Etanercept for the Treatment of Human Immunodeficiency Virus-Associated Psoriatic Arthritis

doi:10.4065/75.10.1093

Mayo Clinic Proceedings

Volume 75, Issue 10, October 2000, Pages 1093-1098

https://doi.org/10.4065/75.10.1093 Get rights and content

Etanercept may play an important role in modulating the inflammatory activity and progression of human immunodeficiency virus (HIV)-associated psoriasis and psoriatic arthritis. We report the case of a 45-year-old homosexual man with a CD4 cell count of less than 0.05 × 10⁹/L and an HIV viral load of 4200 copies/mL (while receiving highly active antiretroviral therapy) who developed extensive psoriatic plaques, 4.5-kg weight loss, onychodystrophy, and psoriatic arthropathy with severe periarticular bone demineralization. The arthritis progressed despite the use of several disease-modifying medications, including corticosteroids, hydroxy chloroquine, and minocycline. Because of uncontrolled, progressive, and disabling arthritis and resulting profound disability, he was treated with etanercept. Within 3 weeks, his psoriasis had improved dramatically and his joint inflammation had stabilized. For the next 4 months, immunologic and viral parameters remained stable, but his clinical course was complicated by frequent polymicrobial infections. Etanercept was thus discontinued despite continued improvements in his psoriasis, psoriatic arthritis, and functional status. While both cutaneous and joint manifestations of psoriasis improved dramatically, the experience with this patient dictates that caution and careful follow-up must be exercised when prescribing etanercept in the setting of HIV infection.

Section snippets

REPORT OF A CASE

In May 1998, a 45-year-old homosexual man with a 15-year history of HIV infection, a CD4 cell count of less than 0.05 × 10⁹/L, and an HIV viral load of 4200 copies/mL (while receiving highly active antiretroviral therapy [HAART]) presented with pruritus and progressive scaling plaques involving the scalp and trunk of 1 month's duration. There was no joint inflammation. He was diagnosed as having psoriasis and was initially treated with antihistamines, topical corticosteroids, and, when his

DISCUSSION

Psoriatic arthritis related to HIV infection is most commonly polyarticular and asymmetrical, although the simultaneous or sequential development of oligoarticular and distal interphalangeal patterns has been documented.² Approximately half of these patients also have extra-articular manifestations such as dactylitis and inflammation of the tendons and ligamentous attachments to bone.⁶ Often, the clinical course is insidious, but in roughly one third of persons, it may be abrupt, with

ACKNOWLEDGMENTS

The authors gratefully acknowledge Scott Kennedy, MD, who provided expert medical care for this patient, and Arleen Sierra for manuscript preparation.

REFERENCES (39)

LR Espinoza et al.
There is an association between human immunodeficiency virus infection and spondyloarthropathics
Rheum Dis Clin North Am
(1992)
LW Moreland
Soluble tumor necrosis factor receptor (p75) fusion protein (ENBREL) as a therapy for rheumatoid arthritis
Rheum Dis Clin North Am
(1998)
J Lahdevirta et al.
Elevated levels of circulating cachectinAumor necrosis factor in patients with acquired immunodeficiency syndrome
Am J Med
(1988)
G Solomon et al.
An approach to the human immunodeficiency virus-positive patient with a spondyloarthro-pathic disease
Rheum Dis Clin North Am
(1991)
J Breuer-McHam et al.
Alterations in HIV expression in AIDS patients with psoriasis or pruritus treated with phototherapy
J Am Acad Dermatol
(1999)
F Diez et al.
Zidovudine treatment of psoriasis associated with acquired immunodeficiency syndrome [letter]
J Am Acad Dermatol
(1990)
FM Brennan et al.
Inhibitory effect of TNK alpha antibodies on synovial cell interlcukin-l production in rheumatoid arthritis
Lancet
(1989)
R Winchester
Psoriatic arthritis
Dermawl Clin
(1995)
S Weitzul et al.
HIV-relaled psoriasis and Reiter's syndrome
Semin Cutan Med Surg
(1997)
A Montageri et al.
Psoriasis and HIV infection
Int J Dermatol
(1996)

R Winchester et al.

The co-occurrence of Rcitcr's syndrome and acquired immunodeficiency

Ann Intern Med

(1987)

IH Calabrese et al.

Rheumatic symptoms and human immunodeficiency virus infection: the influence of clinical and laboratory variables in a longitudinal cohort study

Arthritis Rheum

(1991)

J Romani et al.

Reiler's syndrome-like pattern in AIDS-associaled psoriasiform dermatitis

Int J Dermatol

(1996)

DM Aboulafia

Inflammatory pseudotumor causing small bowel obstruction and mimicking lymphoma in a patient with AIDS: clinical improvement after initiation of thalidomide treatment

Clin Infect Dis

(2000)

C Corcoran et al.

Treatments for wasting in patients with acquired immunodeficiency syndrome

N Engl J Med

(1999)

A Perl

Mechanisms of viral pathogenesis in rheumatic disease

Ann Rheum Dis

(1999)

PJ Clements et al.

Nonsteroidal antirheumatic drugs

LR Espinoza et al.

Psoriatic arthritis and acquired immunodeficiency syndrome

Arthritis Rheum

(1988)

AC Jung et al.

Management of adverse reactions to trimethoprim-sulfamethoxazole in human immunodeficiency virus-infected patients

Arch Intern Med

(1994)

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HIV: Inflammatory dermatoses
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Patients living with HIV may experience a variety of inflammatory dermatoses, ranging from exacerbations of underlying conditions to those triggered by HIV infection itself. This article presents a current literature review on the etiology, diagnosis and management of atopic dermatitis, psoriasis, pityriasis rubra pilaris, lichen planus, seborrheic dermatitis, eosinophilic folliculitis, pruritic papular eruption and pruritus, in patients living with HIV.
Psoriasis and HIV infection, what do French dermatologists do?
2019, Annales de Dermatologie et de Venereologie
Chez les patients atteints du virus d’immunodéficience humaine (VIH), le psoriasis a la même prévalence que dans la population générale mais il est plus sévère et réfractaire, et son traitement est plus difficile. L’objectif de cette enquête était d’évaluer les pratiques des dermatologues français quant au dépistage du VIH au cours du suivi du psoriasis, et quant à la prise en charge thérapeutique et à la surveillance des patients atteints de psoriasis et infectés par le VIH.
Une enquête de pratiques nationale et anonyme a été réalisée à l’aide d’un questionnaire adressé par courriel aux dermatologues hospitaliers et libéraux français, entre mars et juin 2017.
Le questionnaire a été rempli par 262 dermatologues. Ils déclaraient dépister le VIH chez les patients atteints de psoriasis s’ils présentaient des facteurs de risque (79,4 %), avant l’instauration d’une biothérapie (63,4 %) ou d’un autre traitement systémique à l’exception des rétinoïdes (53,1 %), si le psoriasis était sévère (45,8 %) ou en cas d’aggravation (37,8 %). Parmi les praticiens, 28,7 % suivaient des patients atteints de psoriasis et porteurs du VIH, avec un nombre moyen de 3,1 patients suivis. Ils prescrivaient tous les traitements systémiques, à l’exception de la ciclosporine, mais prenaient fréquemment l’avis d’un infectiologue pour prescrire ces molécules. Parmi les biothérapies, l’étanercept était le plus utilisé (65,5 % des praticiens). La surveillance biologique de ces patients était plus rapprochée dans 72,1 % des cas.
Les dermatologues français ne dépistent pas systématiquement le VIH chez les patients atteints de psoriasis. Lorsqu’elle est connue, cette infection modifie néanmoins leurs pratiques. Les choix thérapeutiques sont en accord avec les recommandations françaises. Cependant, des recommandations quant au dépistage de cette population semblent nécessaires.
The prevalence of psoriasis among patients presenting human immunodeficiency virus (HIV)infection is the same as in the general population, but the disease is more severe and refractory, and management is more complex. The aim of this survey was to assess the practices of French dermatologists concerning both screening for HIV in psoriasis patients and therapeutic management and follow-up of psoriasis patients with HIV.
An anonymous national survey of practices was conducted by means of a questionnaire emailed to dermatologists in hospital in private practice in France between March and June 2017.
The questionnaire was completed by 262 dermatologists. They indicated that they carried out screening for HIV in psoriasis patients presenting risk factors (79.4%), prior to biotherapy (63.4%) or different systemic treatments other than retinoids (53.1%), if the psoriasis was severe (45.8%), or in the event of worsening (37.8%). 28.7% of practitioners surveyed were in fact treating patients with psoriasis and HIV, with a mean 3.1 patients being followed up. All practitioners prescribe systemic treatment, other than cyclosporine, but they frequently consult an infectious disease specialist before prescribing these therapies. The most widely used biotherapy was etanercept (65.5% of practitioners). More intensive laboratory follow-up was conducted for these patients in 72.1% of cases.
French dermatologists do not perform routine screening for HIV in psoriasis patients. However, where infection has been identified, their practices are modified accordingly. Therapeutic choices are consistent with the French recommendations. Nevertheless, recommendations appear necessary concerning HIV screening in this population.
Psoriasis: Which therapy for which patient: Focus on special populations and chronic infections
2019, Journal of the American Academy of Dermatology
Citation Excerpt :
Of special note, though not approved for psoriasis, hydroxyurea has been recommended in patients with psoriasis and HIV infection because of its antiretroviral properties and historic use for psoriasis.118 There are a few reports of successful etanercept use in patients with HIV with psoriasis, with only 1 report of polymicrobial infection; CD4 and viral counts either improved or remained stable after treatment.119-123 Infliximab has also been used successfully in patients with HIV and psoriasis.
Despite the availability of several new systemic agents for psoriasis treatment, choosing the right therapy in certain patient populations can be challenging. There are few up-to-date reviews on systemic drugs for moderate to severe psoriasis in pregnant and pediatric patients and in patients with concomitant chronic infections, such as hepatitis, HIV, and latent tuberculosis. These groups are usually excluded from clinical trials, and much of the available evidence is based on anecdotal case reports and case series. As a chronic disease, psoriasis requires long-term treatment, and there are concerns of adverse maternal–fetal outcomes, long-term side effects in children, and the reactivation of latent infections with the use of systemic agents in these patients. The second article in this continuing medical education series provides insights for choosing appropriate systemic agents for treating moderate to severe psoriasis in pregnant and pediatric patients and in the setting of chronic infections, such as hepatitis, HIV, and latent tuberculosis.
Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part)
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Este es el primer Consenso Latinoamericano de la Pan American Crohn's and Colitis Organisation (PANCCO) que corresponde a situaciones especiales en pacientes con enfermedad inflamatoria intestinal (EII). El objetivo de este consenso es concientizar a la comunidad médica de todos los países de América Latina acerca del embarazo, la vacunación, las infecciones y las neoplasias, incluyendo el cáncer colorrectal, así como los aspectos pediátricos en pacientes con EII.
This is the first Latin American Consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) regarding special situations in patients with inflammatory bowel disease (IBD). The aim of this consensus is to raise awareness in the medical community in all Latin American countries with respect to pregnancy, vaccinations, infections, neoplasms, including colorectal cancer, and pediatric issues in patients with IBD.
Use of tumor necrosis factor (TNF) inhibitors in patients with HIV/AIDS
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Citation Excerpt :
She was ultimately intubated, dialyzed, and survived the episode.32 Only 1 patient with infectious complications had a CD4 count less than 250 cells/mm3.18 A 2010 review conducted by the medical board of the National Psoriasis Foundation suggested cautious prescribing of TNF-alpha inhibitors only to closely monitored patients with HIV and very refractory psoriasis or debilitating psoriatic arthritis.33
Patients with HIV and AIDS are living longer because of advancements in antiretroviral therapy. These patients are often susceptible to debilitating inflammatory disorders that are refractory to standard treatment. We discuss the relationship of tumor necrosis factor-alpha and HIV and then review 27 published cases of patients with HIV being treated with tumor necrosis factor-alpha inhibitors. This review is limited because no randomized controlled trials have been performed with this patient population. Regardless, we propose that reliable seropositive patients, who are adherent to medication regimens and frequent monitoring and have failed other treatment modalities, should be considered for treatment with tumor necrosis factor-alpha inhibitors.
HIV/AIDS and rheumatoid arthritis
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The acquired immunodeficiency syndrome (AIDS) is an infectious disease caused by the human immunodeficiency virus (HIV). It was first recognized in the United States in 1981, and the HIV/AIDS epidemic has since spread to affect all countries. The interface of HIV/AIDS with opportunistic infectious diseases is well characterized, but further research is required into the concurrence of other chronic diseases. The objective of this review was to identify possible interferences of HIV infection in the diagnosis and management of rheumatoid arthritis (RA). A review of the available evidence was conducted using the GRADE approach. Overall, the quality of evidence was low. Our main conclusions were: (1) the occurrence of rheumatoid-like arthritis in patients with HIV/AIDS is quite rare; therefore, it is not recommended that HIV infection be considered routinely as a differential diagnosis in this condition (C2); (2) HIV infection may lead to rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody positivity, but usually at low titers (C1); (3) RA might cause false-positive HIV serology and ELISA seems to be a more specific test for HIV in patients with RA (C2); (4) RA and AIDS may coexist, even in cases of severe immunosuppression (C1); (5) RA emergence may seldom occur during or after immune reconstitution (C1); and (6) there is insufficient safety data to recommend use of specific disease-modifying antirheumatic drugs (DMARDs) in RA patients with HIV/AIDS. Therefore, these drugs should be used cautiously (C1).

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Case ReportEtanercept for the Treatment of Human Immunodeficiency Virus-Associated Psoriatic Arthritis

Section snippets

REPORT OF A CASE

DISCUSSION

ACKNOWLEDGMENTS

Rheum Dis Clin North Am

Rheum Dis Clin North Am

Am J Med

Rheum Dis Clin North Am

J Am Acad Dermatol

J Am Acad Dermatol

Lancet

Psoriatic arthritis

Dermawl Clin

HIV-relaled psoriasis and Reiter's syndrome

Semin Cutan Med Surg

Psoriasis and HIV infection

Int J Dermatol

The co-occurrence of Rcitcr's syndrome and acquired immunodeficiency

Ann Intern Med

Rheumatic symptoms and human immunodeficiency virus infection: the influence of clinical and laboratory variables in a longitudinal cohort study

Arthritis Rheum

Reiler's syndrome-like pattern in AIDS-associaled psoriasiform dermatitis

Int J Dermatol

Inflammatory pseudotumor causing small bowel obstruction and mimicking lymphoma in a patient with AIDS: clinical improvement after initiation of thalidomide treatment

Clin Infect Dis

Treatments for wasting in patients with acquired immunodeficiency syndrome

N Engl J Med

Mechanisms of viral pathogenesis in rheumatic disease

Ann Rheum Dis

Nonsteroidal antirheumatic drugs

Psoriatic arthritis and acquired immunodeficiency syndrome

Arthritis Rheum

Management of adverse reactions to trimethoprim-sulfamethoxazole in human immunodeficiency virus-infected patients

Arch Intern Med

Case Report
Etanercept for the Treatment of Human Immunodeficiency Virus-Associated Psoriatic Arthritis