Acute Generalized Exanthematous Pustulosis due to Tocilizumab in a Rheumatoid Arthritis Patient

Abstract

We report a female patient with rheumatoid arthritis which was refractory to methotrexate, leflunomide, and anti-TNF therapy. She was treated with anti-IL-6 tocilizumab (TCZ), with an early appearance of sterile pustules on erythematous swollen skin of trunk, back, and abdominal area. The lesions were consistent with the diagnosis of acute drug-related generalized exanthematous pustulosis (AGEP). This adverse event was controlled with medical treatment without requiring removal of TCZ.

Tocilizumab-Induced Psoriasiform Rash in Rheumatoid Arthritis

“…A previous case report by Wendling et al [5] reported de novo psoriasis in a patient with seronegative RA raising the possibility that this was a new development of psoriasis in a psoriatic arthritis case [2,4,5]. To the best of our knowledge this is the first case report of TCZ psoriasis in an auto-antibody-positive RA case.…”

“…With specific reference to TCZ-induced psoriasis a number of cases have been reported. One of the patients [13] has still disease and the other has RA [4], with exacerbation of pre-existing psoriasis within 2 weeks after the first infusion of TCZ, while 1 patient developed de novo psoriasis [5]. …”

“…In RA, several rare skin manifestations including TCZ-induced erythroderma showing eosinophil infiltration [2], drug eruption [3] and acute generalized exanthematous pustulosis have been reported [4]. Rarely the induction of psoriasis or psoriasiform exanthemata during TCZ treatment has been reported in RA.…”

Tocilizumab‐induced pustular drug eruption

“…Discontinuance of tocilizumab and topical administration of corticosteroids rapidly improved the skin condition within 4 weeks, along with normalization of eosinophil ratio. To date, a few kinds of adverse skin reactions due to tocilizumab have been reported, including psoriasis erythroderma, papular eruptions and acute generalized exanthematous pustulosis (AGEP), some of which contain pustules. By contrast, although small pustular lesions were also intermingled with vesicles in our case, diffuse erythrodermic conditions were not recognized.…”

“…Tocilizumab inhibits signaling from the IL‐6/IL‐6 receptor, which may induce a cytokine imbalance, possibly mediated via regulatory T cells . Alternatively, neutrophils are activated by tocilizumab by some mechanisms which are involved in the induction of some of the above skin rashes . Further accumulation of similar cases and studies are warranted.…”