Development of exclusively cutaneous sarcoidosis in patient with rheumatoid arthritis during treatment with etanercept

Abstract

We report the case of a patient with rheumatoid arthritis who, after 2 months of treatment with etanercept, showed disseminated asymptomatic violaceous papules. Biopsy of the skin lesion showed chronic granulomatous dermatitis with negative staining for fungi and acid-fast bacilli (AFB). After discontinuation of etanercept, the patient's condition improved. Although apparently paradoxical, cases of cutaneous and systemic sarcoidosis after anti-TNF medications have been reported in the literature, with very few cases presenting exclusive cutaneous involvement.

Acute Sarcoidosis (Löfgren's Syndrome) in a Patient Treated with Etanercept for Psoriatic Arthritis-Case Report and Impacts of Biologic Agents Review

“…Biopsy of the skin lesion showed chronic granulomatous dermatitis with negative staining for fungi and acid-fast bacilli (AFB). The lesions improved once etanercept was discontinued [17]. Over the years, similar observations are being reported in literature with significance.…”

Drug-induced sarcoidosis in a patient treated with an interleukin-1 receptor antagonist for hidradenitis suppurativa

“…Immune checkpoint inhibitors can induce sarcoidosis by modifying cytotoxic, Th1/17 and regulatory T-cell ratios 10, 21Table IDrugs that induce cutaneous sarcoidosis and proposed biologic mechanisms of inductionDrugBiologic mechanismIL-1Ra: anakinra 1 Unopposed type I IFN productionFailure of immune regulatory mechanismsImmunosuppression favoring infection with bacterium implicated in sarcoidosisInterferon-α 3 Induction of Th1 cytokinesanti-TNF agents4, 5: entanercept, 6 infliximab, 7 adalimumab 8 Unopposed type I IFN productionMove toward a Th1/Th17 profileDecreased TNF-mediated suppression of Treg expansion/activityAlteration in ratio of membrane bound to soluble TNFR2Process of anti-IFX antibody productionPredisposition secondary to genetic variation of TNF-α genePD-1 inhibitors: pembrolizumab, 9 nivolumab 10 Increased T-cell proliferative capacityNote: PD-1 up-regulation has also been associated with sarcoidosis with a proposed mechanism of decreased T-cell proliferative capacity leading to immunologic derangements conducive to sarcoidosis BRAF inhibitor: vemurafenib 11 Increased TNF-α and IFN-γ levelsNote: Study suggests patients who have sarcoidosis with vemurafenib therapy carry a better prognosisanti-CTLA4 mAb: ipilimumab 12 Enhanced T-cell responsesanti-IgE mAb: omalizumab 13 Decreased expression of dendritic cell IgE high affinity receptor/Th2 cytokine production with subsequent shift from Th2 to Th1 cytokine profileUnmasking of sarcoidosis with prednisone taper accompanying omalizumab treatment initiationFillers for aesthetic procedures: hyaluronic acid 14 Tissue injury and foreign body reaction to fillerInsulin15, 16Traumatic induction (Koebnerization) and foreign body reaction to materials introduced with insulin injectionInflammatory response to zinc component of insulin formulationBotulinum neurotoxin A 17 Foreign body reaction after deposition of crystalline preparation of botulinum neurotoxin A in the skinForeign body reactio...…”