LEUKOCYTOCLASTIC CUTANEOUS VASCULITIS ASSOCIATED WITH ANTI-TNF IN A PATIENT WITH CROHN'S DISEASE

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.

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Artikel online veröffentlicht:
25. April 2025