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Disseminated cutaneous Herpes Simplex Virus-1 in a woman with rheumatoid arthritis receiving Infliximab: A case report

Justice EA, Khan SY, Logan S, Jobanputra P - J Med Case Rep (2008)

Bottom Line: Our patient presented with an inflammatory arthritis which failed to respond to both methotrexate and leflunomide, and sulphasalazine treatment led to side effects.We discuss the clinical manifestations of Herpes Simplex Virus infections with particular emphasis on the immunosuppressed patient and the use of prophylactic acyclovir.Pustular psoriasis is now a well recognised but uncommon side effect of antitumour necrosis factor therapy and can lead to cessation of therapy, as in our patient's case.

Affiliation: Rheumatology Department, Selly Oak Hospital, University Hospital Birmingham NHS Trust, Raddlebarn Road, Birmingham, UK. elizabethjustice@yahoo.com

ABSTRACT

Introduction: We present the case of a 49-year-old woman with a seronegative rheumatoid arthritis who developed pustular psoriasis whilst on etanercept and subsequently developed disseminated herpes simplex on infliximab.

Case presentation: Our patient presented with an inflammatory arthritis which failed to respond to both methotrexate and leflunomide, and sulphasalazine treatment led to side effects. She was started on etanercept but after 8 months of treatment developed scaly pustular lesions on her palms and soles typical of pustular psoriasis. Following the discontinuation of etanercept, our patient required high doses of oral prednisolone to control her inflammatory arthritis. A second biologic agent, infliximab, was introduced in addition to low-dose methotrexate and 15 mg of oral prednisolone. However, after just 3 infusions of infliximab, she was admitted to hospital with a fever, widespread itchy vesicular rash and worsening inflammatory arthritis. Fluid from skin vesicles examined by polymerase chain reaction showed Herpes Simplex Virus type 1. Blood cultures were negative and her chest X-ray was normal. Her infliximab was discontinued and she was started on acyclovir, 800 mg five times daily for 2 weeks. She made a good recovery with improvement in her skin within 48 hours.She continued for 2 months on a prophylactic dose of 400 mg bd. Her rheumatoid arthritis became increasingly active and a decision was made to introduce adalimumab alongside acyclovir. Acyclovir prophylaxis has been continued but the dose tapered so that she is taking only 200 mg of acyclovir on alternate days. There has been no recurrence of Herpes Simplex Virus lesions despite increasing adalimumab to 40 mg weekly 3 months after starting treatment.

Conclusion: We believe this to be the first reported case of widespread cutaneous Herpes Simplex Virus type 1 infection following treatment with infliximab. We discuss the clinical manifestations of Herpes Simplex Virus infections with particular emphasis on the immunosuppressed patient and the use of prophylactic acyclovir. Pustular psoriasis is now a well recognised but uncommon side effect of antitumour necrosis factor therapy and can lead to cessation of therapy, as in our patient's case.

Scaly pustular lesions on soles of feet typical of pustular psoriasis.
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Figure 1: Scaly pustular lesions on soles of feet typical of pustular psoriasis.

Mentions: We describe a 49-year-old woman with seronegative polyarthritis who developed pustular psoriasis whilst on etanercept and subsequently developed disseminated herpes simplex on infliximab in combination with methotrexate. Our patient presented in 2004 and was initially treated with methotrexate. She was unable to tolerate doses beyond 15 mg per week because of troublesome mouth ulcers. Her disease failed to come under control and she was dependent on oral prednisolone at doses above 20 mg. After 5 months, she was switched to sulphasalazine 3 g daily. She developed severe headaches and 3 months later was switched to leflunomide 20 mg daily without any clinical improvement. Her erythrocyte sedimentation rate (ESR) was raised at 44 mm/hour despite oral prednisolone at 25 mg daily and 10 months after diagnosis was started on Etanercept 25 mg subcutaneous injections twice weekly combined with low-dose oral methotrexate (10 mg/week). Three months later, her ESR had fallen to 26 mm/hour and the oral prednisolone reduced to 10 mg daily. Eight months after starting etanercept, she developed scaly pustular lesions on her palms and soles typical of pustular psoriasis (Fig. 1). She ceased etanercept temporarily and her skin improved markedly but her arthritis worsened. On restarting etanercept, the pustular psoriasis recurred. She switched to infliximab, administered intravenously at a dose of 3 mg/kg, and she received the first 3 infusions over the course of 6 weeks. Three weeks after her third infusion, she was admitted to hospital with a fever, a widespread vesicular rash (Fig. 2) and a flare of her arthritis. On admission, she was taking prednisolone 15 mg daily and methotrexate 5 mg weekly. Her full blood count revealed a total count of 17.5 × 109 with a neutrophilia of 10.9 × 109, a C-reactive protein of 153 mg/litre, and an ESR of 75 mm/hour. Renal and liver function tests were normal and immunoglobulins A, G and M were normal. There was no growth on blood cultures and her chest X-ray (CXR) was unremarkable. Fluid from skin vesicles examined by polymerase chain reaction showed Herpes Simplex Virus type 1 (HSV-1). Serological tests showed no evidence of acute Varicella Zoster Virus but indicated past exposure. Infliximab was discontinued and acyclovir 800 mg five times daily was given for 2 weeks. She improved systemically and her vesicular rash started to resolve within 48 hours of acyclovir.

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Disseminated cutaneous Herpes Simplex Virus-1 in a woman with rheumatoid arthritis receiving Infliximab: A case report

Justice EA, Khan SY, Logan S, Jobanputra P - J Med Case Rep (2008)

Scaly pustular lesions on soles of feet typical of pustular psoriasis.
© Copyright Policy - open-access
Figure 1: Scaly pustular lesions on soles of feet typical of pustular psoriasis.
Mentions: We describe a 49-year-old woman with seronegative polyarthritis who developed pustular psoriasis whilst on etanercept and subsequently developed disseminated herpes simplex on infliximab in combination with methotrexate. Our patient presented in 2004 and was initially treated with methotrexate. She was unable to tolerate doses beyond 15 mg per week because of troublesome mouth ulcers. Her disease failed to come under control and she was dependent on oral prednisolone at doses above 20 mg. After 5 months, she was switched to sulphasalazine 3 g daily. She developed severe headaches and 3 months later was switched to leflunomide 20 mg daily without any clinical improvement. Her erythrocyte sedimentation rate (ESR) was raised at 44 mm/hour despite oral prednisolone at 25 mg daily and 10 months after diagnosis was started on Etanercept 25 mg subcutaneous injections twice weekly combined with low-dose oral methotrexate (10 mg/week). Three months later, her ESR had fallen to 26 mm/hour and the oral prednisolone reduced to 10 mg daily. Eight months after starting etanercept, she developed scaly pustular lesions on her palms and soles typical of pustular psoriasis (Fig. 1). She ceased etanercept temporarily and her skin improved markedly but her arthritis worsened. On restarting etanercept, the pustular psoriasis recurred. She switched to infliximab, administered intravenously at a dose of 3 mg/kg, and she received the first 3 infusions over the course of 6 weeks. Three weeks after her third infusion, she was admitted to hospital with a fever, a widespread vesicular rash (Fig. 2) and a flare of her arthritis. On admission, she was taking prednisolone 15 mg daily and methotrexate 5 mg weekly. Her full blood count revealed a total count of 17.5 × 109 with a neutrophilia of 10.9 × 109, a C-reactive protein of 153 mg/litre, and an ESR of 75 mm/hour. Renal and liver function tests were normal and immunoglobulins A, G and M were normal. There was no growth on blood cultures and her chest X-ray (CXR) was unremarkable. Fluid from skin vesicles examined by polymerase chain reaction showed Herpes Simplex Virus type 1 (HSV-1). Serological tests showed no evidence of acute Varicella Zoster Virus but indicated past exposure. Infliximab was discontinued and acyclovir 800 mg five times daily was given for 2 weeks. She improved systemically and her vesicular rash started to resolve within 48 hours of acyclovir.

Bottom Line: Our patient presented with an inflammatory arthritis which failed to respond to both methotrexate and leflunomide, and sulphasalazine treatment led to side effects.We discuss the clinical manifestations of Herpes Simplex Virus infections with particular emphasis on the immunosuppressed patient and the use of prophylactic acyclovir.Pustular psoriasis is now a well recognised but uncommon side effect of antitumour necrosis factor therapy and can lead to cessation of therapy, as in our patient's case.

Affiliation: Rheumatology Department, Selly Oak Hospital, University Hospital Birmingham NHS Trust, Raddlebarn Road, Birmingham, UK. elizabethjustice@yahoo.com

ABSTRACT

Introduction: We present the case of a 49-year-old woman with a seronegative rheumatoid arthritis who developed pustular psoriasis whilst on etanercept and subsequently developed disseminated herpes simplex on infliximab.

Case presentation: Our patient presented with an inflammatory arthritis which failed to respond to both methotrexate and leflunomide, and sulphasalazine treatment led to side effects. She was started on etanercept but after 8 months of treatment developed scaly pustular lesions on her palms and soles typical of pustular psoriasis. Following the discontinuation of etanercept, our patient required high doses of oral prednisolone to control her inflammatory arthritis. A second biologic agent, infliximab, was introduced in addition to low-dose methotrexate and 15 mg of oral prednisolone. However, after just 3 infusions of infliximab, she was admitted to hospital with a fever, widespread itchy vesicular rash and worsening inflammatory arthritis. Fluid from skin vesicles examined by polymerase chain reaction showed Herpes Simplex Virus type 1. Blood cultures were negative and her chest X-ray was normal. Her infliximab was discontinued and she was started on acyclovir, 800 mg five times daily for 2 weeks. She made a good recovery with improvement in her skin within 48 hours.She continued for 2 months on a prophylactic dose of 400 mg bd. Her rheumatoid arthritis became increasingly active and a decision was made to introduce adalimumab alongside acyclovir. Acyclovir prophylaxis has been continued but the dose tapered so that she is taking only 200 mg of acyclovir on alternate days. There has been no recurrence of Herpes Simplex Virus lesions despite increasing adalimumab to 40 mg weekly 3 months after starting treatment.

Conclusion: We believe this to be the first reported case of widespread cutaneous Herpes Simplex Virus type 1 infection following treatment with infliximab. We discuss the clinical manifestations of Herpes Simplex Virus infections with particular emphasis on the immunosuppressed patient and the use of prophylactic acyclovir. Pustular psoriasis is now a well recognised but uncommon side effect of antitumour necrosis factor therapy and can lead to cessation of therapy, as in our patient's case.

View Similar Images In: Results  - Collection
View Article: PubMed Central - HTML -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=2542400&rFormat=json&query=null&req=5