CASE REPORT - Disseminated cutaneous HSV-1 in a woman with RA receiving Remicade

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J Med Case Reports. 2008 Aug 26;2:282.

Disseminated cutaneous Herpes Simplex Virus-1 in a woman with

rheumatoid arthritis receiving Infliximab: A case report.

Justice EA, Khan SY, Logan S, Jobanputra P.

Rheumatology Department, Selly Oak Hospital, University Hospital

Birmingham NHS Trust, Raddlebarn Road, Birmingham, B29 6JD, UK.

ABSTRACT: INTRODUCTION: We 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 PRESENTATION: Our 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 15 mg 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, 800 mg 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

400 mg 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 200 mg of acyclovir on alternate days. There has

been no recurrence of Herpes Simplex Virus lesions despite increasing

adalimumab to 40 mg weekly 3 months after starting treatment.

CONCLUSION: 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.

PMID: 18727822

http://www.ncbi.nlm.nih.gov/pubmed/18727822

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