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Various toxicities: case report A 55-year-old man developed various toxicities, including vitiligo, vasculitis, hypergammaglobulinaemia, hyperestrogenaemia and antinuclear antibodies (ANA) after receiving infliximab and etanercept [route and duration of treatment not stated] for psoriatic arthritis. The man had started receiving infliximab infusions at 5 mg/kg every 6 weeks. Two years later, his doctor doubled the dose of infliximab from 400 to 800mg. Over the next 2 weeks, he developed vitiligo on his face, hands and groin. He recalled having developed areas of hypopigmentation after he received 500mg instead of 400mg of infliximab 2 years earlier. On presentation, laboratory tests revealed a total IgG level of 2238 mg/dL. Other findings included early signs of gynecomastia and decreased libido. Several weeks after infliximab was discontinued (day 700), the vitiligo stabilised and repigmentation was observed in 5% of his lesions. However, he had elevated estradiol, prolactin and CRP levels. Five months after infliximab was stopped, he developed pyoderma gangrenosum on his legs, gangrene on 2 of his toes and pedal oedema. His wounds were successfully treated with corticosteroids, but his CRP and thyroid peroxidase levels increased. Etanercept [dosage not stated] was started on day 1000 due to persistent arthritic pain. Improvement was observed from days 1016 to 1288. However, the man’s thyroid peroxidase levels rose further and he developed purpuric vasculitis lesions with blebs and blisters on his lower torso and legs. Etanercept was discontinued as a biopsy confirmed leukocytoclastic vasculitis. At this time, his ESR began to increase and his CRP rose sharply to 180 mg/L. In addition, he tested positive for ANA and his testosterone levels declined. On day 1300, his testosterone remained low and his estradiol levels were normal. He subsequently developed acute glomerulonephritis and his creatinine increased to 2.1 mg/dL. Biopsy revealed crescentic necrotising glomerulonephritis. Cytotoxic therapy and steroids improved his creatinine level to 1.4 mg/dL. On day 1800, he had an estradiol level of 78 pg/mL and marked gynecomastia. He was not receiving any steroids or antitumour necrosis factors at the time [treatment and patient outcome not stated]. Lahita RG, et al. Vasculitis, vitiligo, thyroiditis, and altered hormone levels after anti-tumor necrosis factor therapy. The Journal of rheumatology 38: 579-580, No. 3, Mar 2011. Available from: URL: http://dx.doi.org/10.3899/jrheum.100968 803052794 USA

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Reactions 16 Apr 2011 No. 1347