Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obervation Letter
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
LETTER TO THE EDITOR
2014:80:2;187-189
doi: 10.4103/0378-6323.129422
PMID: 24685874

Severe eosinophilia during anti-tumor necrosis factor-alpha therapy for psoriatic arthritis

Giacomo Maria Guidelli, Sara Tenti, Antonella Fioravanti
 Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, Siena University, Viale Bracci 1, 53100 Siena, Italy

Correspondence Address:
Giacomo Maria Guidelli
Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, Siena University, Viale Bracci 1, 53100 Siena
Italy
How to cite this article:
Guidelli GM, Tenti S, Fioravanti A. Severe eosinophilia during anti-tumor necrosis factor-alpha therapy for psoriatic arthritis. Indian J Dermatol Venereol Leprol 2014;80:187-189
Copyright: (C)2014 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Since 1999, tumor necrosis factor-alpha (TNF-alpha) antagonists are being commonly used in the treatment of rheumatological, dermatological and gastroenterological autoimmune diseases.

Despite their striking effectiveness and an acceptable toxicity profile, several side effects have been reported, including increased risk of serious infections due to both commensal and opportunistic microorganisms, lymphoma and solid tumors and adverse dermatological reactions. [1]

Here, we briefly report the case of a man with psoriatic arthritis who developed blood eosinophilia first during treatment with etanercept and then with adalimumab.

A 59-year-old Caucasian man had been diagnosed with psoriatic arthritis 15 years ago. Initially, during the early years of the disease, he reported being treated with oral corticosteroids and sulfasalazine and then with methotrexate.

In 2010, the patient still had active arthritis, with a psoriasis area severity index (PASI) score of 6.7; hence, he had been receiving combination therapy with etanercept, 25 mg twice a week and oral methylprednisolone, 4 mg/day. Joint involvement rapidly improved while the PASI score did not change during treatment [Figure - 1]. However, routine blood analysis after the first month of therapy, which included a total of eight injections, revealed eosinophilia of 24% (normal value: 0-6%) with a total white blood cell count of 8.30 × 10 3 /mm 3 ; [Figure - 1]. Other causes of eosinophilia, such as parasitic infections, allergies and non-Hodgkin′s lymphoma were excluded by complete hematological, allergological and microbiological work-up. On this basis, etanercept was withdrawn and laboratory findings returned to normal within 30 days.

Figure 1: Variation in eosinophil counts over time

After 6 months of treatment with oral corticosteroids alone, the patient was seen in our rheumatologic outpatient clinic for a relapse of the arthritis. Clinically, the patient showed joint effusion of his right knee, wrists and small joints of the left hand; psoriasis plaques were still present on his elbows (PASI score: 5.9).

Laboratory tests showed anemia with features of chronic disease with a hemoglobin level of 11.2 g/dl, with low serum iron and high ferritin levels, a raised erythrocyte sedimentation rate of 58 mm/h (normal value: 0-35) and C-reactive protein of 2.7 mg/dl (normal value: <0.5). X-rays showed erosive lesions in the wrist and metacarpophalangeal joints, bilaterally. The patient was treated with subcutaneous injections of adalimumab, 40 mg every 14 days, which resulted in a rapid clinical improvement of the tender and swollen joints.

However, after 5 months, the eosinophil count rose up to 38.6% of a total white blood cell count of 6.2 × 10 3 /mm 3 [Figure - 1].

As with the previous episode of eosinophilia following etanercept therapy, a parasite screen was negative, total IgE remained normal and no signs of a hematological disorder were found. After discontinuation of adalimumab, eosinophilia disappeared within 40 days [Figure - 1].

Currently, the patient is being treated with leflunomide, 20 mg/day, a conventional disease-modifying anti-rheumatic drug, without relapse of the arthritis.

The introduction of biologic drugs such as TNF-alpha inhibitors has improved treatment efficacy in several chronic inflammatory disorders including psoriatic arthritis. However, the challenge for clinicians is to evaluate the potential drug-related side-effects.

In our case, the link between the administration of etanercept and then adalimumab with the increase in eosinophil count is clear.

Some authors have previously described eosinophilic pathology associated with anti TNF-alpha drugs. Boura et al.[2] and Winfield et al. [3] described the development of eosinophilic cellulitis (Wells syndrome) after administration of adalimumab and etanercept. Cancelliere et al.[4] reported the case of a patient with rheumatoid arthritis who developed subacute prurigo with eosinophilia after infliximab and etanercept therapy. Furthermore, a transient blood eosinophilia during adalimumab administration for acrodermatitis continua of Hallopeau has been described by Vester et al.[1] More recently, Malisiewicz et al.[5] showed the development of isolated eosinophilia in three patients with psoriasis (two of who also had joint involvement) during TNF blockade.

In the eHealthMe database, on October 6, 2012, among 126860 people reporting to have side effects when taking adalimumab, 74 (0.06%) had eosinophilia. At the same date, with regard to etanercept, 60 (0.04%) patients among 166562 people reporting side-effects reported the development of eosinophilia. The majority of these patients were women in the fifth decade of life.

The mechanism by which TNF-alpha inhibition leads to blood eosinophilia remains unclear. It has been hypothesized that the generation of IgE-class-switched antibodies might determine IgE-mediated drug hypersensitivity and subsequent eosinophilia; furthermore, anti-TNF-alpha agents, especially adalimumab, might also be able to influence eosinophil apoptosis. [6]

This case highlights the importance of early identification and reporting of drug side-effects, such as eosinophilia, which, however, remains a rare adverse event of TNF-alpha blockers. This side effect is not often clinically detectable, but it could be responsible for severe organ damage due to the release of toxic granule proteins such as eosinophil-derived neurotoxin, eosinophilic cationic protein, eosinophil peroxidase and eosinophil major basic protein.

Our case and some cases reported in the literature suggest that after the development of eosinophilia, clinicians should switch therapy, not from one TNF-alpha inhibitor to another one, but to other drugs with a different mechanism of action.

References
1.
Vester K, Rüger RD, Harth W, Simon JC. Transient blood eosinophilia during treatment with adalimumab. J Eur Acad Dermatol Venereol 2012;26:924-5.
[Google Scholar]
2.
Boura P, Sarantopoulos A, Lefaki I, Skendros P, Papadopoulos P. Eosinophilic cellulitis (Wells' syndrome) as a cutaneous reaction to the administration of adalimumab. Ann Rheum Dis 2006;65:839-40.
[Google Scholar]
3.
Winfield H, Lain E, Horn T, Hoskyn J. Eosinophilic cellulitis-like reaction to subcutaneous etanercept injection. Arch Dermatol 2006;142:218-20.
[Google Scholar]
4.
Cancelliere N, Barranco P, Vidaurrázaga C, Benito DM, Quirce S. Subacute prurigo and eosinophilia in a patient with rheumatoid arthritis receiving infliximab and etanercept. J Investig Allergol Clin Immunol 2011;21:248-9.
[Google Scholar]
5.
Malisiewicz B, Murer C, Pachlopnik Schmid J, French LE, Schmid-Grendelmeier P, Navarini AA. Eosinophilia during psoriasis treatment with TNF antagonists. Dermatology 2011;223:311-5.
[Google Scholar]
6.
Simon HU, Yousefi S, Dibbert B, Levi-Schaffer F, Blaser K. Anti-apoptotic signals of granulocyte-macrophage colony-stimulating factor are transduced via Jak2 tyrosine kinase in eosinophils. Eur J Immunol 1997;27:3536-9.
[Google Scholar]

Fulltext Views
184

PDF downloads
55
Show Sections