Reiter syndrome triggered by adalimumab (Humira�) and leflunomide (Arava�) in a patient with ankylosing spondylarthropathy and Crohn disease

Abstract

Conflicts of interest: none declared. Sir, The new class of biological agents targeting tumour necrosis factor (TNF)‐α has been increasingly associated with the triggering and/or the aggravation of psoriasiform or pustular eruptions.1–4 We have recently evaluated a 26‐year‐old HLAB27‐positive patient who has been treated with adalimumab (Humira®; Abbott AG, Baar, Switzerland) and leflunomide (Arava®; Sanofi‐Aventis AG, Meyrin, Switzerland) to control Crohn disease and ankylosing spondylarthropathy with gastrointestinal and articular manifestations refractory to conventional therapies including methotrexate, infliximab and nonsteroidal anti‐inflammatory drugs. Four days after the third adalimumab injection (40 mg) the patient developed a diffuse rash consisting of erythematous, papular and squamous lesions involving the groin, axillar folds, periumbilical region (Fig. 1) and the trunk. He also had genital lesions with sharply delimited erosions of the glans that were consistent with a circinate balanitis (Fig. 2) and two erythematosquamous papules of the feet consistent with plantar keratoderma (Fig. 3). No oral involvement was observed. Light microscopy studies of a biopsy specimen obtained from the trunk disclosed parakeratosis, acanthosis, elongation of the epidermal ridges and a diffuse inflammatory infiltrate of the superficial dermis that was consistent with a psoriasiform pattern (Fig. 4). Of note, the patient had no new systemic complaints, including digestive, urinary or ocular symptoms. An aerobe urine culture detected an infectious urethritis caused by Ureaplasma urealyticum (104 mL−1). The skin lesions regressed completely after doxycycline treatment (200 mg daily for 14 days) and class 2 topical steroid therapy (hydrocortisone butyrate 0.1% once daily).