Simultaneous development of cutaneous vasculitis and an autoimmune bullous skin disease during anti-TNF therapy for rheumatoid arthritis: a case report and review of the literature

Abstract

Tumour necrosis factor inhibitors (TNFi) have led to a paradigm shift in the treatment for various diseases including rheumatoid arthritis (RA). During the course of treatment, however, they sometimes cause adverse autoimmune disorders such as lupus, psoriasis and vasculitis. Here, we report a case in which a patient with RA under etanercept (ETN) treatment developed simultaneous ulcerations and blisters on the extremities. Skin biopsies showed leucocytoclastic vasculitis (LCV) at the ulcerative lesion, and subepidermal blistering with linear deposits of IgG and C3 at the basement membrane zone of the blister suggesting a pemphigoid disease. Such simultaneous development of LCV and pemphigoid in an RA patient has not previously been reported. We reviewed 71 cases of vasculitis and 7 cases of pemphigoid diseases during anti-TNF therapy. The prevalence of pemphigoids in RA patients appeared to be comparable to that in healthy individuals. This case showed that TNFi treatment may be involved in two distinct autoimmune reactions, in which vasculitis is related to the augmentation of pemphigoid.

Rheumatoid arthritis, pemphigoid, vasculitis, biologic disease-modifying anti-rheumatic drugs, tumour necrosis factor inhibitors