P006 Tumour Necrosis Factor-Α-induced Lupus Panniculitis: One Case Report and Literature Review

The anti-tumour necrosis factor (TNF)-α therapies have revolutionized the management of multiple chronic inflammatory diseases. However, a wide range of adverse events have been reported over the years (Durand A, Goussot J, Thiolat D et al. Anti-tumour necrosis factor α-induced lupus erythematosus panniculitis. J Eur Acad Dermatol Venereol 2017; 3: e307–48). Lupus erythematosus panniculitis (LEP) is a rare variant of cutaneous lupus erythematosus (1–3% of cutaneous lupus erythematosus), with just two reports of cases potentially triggered by anti-TNF-α therapies (Durand et al.; and Lee H, Kim DS, Chung DY. Adalimumab-induced lupus panniculitis. Letter to the editor. Lupus 2014 ; 23: 1443–4). We report a case of a 62-year-old woman with rheumatoid arthritis treated with etanercept, who previously had not responded to multiple therapies including methotrexate, sulfasalazine and adalimumab. She presented with an 18-month history of a rash on her left upper arm that developed 6 months after initiation of adalimumab. Despite a switch to etanercept, the rash continued to evolve. Examination revealed several discrete telangiectatic plaques on the left upper arm with marked subcutaneous atrophy, clinically suspicious for lupus panniculitis. A similar area was found on the right upper arm. Two punch biopsies for haematoxylin and eosin staining were performed. Histology revealed a thin epidermis with a slightly thickened basement membrane, chronic inflammation at the dermoepidermal junction with lymphocyte exocytosis, transdermal perivascular chronic inflammation and mild lymphoplasmacytic lobular inflammation within the subcutis consistent with lupus panniculitis. Following a switch by her rheumatologist to certolizumab pegol for active rheumatoid arthritis, she had an episode of acute lupus panniculitis requiring hospitalization. A trial of hydroxychloroquine (5 mg kg−1 real bodyweight) and mepacrine in conjunction with potent topical steroids failed to control her panniculitis. Her anti-TNF-α therapies were suspected as a potential cause. Certolizumab was changed to a Janus kinase inhibitor (baricitinib), and dapsone was added to the current treatment. A considerable clinical improvement was noticed. Moreover, her LEP has been in remission for 18 months without any flares. Our literature review highlights only two case of lupus panniculitis induced by anti-TNF-α agents. Lee et al. published a case of adalimumab-induced LEP for first time in 2014, followed by Durand et al., who reported the second case of LEP after 24 months of TNF-α treatment. Interestingly, both patients were female and had known rheumatoid arthritis. In conclusion, our case report and literature review highlights that anti-TNF-α therapies can induce lupus panniculitis, especially in the cohort of patients with rheumatoid arthritis. Is there any relation between these two diseases or is it just a coincidence? Further research in this field is required.