Certolizumab pegol-induced immunoglobulin A vasculitis in a patient with rheumatoid arthritis

Abstract

Abstract Rationale: Certolizumab pegol (CZP) is a tumor necrosis factor (TNF) inhibitor with the unique characteristic of being a humanized Fab′ fragment. Immunoglobulin A (IgA) vasculitis has been reported to be associated with the use of TNF inhibitors, including infliximab, etanercept, and adalimumab. Patient concerns: The case was a 34-year-old Japanese woman with rheumatoid arthritis who had been treated with CZP for 3 years. She had delivered a healthy child 5 months earlier. On presentation, she had a 2-day history of abdominal pain and purpura on the lower extremities. Diagnoses: Histological analyses of a skin specimen revealed inflammatory cell infiltrates around the vessel walls and IgA and C3 deposits in the vessel walls of the upper dermis. Computed tomography showed terminal ileitis. The diagnosis was IgA vasculitis, presumably associated with use of CZP. Intervention: CZP was discontinued and prednisolone was administered. Outcomes: The abdominal pain and purpura promptly improved in response to treatment. No relapse of vasculitis occurred after discontinuation of CZP. Lessons: In this case, the cumulative immunomodulatory effects of the TNF inhibitor and the patient postpartum status were considered to be involved in inducing IgA vasculitis. Clinicians should be aware of IgA vasculitis-related symptoms as a possible adverse effect of TNF inhibitors to ensure prompt diagnosis and appropriate treatment.