Most biologics-associated cutaneous vasculitis cases involve tumor necrosis factor inhibitors, but here we report a case possibly induced by an interleukin (IL)-6 inhibitor, suggesting such autoimmune events may be underestimated.
The patient, a 70-year-old female, suddenly presented with hematoma of multiple fingers while using tocilizumab (TCZ), a monoclonal antibody that targets the IL-6 receptor. She developed rheumatoid arthritis (RA) at the age of 62. She developed malignant lymphoma prior to the onset of RA, achieved remission, and has remained in remission since then. When she was 68 years old, along with glucocorticoids and sulfasalazine, she started subcutaneous TCZ 162 mg biweekly. At the age of 70, due to high disease activity of RA, the subcutaneous TCZ frequency was increased to weekly, whereas the other medications remained unchanged. Eight months later, she suddenly developed hematoma and purpura in multiple fingers (Figure 1A), some of which formed ulcers (Figure 1B), and blisters with purpura around the ankles (Figure 1C). TCZ was promptly discontinued. Biopsy of a blister showed leukocytoclastic vasculitis (Figure 1D), and direct immunofluorescence results were negative, without thrombosis or malignancy. Antineutrophil cytoplasmic antibodies were negative, and she showed no other vasculitis symptoms, including renal disorders or neuropathy. No other possible causes of vasculitis were identified. Within 4 weeks after TCZ withdrawal, all skin symptoms began to improve, without additional treatment.
(A, B) Hematoma and purpura in multiple fingers, some of which formed ulcers; (C) blisters with purpura around ankles; and (D) biopsy of a blister showing leukocytoclastic vasculitis.
Only 2 cases with TCZ-induced cutaneous vasculitis have been reported previously: one resolved rapidly with TCZ discontinuation and showed only leukocytoclastic vasculitis.1 The other case presenting purpura with central necrotic areas needed to be treated with glucocorticoids and fresh-frozen plasma, and her skin biopsy revealed extensive thrombosis with leukocytoclastic vasculitis.2 In our case, increased TCZ could have caused vasculitis, suggesting even severe skin symptoms including ulcers can improve solely with TCZ discontinuation if without thrombosis.
Footnotes
CONTRIBUTIONS
SY drafted the initial manuscript with critical input from TA. Both SY and TA were involved in revising the manuscript for important intellectual content, and contributed to and approved the final version for submission
FUNDING
The authors declare no funding or support for this work.
COMPETING INTERESTS
The authors declare no conflicts of interest relevant to this article.
ETHICS AND PATIENT CONSENT
Ethics approval was not required according to the authors’ institutions. The patient provided written informed consent to publish this article.
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