Erythrodermic Psoriasis Causing Uric Acid Crystal Nephropathy

Abstract

Background. Erythrodermic psoriasis is a rare and severe variant of psoriasis. It is characterized by widespread skin erythema, scaling, pustules, or exfoliation of more than 75% of the body’s surface area. This condition has life-threatening complications to include hemodynamic, metabolic, immunologic, and thermoregulatory disturbances. One metabolic complication, hyperuricemia, occurs from rapid keratinocyte differentiation and infiltration of inflammatory cells into psoriatic lesions. Although renal injury caused by shunting of blood to the skin has been reported, there are no reports of erythrodermic psoriasis causing crystal-induced nephropathy. We present a case of erythrodermic psoriasis and hyperuricemia complicated by uric acid crystal nephropathy. Case Presentation. A 57-year-old male with long-standing psoriatic arthritis presented with diffuse scaling of his skin. He was being treated with adalimumab, leflunomide, and topical clobetasol, but had recently stopped taking his medications. Physical exam revealed yellow scaling covering his entire body with underlying erythema and tenderness without mucosal involvement. Labs were notable for a creatinine of 3.3 mg/dL, with no prior history of renal disease, and uric acid of 12.7 mg/dL. He was admitted to the intensive care unit given >80% of body surface area involvement and acute renal failure. Despite aggressive fluid resuscitation, renal function did not improve, and creatinine peaked at 4.61 mg/dL. Urine microscopy showed diffuse polymorphic uric acid crystals, consistent with uric acid crystal-induced nephropathy. He was started on rasburicase, urinary alkalinization, and fluids. His renal function improved dramatically; urine output, uric acid, and electrolytes normalized. He was discharged on topical clobetasol and leflunomide and started on secukinumab with little to no skin involvement. Conclusion. This case presents the rare complication of crystal-induced nephropathy in a patient with erythrodermic psoriasis. Uric acid crystal nephropathy is well described in diseases with rapid cell turnover such as tumor lysis syndrome. It is thought that rapid keratinocyte differentiation and inflammatory infiltration of psoriatic lesions produced life-threatening electrolyte abnormalities similar to tumor lysis syndrome. Early recognition of this rare complication is critical, and aggressive fluid resuscitation, urine alkalinization, and uric acid lowering agents should be administered immediately.

Psoriasis and Renal Disorders: A Large-Scale Population-Based Study in Children and Adults

“…Different types of glomerulonephritis were described in adults with long-standing psoriasis [22-30]. Nephropathies and end-stage renal failure were reported in patients with acute forms of psoriasis such as generalized pustular psoriasis and erythrodermic psoriasis [31, 32]. Similar findings were reported in the pediatric psoriasis population, but in smaller numbers [13-18].…”

“…In recent years, coexistence of psoriasis and renal diseases has increasingly been reported, resulting in the term "psoriatic nephropathy" [5][6][7][8][9][10][11][22][23][24][25][26][27][28][29][30][31][32]. In adults, this term takes many forms.…”

“…Numerous reports of various types of glomerulonephritis suggest an immunological pathogenesis such as T-cell dysregulation and increased levels of immune complexes [11,26,36,45]. Therefore, it is not surprising that glomerulonephritis was reported in both adults and children with psoriasis [13][14][15][16][17][18][22][23][24][25][26][27][28][29][30][31]. Lately, interleukin-17, a proinflammatory factor detected in high levels in psoriasis patients, was found to also play a role in various renal diseases [46,47].…”

The impact of serum uric acid on psoriasis: NHANES 2005–2014 and Mendelian randomization

“…Covariates were assessed based on previously described methods and clinical practices ( Ellis et al, 2019 ; Xu et al, 2023 ), encompassing a range of potential factors, including gender, age, ethnicity, education level, body mass index (BMI), smoking status, alcohol consumption, hypertension, and diabetes. Additionally, data related to psoriasis were included for analysis following the selection criteria from relevant studies.…”

Псориатическая Нефропатия: Сущность, Спектр Клинических Проявлений И Доказательства Поражения Почек При Псориазе

“…Особенно это касается эритродермического псориаза -редкого и тяжелого варианта псориаза с распространенностью псориатических высыпаний на более 75 % площади тела. Описаны единичные клинические наблюдения кристалл-индуцированной уратной нефропатии у пациента с эритродермическим псориазом [49]. Кроме того, гиперурикемия чаще встречается у пациентов с сопутствующим ПсА, с большей продолжительностью заболевания и сопутствующим ожирением.…”