Elsevier

Mayo Clinic Proceedings

Volume 87, Issue 8, August 2012, Pages 739-745
Mayo Clinic Proceedings

Original article
Vasculitis Associated With Tumor Necrosis Factor-α Inhibitors

https://doi.org/10.1016/j.mayocp.2012.04.011Get rights and content

Abstract

Objective

To describe the clinical characteristics, histopathologic features, and outcomes of patients in whom vasculitis developed in association with use of tumor necrosis factor-α (TNF-α) inhibitors.

Patients and Methods

This is a retrospective review of patients evaluated at Mayo Clinic, Rochester, Minnesota, from January 1, 1998, through March 31, 2011, with a diagnosis of vasculitis induced by anti–TNF-α therapy.

Results

Of 8 patients with vasculitis associated with anti–TNF-α therapy (mean age, 48.5 years), 6 (75%) were female. Four (50%) had rheumatoid arthritis, 1 (13%) had Crohn disease, and 3 (38%) had ulcerative colitis. Five (63%) were treated with infliximab, 2 (25%) with etanercept, and 1 (13%) with adalimumab. The mean duration of treatment before development of vasculitis was 34.5 months. The skin was the predominant organ affected (5 patients [63%]), with the most common cutaneous lesion being palpable purpura (4 of 5 [80%]). Two organs involved in systemic vasculitis were the peripheral nervous system (4 patients [50%]) and kidney (1 patient [13%]). All cases of vasculitis were histopathologically confirmed. Seven of 8 patients improved with discontinuation of therapy (mean time to resolution, 6.9 months) and adjuvant treatment (all 8 received prednisone; another agent was also used in 7); rechallenge with anti–TNF-α therapy was not attempted in any patient. At last follow-up, no patients had experienced a recurrence of vasculitis after therapy discontinuation.

Conclusion

Cutaneous small-vessel vasculitis was the most common finding, but systemic vasculitis, including peripheral nerve and renal vasculitis, was also frequently observed.

Section snippets

Patients and Methods

After approval by the Mayo Clinic Institutional Review Board, we searched the institutional medical index and text retrieval system to retrospectively identify patients who were evaluated at Mayo Clinic, Rochester, Minnesota, from January 1, 1998, through March 31, 2011, and who had a diagnosis of any form of vasculitis induced by anti–TNF-α therapy. We searched coded medical index data to identify patients with a diagnosis containing the terms vasculitis, Wegener's granulomatosis,

Results

The combined searches of the institutional medical index and text retrieval system yielded a preliminary cohort of 345 patients. Patients who did not meet the predefined inclusion criteria for this study were excluded (ie, evaluation was not compatible with vasculitis, patient was not receiving anti–TNF-α agent at the time vasculitis developed, underlying disease [eg, RA or IBD] was active at the time of vasculitis, or another more likely cause of vasculitis was found [eg, infection]), for a

Discussion

Anti–TNF-α therapy has been increasingly associated with drug-induced autoimmune diseases, such as cutaneous vasculitis, lupus-like syndrome, systemic lupus erythematosus, and interstitial lung disease.10, 13, 14, 15, 16 Vasculitis is the most common autoimmune disease that results from anti–TNF-α therapy.8, 9 To date, 213 cases of TNF-induced vasculitis have been reported in the medical literature: 39 in a nationwide series in France, 139 in Spain, and 35 in the United States that were derived

Conclusion

Anti–TNF-α therapy remains a valuable treatment for rheumatic and systemic autoimmune diseases. Although the risk of systemic vasculitis may be minimal, health care professionals should nonetheless be aware of, and should monitor for, this potential complication. If vasculitis associated with anti–TNF-α is suspected, histologic evaluation and extensive investigations for organ involvement must be pursued. The resolution of symptoms may be achieved by discontinuing use of the culprit anti–TNF-α

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