Case Presentation Male, 45 years old, with Crohn's disease (CD) A2L1B2, underwent ileocolectomy with
terminal ileostomy as the first treatment 12 years ago due to complications from perforation
and retroperitoneal abscess. He received maintenance therapy postoperatively with
infliximab and reconstructed intestinal transit after one year. After six years of
anti-TNF use, he developed cutaneous leukocytoclastic vasculitis (CLV). Due to pharmacodermia,
the biological treatment was switched to ustekinumab. He used it for two years with
a good response, but due to socioeconomic reasons, it had to be discontinued, and
a new induction with anti-TNF was done. Given the previous dermatological condition,
certolizumab pegol was chosen for being humanized and having low immunogenicity. Four
years after returning to anti-TNF therapy, erythematous punctate macules, non-pruritic,
appeared on the hands, forearms, legs, and feet. He was hospitalized with the clinical
and histological diagnosis of CLV. After 30 days of treatment with corticosteroids
and azathioprine, the patient showed improvement in the skin condition but later died
from a nosocomial infection.
Discussion Anti-TNF therapy optimized the management of Crohn's disease, providing sustained
remission of symptoms. However, the use of these biological agents is not without
complications, with CLV being a rare but clinically significant complication associated
with its use. CLV is characterized by neutrophilic infiltration in the vascular wall
with fragmentation of neutrophil nuclei, possibly with immune complex deposition.
The result is skin lesions, such as papules, purpura, and ulcers, which can progress
to necrosis. The epidemiology is variable, and its pathogenesis remains uncertain.
Management of these cases is based on discontinuation of the biological agent and
treatment of the skin manifestations, usually with corticosteroids. In severe or refractory
cases, additional therapies such as immunosuppressants and other biological agents,
like the anti-CD20 rituximab, may be necessary.
Conclusion Anti-TNF-induced CLV represents a rare but potentially severe complication of biological
therapy. Early recognition, accurate diagnosis, and proper management of this condition
are essential to minimize complications and optimize clinical outcomes for affected
patients.
