A case of leukocytoclastic vasculitis associated with anti-tumor necrosis factor therapy

Tumor necrosis factor- (TNF-) is one of the known cytokines, which is implicated in the pathogenesis of many chronic inflammatory diseases, including rheumatoid arthritis and ankylosing spondylitis [1]. Tumor necrosis factor-inhibitors are increasingly used for the treatment of rheumatoid diseases. Anti-TNF- therapy is generally well tolerated. However, there are a growing number of reports of the development of adverse events related to anti-TNF- agents [2, 3]. A number of cutaneous side effects have been reported with anti-TNF- therapy, including psoriatic eruption, lupus-like disorders and vasculitis [4]. However, only a few cases of leukocytoclastic vasculitis have been reported and they are rarely related to adalimumab [5–7].
Here we report a case of a patient with ankylosing spondylitis, who developed leukocytoclastic vasculitis after adalimumab treatment.
A 23-year-old male patient had a 13-year history of arthralgia, especially the knee joints and spine. In addition, he underwent surgical treatment of bilateral cleft lip and palate and surgical treatment of pyloric stenosis. In 2010, juvenile idiopathic arthritis was diagnosed. The patient received therapy with sulfasalazine (in 2010–2013), methotrexate (in 2010–2011) and periodically glucocorticoids and non-steroidal anti-inflammatory drugs, with no satisfactory treatment effects. In 2013, the patient was hospitalized in the Department of Rheumatology. The laboratory tests showed elevated inflammatory markers, with negative rheumatoid factor and positive HLA-B27 antigen. Radiological studies showed typical inflammation in the sacroiliac joints. The ankylosing spondylitis was diagnosed. The patient received adalimumab of 40 mg subcutaneously every 2 weeks and showed good response to therapy. After 35 months of treatment, the patient complained of pain and swollen ankles and appearance of skin lesions. Blotchy rash initially included the ankle and then spread to the entire lower limbs. Dermatological examination revealed purpura with erosions and blisters filled with the contents of sero-blood (Figures 1, 2). There were no other systemic signs, however the patient was undergoing dental treatment. The laboratory tests showed no inflammatory markers, and results of all basic laboratory tests (complete blood count, renal, liver and thyroid function, urinalysis) were within the reference values. However, the laboratory tests showed an anti-nuclear antibody (ANA) 1/320 of a granular...


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