INTRODUCTION
Tumor necrosis factor (TNF) antagonists have revolutionized management for various autoimmune and inflammatory conditions, including rheumatoid arthritis (RA), inflammatory bowel disease, hidradenitis suppurativa, psoriatic arthritis, and plaque psoriasis. However, adverse effects may necessitate switching to another biologic with a different mechanism of action. Here we report TNF-α antagonist-induced lupus syndrome (TAILS) revealed by interstitial granulomatous dermatitis (IGD), in the atypical context of Crohn's disease (CD).
A 36-year-old female with a history of CD presented with five months of an intermittent red rash on her forehead, elbows, hands, and feet, associated with one month of migratory joint pain and swelling limiting activities of daily living. Medications included subcutaneous adalimumab 40 mg every two weeks for 2 years and escitalopram 10 mg once daily for anxiety. The patient denied any other constitutional symptoms or known drug allergies. Physical examination showed dermal red plaques on the forehead and eyelids, pink papules coalescing to hemiarcuate plaques on the extensor elbows, and pink papules on the dorsal hands (Figure 1).
Labwork was significant for positive ANA with 1:1280 homogenous staining pattern, positive anti-histone antibodies, and decreased C3. Punch biopsy of a papule on the elbow revealed a lymphocytic infiltrate throughout the dermis, leukocytoclasia, and eosinophils, histiocytes palisaded around degenerated and thickened collagen bundles, and stromal mucin deposition (Figure 2). This patient’s dermal plaques and migratory arthralgias, in the setting of a high ANA titer, anti-histone antibodies, hypocomplementemia, and neutrophilic and granulomatous dermatitis on histology, are most consistent with IGD with TAILS secondary to adalimumab. Pivoting the Crohn therapy to vedolizumab relieved the joint pain within 3 weeks, and the skin manifestations resolved with topical clobetasol propionate 0.05% and pimecrolimus 1% creams.
Dermatologic adverse events associated with anti-TNF agents include psoriasiform dermatitis, palmoplantar pustulosis, and cutaneous infections.1 Although IGD and TAILS from this drug class have been reported separately in the setting of RA,2,3 concurrent diagnoses have been described only once and only in RA.4 Recognizing these unique, rare complications is crucial because they require removal of the offending medication and possibly immunosuppressive therapy to relieve symptoms. TAILS can be a distinct clinical entity from drug-induced lupus erythematosus, with more skin burden, including increased photosensitivity, malar rash, or discoid lupus-like lesions. Serologically, anti-double stranded DNA antibodies and
A 36-year-old female with a history of CD presented with five months of an intermittent red rash on her forehead, elbows, hands, and feet, associated with one month of migratory joint pain and swelling limiting activities of daily living. Medications included subcutaneous adalimumab 40 mg every two weeks for 2 years and escitalopram 10 mg once daily for anxiety. The patient denied any other constitutional symptoms or known drug allergies. Physical examination showed dermal red plaques on the forehead and eyelids, pink papules coalescing to hemiarcuate plaques on the extensor elbows, and pink papules on the dorsal hands (Figure 1).
Labwork was significant for positive ANA with 1:1280 homogenous staining pattern, positive anti-histone antibodies, and decreased C3. Punch biopsy of a papule on the elbow revealed a lymphocytic infiltrate throughout the dermis, leukocytoclasia, and eosinophils, histiocytes palisaded around degenerated and thickened collagen bundles, and stromal mucin deposition (Figure 2). This patient’s dermal plaques and migratory arthralgias, in the setting of a high ANA titer, anti-histone antibodies, hypocomplementemia, and neutrophilic and granulomatous dermatitis on histology, are most consistent with IGD with TAILS secondary to adalimumab. Pivoting the Crohn therapy to vedolizumab relieved the joint pain within 3 weeks, and the skin manifestations resolved with topical clobetasol propionate 0.05% and pimecrolimus 1% creams.
Dermatologic adverse events associated with anti-TNF agents include psoriasiform dermatitis, palmoplantar pustulosis, and cutaneous infections.1 Although IGD and TAILS from this drug class have been reported separately in the setting of RA,2,3 concurrent diagnoses have been described only once and only in RA.4 Recognizing these unique, rare complications is crucial because they require removal of the offending medication and possibly immunosuppressive therapy to relieve symptoms. TAILS can be a distinct clinical entity from drug-induced lupus erythematosus, with more skin burden, including increased photosensitivity, malar rash, or discoid lupus-like lesions. Serologically, anti-double stranded DNA antibodies and
