Disseminated cutaneous herpes simplex virus-1 in a patient with rheumatoid arthritis receiving infliximab: a case report
IntroductionWe present the case of a 49-year-old woman with a seronegative rheumatoid arthritis who developed pustular psoriasis whilst on etanercept and subsequently developed disseminated herpes simplex on infliximab. Case presentationOur patient presented with an inflammatory arthritis which failed to respond to both methotrexate and leflunomide, and sulphasalazine treatment led to side effects.
She was started on etanercept but after 8 months of treatment developed scaly pustular lesions on her palms and soles typical of pustular psoriasis. Following the discontinuation of etanercept, our patient required high doses of oral prednisolone to control her inflammatory arthritis.
A second biologic agent, infliximab, was introduced in addition to low-dose methotrexate and 15mg of oral prednisolone. However, after just 3 infusions of infliximab, she was admitted to hospital with a fever, widespread itchy vesicular rash and worsening inflammatory arthritis.
Fluid from skin vesicles examined by polymerase chain reaction showed Herpes Simplex Virus type 1. Blood cultures were negative and her chest X-ray was normal.
Her infliximab was discontinued and she was started on acyclovir, 800mg five times daily for 2 weeks. She made a good recovery with improvement in her skin within 48 hours.
She continued for 2 months on a prophylactic dose of 400mg bd. Her rheumatoid arthritis became increasingly active and a decision was made to introduce adalimumab alongside acyclovir.
Acyclovir prophylaxis has been continued but the dose tapered so that she is taking only 200mg of acyclovir on alternate days. There has been no recurrence of Herpes Simplex Virus lesions despite increasing adalimumab to 40mg weekly 3 months after starting treatment.
Conclusions: We believe this to be the first reported case of widespread cutaneous herpes simplex virus type 1 infection following treatment with infliximab. We discuss the clinical manifestations of herpes simplex virus infections with particular emphasis on the immunosuppressed patient and the use of prophylactic acyclovir.
Pustular psoriasis is now a well recognised but uncommon side effect of antitumour necrosis factor therapy and can lead to cessation of therapy, as in our patient's case.
Author: Elizabeth Ann Justice, Sophia Yasmin Khan, Sarah Logan and Paresh Jobanputra
Credits/Source: Journal of Medical Case Reports 2008, 2:282
Published on: 2008-08-26
Copyright by the authors listed above - made available via BioMedCentral (Open Access). Please
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