Improvement of Arterial Wall Lesions in Parallel with Decrease of Plasma Pentraxin-3 Levels in a Patient with Refractory Takayasu Arteritis after Treatment with Tocilizumab

Abstract

A 19-year-old Japanese woman with active Takayasu arteritis despite multiple conventional immunosuppressive therapies with glucocorticoids in combination with intravenous cyclophosphamide, azathioprine, or infliximab with methotrexate and tacrolimus was successfully treated by switching from infliximab to intravenous tocilizumab. Worsening of claudication of the legs and elevated acute phase reactants, including plasma pentraxin-3 levels, were observed during combination therapy with infliximab. Computed tomography demonstrated increased wall thickening with contrast enhancement in the preexisting lesion of the descending aorta and the femoral arteries. After switching from infliximab to tocilizumab, plasma pentraxin-3 levels gradually decreased to the normal range in parallel with the improvement of claudication. Follow-up computed tomographic scans confirmed the marked improvement of these arterial lesions. Moreover, plasma pentraxin-3 level was increased in response to the worsening of claudication that occurred just after switching to a subcutaneous tocilizumab injection. Measurements of plasma pentraxin-3 might be useful for evaluation of the vascular wall inflammation and therapeutic efficacy even during biologic therapy targeting tumor necrosis factor α and interleukin-6.

Figure 1

Changes in disease activity, biomarkers, and treatment during anticytokine biologic therapy. Infliximab (IFX) was administered at a dose of 6 mg per kilogram of body weight every four weeks (white bar). Intravenous tocilizumab (TCZ-IV) was administered at a dose of 8 mg per kilogram of body weight every four weeks (black bar), and subcutaneous tocilizumab (TCZ-SC) was administered at a dose of 162 mg per body weight every other week (gray bar). CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; IL-6, interleukin-6; ITAS2010, The Indian Takayasu Activity Score 2010; PSL, prednisolone; PTX3, pentraxin-3.

Figure 2

Changes in the computed tomographic findings of arterial lesions of Takayasu arteritis before and after starting tocilizumab therapy. Contrast-enhanced CT of the descending aorta (the upper), the right femoral artery (the bottom left), and the left femoral artery (the bottom right) was performed. Three months before starting tocilizumab therapy, while on the treatment with infliximab, arterial wall thickening of the femoral arteries was observed (a). After six months of tocilizumab therapy, there was a significant decrease in the wall thickness of the descending aorta and the femoral arteries (b). After 17 months of tocilizumab therapy, there was a further decrease in arterial wall thickness and an increase in the intraluminal diameter of the descending aorta and the femoral arteries (c).