Paradoxical reactions induced by tumor necrosis factor-alpha antagonists: A literature review based on 46 cases.

Anti-tumor necrosis factor (TNFα) agents have acquired a prominent place in the treatment options for inflammatory disorders. Among the side effects of these agents are the so-called paradoxical reactions which have increasingly been reported in recent years. A review of literature was carried out using Medline (PubMed) database from January 2010 to December 2014 to collect all published articles on cases of anti-TNFα-induced psoriasis and psoriatic arthritis. Published articles were identified, reviewed and the relevant data extracted. A total of 22 studies (46 patients) fulfilled the inclusion criteria and were selected for analysis. Of the 46 patients, 45 (97.8%) developed psoriasis and 1 (2.1%) psoriatic arthritis. The mean age of patients was 47 years; three (6.5%) patients had a past history of psoriasis. Infliximab caused cutaneous reactions in the most number, 26 (56.5%) cases. Thirty seven (80.4%). patients developed primary plaque-type psoriasis. Women accounted for 86.9% of patients. There was complete resolution of psoriasis in 12 (26%) patients despite differences in the therapeutic approach. Cessation of the incriminated drug led to resolution of cutaneous lesions in 5 (10.8%), switching to another TNFα antagonist led to resolution in 6 (13%) and one (2.1%) patient improved despite continuation of the drug. As for the lone case of psoriatic arthritis, drug withdrawal did not result in improvement; only switching to another anti-TNFα agent helped. Since our sample was small, it was not adequately powered to draw any firm conclusions. However, in this analysis, we found that paradoxical reactions occurred predominantly in adult women, there were only isolated cases with a personal history of psoriasis, infliximab was responsible for most cases of these reactions and the most prevalent form was plaque-type psoriasis. The decision whether to continue or discontinue the triggering anti-TNFα agent should be individualized as results are highly variable.

Development of leprosy in a patient with ankylosing spondylitis during the infliximab treatment: reactivation of a latent infection?

The use of tumor necrosis factor alpha as a treatment for chronic inflammatory conditions has been shown to be associated with an increased risk of developing infections, especially Mycobacterium tuberculosis, atypical mycobacteria, and other microorganisms. We report the case of a 58-year-old man with ankylosing spondylitis, receiving infliximab treatment, who presented with multiple plaques on the face, chest, and extremities, a thickened, tender ulnar nerve, and severe neuritis of the feet. The results of a biopsy of these lesions revealed histopathological features of lepromatous Hansen disease. The use of anti-tumor necrosis factor biologic agent on this patient may have resulted in either a new infection or reactivation of a latent infection of Mycobacterium leprae.