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CORRESPONDENCE
Year : 2021  |  Volume : 66  |  Issue : 1  |  Page : 108-112
Erythrodermic psoriasis after rituximab treatment in a patient with autoimmune hemolytic anemia


1 Department of Dermatology, University Hospital of Heraklion, Crete, Greece
2 Department of Microbiology, Medical School of Athens, Athens, Greece
3 Department of Pathology, University Hospital of Heraklion, Crete, Greece
4 2nd Department of Dermatology and Venereology, National and Kapodistrian University of Athens, Medical School, “Attikon” General University Hospital, Athens, Greece
5 Department of Medical Oncology, Agioi Anargyroi, General Oncological Hospital, Athens, Greece
6 Department of Haematology, University Hospital of Heraklion, Crete, Greece
7 Department of Rheumatology, University Hospital of Heraklion, Crete, Greece
8 Department of Gastroenterology, University Hospital of Heraklion, Crete, Greece

Date of Web Publication1-Feb-2021

Correspondence Address:
Dimitra Koumaki
Department of Dermatology, University Hospital of Heraklion, Crete
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_336_19

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How to cite this article:
Koumaki D, Koumaki V, Haniotis V, Katoulis A, Boumpoucheropoulos S, Stefanidou M, Pontikoglou C, Bertsias G, Evangelou G, Zografaki K, Mantaka A, Krueger-Krasagakis SE, Krasagakis K. Erythrodermic psoriasis after rituximab treatment in a patient with autoimmune hemolytic anemia. Indian J Dermatol 2021;66:108-12

How to cite this URL:
Koumaki D, Koumaki V, Haniotis V, Katoulis A, Boumpoucheropoulos S, Stefanidou M, Pontikoglou C, Bertsias G, Evangelou G, Zografaki K, Mantaka A, Krueger-Krasagakis SE, Krasagakis K. Erythrodermic psoriasis after rituximab treatment in a patient with autoimmune hemolytic anemia. Indian J Dermatol [serial online] 2021 [cited 2021 Feb 28];66:108-12. Available from: https://www.e-ijd.org/text.asp?2021/66/1/108/308500




Sir,

A 57-year-old Caucasian man was diagnosed with autoimmune hemolytic anemia (AIHA) in December 2017. He had been treated, for his AIHA, with a gradually reduced course of oral methylprednisolone starting from 32 mg once daily tapered to 4 mg once daily within 12 months, valaciclovir 500 mg once daily, filicine 5 mg once daily, trimethoprim/sulfamethoxazole (800 + 160 mg) once daily, oral fluconazole 200 mg once daily, and oral dimethindene 10 mg once daily. His past medical history included essential hypertension and type 2 diabetes mellitus. He was on treatment with oral metformin 500 mg three times a day, insulin glargine 20–30 units daily and eprosartan, an angiotensin II receptor antagonist, 600 mg once daily. In October 2018, after failing the aforementioned medications, he was started on rituximab originator (MabThera) 750 mg intravenously once weekly for 4 consecutive weeks. Seven weeks after the first infusion of rituximab, he developed widespread erythrodermic psoriasis affecting his trunk, limbs, neck, and face. At that time, the patient was referred to our dermatology department for review. On examination, he had widespread erythematous psoriatic plaques on the trunk, upper and lower limbs, face, and neck [Figure 1] clinically more in keeping with erythrodermic psoriasis. He reported that in the last one year, he had developed multiple scaly erythematous papules and plaques on his trunk, upper and lower limbs that severely deteriorated in the last 7 days. Upon review of his notes, there was a history of mild erythematous plaques on elbows in the last 6 years that flared up every summer but he had not previously visited a dermatologist for this. He also reported that his father had similar scaly erythematous plaques on his elbows. Acute infections in the last 6 months were not reported. A skin biopsy specimen was consistent with psoriasis [Figure 2] and [Figure 3]. He was initially started on treatment with topical emollients, soap substitutes, and oral prednisolone 20 mg once daily with gradual tapering over an eight-week period for his erythrodermic psoriasis. Two weeks after having started oral prednisolone, he was administered also oral methotrexate 10 mg once weekly that was increased after 2 weeks to oral methotrexate 12.5 mg once weekly achieving almost complete remission of psoriasis within 4 weeks. No further rituximab cycles were given. The patient is receiving ongoing follow-up with the hematology department.
Figure 1: Widespread psoriatic plaques on the trunk and limbs

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Figure 2: Histology showed psoriasiform epidermal hyperplasia with intraepidermal collection of neutrophils and mild lymphocytic infiltrate in papillary dermis (hematoxylin-eosin stain; magnification: ×4)

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Figure 3: The epidermis shows thickening (acanthosis) with regular rete ridges and parakeratosis. Papillary dermis shows a chronic inflammatory infiltrate (hematoxylin-eosin stain; magnification: ×20)

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The close temporal association between the rituximab infusions and the onset of erythrodermic psoriasis together with the almost complete recovery after 8 weeks pointed out a drug-related adverse event.

Between 2007 and 2016, 16 cases of new-onset psoriasis and 6 cases of exacerbation of psoriasis were reported in patients taking rituximab.

Fifteen case reports have described the development or exacerbation of chronic plaque psoriasis secondary to rituximab[1],[2],[3],[4] and one multicenter analysis reviewed 1927 patients taking rituximab for rheumatoid arthritis [Table 1].[5] Two patients developed psoriasis and five patients had an exacerbation of preexisting psoriasis.[5]
Table 1: Summary of rituximab (RTX) induced or exacerbation of psoriasis cases

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To the best of our knowledge here, we have reported a rare case of erythrodermic psoriasis after rituximab treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Dass S, Vital EM, Emery P. Development of psoriasis after B cell depletion with rituximab. Arthritis Rheum 2007; 56:2715-8.  Back to cited text no. 1
    
2.
Mielke F, Schneider-Obermeyer J, Dörner T. Onset of psoriasis with psoriatic arthropathy during rituximab treatment of non-Hodgkin lymphoma. Ann Rheum Dis 2008;67:1056-7.  Back to cited text no. 2
    
3.
Markatseli TE, Kaltsonoudis ES, Voulgari PV, Zioga A, Drosos AA. Induction of psoriatic skin lesions in a patient with rheumatoid arthritis treated with rituximab. Clin Exp Rheumatol 2009;27:996-8.  Back to cited text no. 3
    
4.
Brunasso AM, Massone C. Plantar pustulosis during rituximab therapy for rheumatoid arthritis. J Am Acad Dermatol 2012;67:e148-50.  Back to cited text no. 4
    
5.
Thomas L, Canoui-Poitrine F, Gottenberg JE, Economu-Dubosc A, Medkour F, Chevalier X, et al. Incidence of new-onset and flare of preexisting psoriasis during rituximab therapy for rheumatoid arthritis: Data from the French AIR registry. J Rheumatol 2012;39:893-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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