to DM, while there is no evidence of hypoxia-mediated or type I Interferon associated processes with perifascicular fibre atrophy, indicating different pathomechanisms of muscle involvement.

Diagnosis and treatment of eosinophilic fasciitis: Report of two cases

BACKGROUND

Eosinophilic fasciitis (EF) is a rare disease characterized by inflammation of the fascia with immune system involvement. Failure to promptly diagnose and treat this disease can seriously affect the quality of life of patients. However, no clear and uniform criteria for diagnosis and treatment exist.

CASE SUMMARY

In this paper, we report two cases of EF, both of which showed symmetrical limb swelling and rigidity, increased eosinophils in the peripheral blood and bone marrow, increased red blood cell sedimentation rate, increased antinuclear antibody titer, and pathological changes in the tissues such as eosinophil and lymphocyte infiltration. Both patients were treated with hormones and cyclosporine, and showed significant improvements in their conditions.

CONCLUSION

EF is an autoimmune disease causing swelling and sclerosis of the fascia and eosinophilia. It is diagnosable by magnetic resonance imaging, positron emission tomography-computed tomography, blood routine tests, and bone marrow puncture. Glucocorticoids and immunosuppressants are effective treatments.

A Literature Review of Eosinophilic Fasciitis with an Illustrative Case

Eosinophilic fasciitis (EF), a rare connective tissue disorder, was first reported by Lawrence Shulman in 1974. Since then over 300 cases have been reported worldwide. EF has variable clinical presentations and currently does not have internationally accepted diagnostic criteria. Dermatological features are the most ubiquitously present symptoms. It often presents with sclerodermalike skin changes. Extracutaneous presentations, such as arthritis and carpal tunnel syndrome can precede cutaneous changes. The most useful clinical features are the lack of Raynaud's phenomenon, telangiectasia and visceral involvement, differentiating it from Scleroderma. Haematological disorders, solid tumours and autoimmune disorders are frequently associated with EF. Historically, the presence of peripheral eosinophilia, elevated ESR and hypergammaglobulinemia were considered to be diagnostic of EF. It is now well recognised that neither the presence of eosinophilia in the blood nor eosinophilic infiltartion in the fascia is necessary for its diagnosis. An en bloc surgical biopsy including skin, subcutis, fascia and muscle is the gold-standard test for diagnosing EF. Magnetic resonance imaging helps to locate a suitable biopsy site and to monitor treatment response. Although its underlying aetiology is unknown, there is a growing body of evidence supporting an immunological origin. Immunosuppressive drugs are used to treat EF and the corticosteroid is the first line treatment. A significant proportion of patients can develop permanent disabilities such as joint contractures, tendon retraction and subdermal sclerosis. Occasionally it can be treatment refractory or have a relapse-remitting course. We report another case of EF with a literature review.

[Eosinophilic fasciitis, morphea and vitiligo in a single patient]

BACKGROUND

Fasciitis with eosinophilia (FE), or Shulman syndrome, is a rare disease of unknown origin for which the nosological profile has not been clearly defined. It is clinically characterised by oedema and induration of the limbs with hypereosinophilia. It may be associated with morphea, in which case it carries a poor prognosis, or other diseases, particularly autoimmune conditions. Herein, we report a case of fasciitis associated with eosinophilia, morphea and vitiligo.

PATIENT AND METHODS

A 45-year-old male patient followed up for vitiligo for 20 years had been presenting swelling and induration of the skin on all 4 limbs for the previous 7 months associated with morphea on the trunk. Treatment consisting of systemic corticosteroids and methotrexate was initiated and displayed a certain degree of efficacy.

DISCUSSION

The association of morphea/fasciitis with eosinophilia is a classical finding; the presence of vitiligo raises the question of possible association between these different disorders.

Rituximab for refractory eosinophilic fasciitis: a case series with long-term follow-up and literature review

KEY MESSAGE

RTX could be an effective and safe alternative treatment for refractory EF. Rituximab (RTX) is a successful therapeutic option for various autoimmune diseases. Our aim is to report our experience with RTX in eosinophilic fasciitis (EF) and review published data on its efficacy for the treatment of EF. We reviewed the medical charts of all patients with a diagnosis of EF treated with RTX from 2008 to 2020 in the Department of Rheumatology and Clinical Immunology in the University Hospital of Heraklion, Crete, Greece. We also reviewed the English literature for cases of EF treated with RTX. Demographics, clinical manifestations, laboratory findings, prior treatments, response to RTX, cumulative RTX dose, duration of treatment and follow-up are reported. We report three cases of EF refractory to conventional DMARDs (cDMARDs) that responded to RTX. Furthermore, literature review revealed five cases. In our case series in all patients, RTX was the first biologic. RTX could be effective in cases of (EF) refractory to standard immunosuppressive treatment.

Ultrasonographic images of the hand in a case with early eosinophilic fasciitis

Eosinophilic fasciitis (EF), a rare rheumatic disease, usually affects the limbs symmetrically and generally spares the hands and feet. Cases of unilateral hand involvement are rarely reported. Here, we report such a rare case. Ultrasonography demonstrated thickening of the overlying skin and subcutaneous tissue, peripheral deep fascia, myositis of lumbrical muscles and adductor pollicis muscle, and edema surrounding flexor digitorum tendons. It reminds us that EF should be considered in the differential diagnosis of unilateral painful hand swelling despite being uncommon. Ultrasonography can be used to aid the diagnosis and monitor therapeutic response in patients with EF.

Eosinophilic fasciitis (Shulman syndrome), a rare entity and diagnostic challenge, as a manifestation of severe chronic graft-versus-host disease: a case report

Background

Shulman’s disease, or eosinophilic fasciitis (EF), is a rare autoimmune disease, characterized by sclerodermic skin lesions with progressive induration and thickening of the soft tissues. Chronic graft-versus-host-disease (GVHD) presenting as EF is a very rare manifestation of cutaneous GVHD.

Case presentation

We report an unusual case of EF in a 46-year-old Caucasian male patient who had received an allogenic hematopoietic stem cell transplantation in the context of relapsed/refractory multiple myeloma. The diagnosis was challenging, with the patient presenting hepatic dysfunction, normal eosinophils count, and incomplete clinical signs. Magnetic resonance imaging (MRI) and skin biopsy confirmed the diagnosis of EF. Early initiation of specific treatment with corticosteroids and prednisolone achieved complete response.

Conclusion

In practice, incomplete signs in this rare complication should lead to MRI as it is a major tool to guide decision-making based on the skin biopsy, allowing a rapid diagnosis and the initiation of treatment without delay.

Refractory eosinophilic fasciitis successfully treated with infliximab: A case report

Eosinophilic fasciitis is a rare connective tissue disease of unknown etiology. Therapeutic options include high-dose corticosteroids and other immunosuppressive drugs. We present a typical eosinophilic fasciitis case, which did not respond to first-line treatment, but improved remarkably after infliximab administration. This report demonstrates that in case of initial treatment failure, infliximab might be a relatively safe and effective way of eosinophilic fasciitis management.

Imatinib as a potentially effective therapeutic alternative in corticosteroid-resistant eosinophilic fasciitis

Eosinophilic fasciitis (EF) is a rare condition in children that is typically treated with systemic corticosteroids. We present the case of a 9-year-old boy with biopsy-proven EF, refractory to systemic corticosteroids and methotrexate. The tyrosine kinase inhibitor imatinib was added as adjuvant therapy, leading to improvement in joint function and skin laxity. Our case is the first to suggest the anti-fibrotic properties of imatinib may benefit EF patients.

Eosinophilic Fasciitis With a Malignant Outcome

Eosinophilic fasciitis (EF) is an uncommon localized fibrosing disorder affecting the fascial layers of the human body. To date less than 300 cases of EF have been reported worldwide. Due to the limited prevalence, extensive studying of its pathogenesis and treatment has not yet been established. Furthermore, little is known regarding the long-term prognosis and comorbidities associated with EF. In this case study, we discuss a 72-year-old female patient who was diagnosed with EF and subsequently developed squamous cell carcinoma (SCC) of the skin in areas of previously exposed EF. This case represents the first reported case of SCC of the skin in a patient with previously active EF in the same area of skin.

Eosinophilic fasciitis difficult to differentiate from scleroderma: A case report

BACKGROUND

Eosinophilic fasciitis (EF) is a rare connective tissue disease that can cause swelling and sclerosis of the extremities, and special attention is needed to differentiate EF from systemic sclerosis. Misdiagnosis or omission markedly delays treatment of EF, and severe skin sclerosis in advanced stages can cause joint contracture and tendon retraction, worsening the patient's prognosis and quality of life.

CASE SUMMARY

We report a case of EF in a young woman diagnosed by tissue biopsy, confirming the difficulty of differential diagnosis with scleroderma.

CONCLUSION

Focusing on skin manifestations, completing tissue biopsy and radiography can help diagnose EF effectively. Clinicians should enhance their understanding of the differences between EF and scleroderma, and early diagnosis and standardized treatment can improve the prognosis of patients with EF.

A case of eosinophilic fasciitis without skin manifestations: a case report in a patient with lupus and literature review

Eosinophilic fasciitis (EF) is a rare connective tissue disease that causes inflammation and fibrosis of the fascia, inducing pain and motor dysfunction. Characteristic skin manifestations, such as edema, erythema, induration, peau d'orange appearance, and the groove sign, are of diagnostic significance and observed in the majority of patients with EF. We herein report a case of EF without these characteristic skin manifestations. A 66-year-old Japanese woman developed progressive limb pain and motor dysfunction. No skin changes were observed. We diagnosed the patient with EF based on the clinical course, magnetic resonance imaging, and en bloc biopsy containing fascia and muscle. Oral prednisolone therapy markedly attenuated limb pain and motor dysfunctions. Through a systemic search of the medical literature, we retrieved 4 juvenile cases and 8 adult cases of EF without characteristic skin manifestations during the clinical course. We herein present a systemic review on EF without skin manifestations and discuss differences between the two proposed sets of diagnostic criteria of EF.

Eosinophilic fasciitis during pregnancy: case report and review of literature

The authors describe the case of a 23-year-old woman who was referred to the rheumatologist due to symmetrical and progressive stiffness, induration, and swelling of arms and thighs at the 12th week of her first gestation. The characteristic clinical aspect of 'peau d'orange', associated to the histopathologic results of the deep biopsy of the skin confirmed the diagnosis of eosinophilic fasciitis. Treatment with oral prednisone, at an initial dose of 1 mg/kg/day, was effective and rapidly tapered to 10 mg/day till the birth of a healthy newborn. A literature review showed only one previous description of pregnancy and eosinophilic fasciitis.