Nodular Vasculitis That Developed during Etanercept (Enbrel) Treatment in a Patient with Psoriasis

Abstract

Nodular vasculitis was introduced by Montgomery for cases of erythema induratum-like lesions that were not associated with tuberculosis. Nodular vasculitis has been associated with both nontuberculous infections and noninfectious conditions. However, there has been no report on the development of nodular vasculitis during tumor necrosis factor-α inhibitor treatment. A 28-year-old man visited our clinic for the treatment of severe psoriasis with a 20-year history. Subcutaneous injection of etanercept (25 mg, twice weekly) was started. One year later, erythematous nodules developed on his lower leg. A skin biopsy showed lobular panniculitis with extensive necrosis and vasculitis. To exclude latent tuberculosis, an assay specific for Mycobacterium tuberculosis antigens was performed, with a negative result. After stopping etanercept under the diagnosis of nodular vasculitis associated with etanercept, the lesions gradually disappeared, leaving depressed scars in 3 months. There has been no recurrence after 6 months of follow-up.

Keywords: Etanercept; Psoriasis; Vasculitis.

Fig. 1. (A) Erythematous tender nodule with crust on both lower legs. (B) Close-up view. (C) Three months later, the skin lesions gradually improved, leaving depressed scars.

Fig. 2. Skin biopsy specimen showing (A) septal and lobular panniculitis with extended necrosis (H&E, ×40) and (B) leukocytoclastic vasculitis and infiltration of inflammatory cells consisting of neutrophils and lymphocytes (H&E, ×100).