Baylor University Medical Center Proceedings April 2017 - 213

Leukocytoclastic vasculitis drug reaction to
certolizumab pegol
Meghan Woody, MD, MPH, Donald Warren, MD, Laura Speck, MD, and Julie Jackson, MD

Tumor necrosis factor (TNF)-alpha antagonists are a common treatment
modality for autoimmune disorders, but
their use can be associated with many
side effects, including various dermatologic conditions. Certolizumab pegol, a
newer TNF antagonist that lacks the Fc
portion of the IgG antibody, has recently
been approved to treat psoriatic arthritis,
rheumatoid arthritis, and Crohn's disease.
Though other TNF antagonists have been
Figure. (a) Pruritic inflammatory macules and papules on the patient's legs and feet. (b) Extensive small vesicles
associated with leukocytoclastic vasculi- on the plantar surface of the patient's feet.
tis, this finding has not yet been reported
with certolizumab pegol. We present a case report of leukocytoclastic
legs and feet and extensive small vesicles were evident on the
plantar surface of the patient's feet (Figure). Several months after
vasculitis caused by certolizumab pegol.

ertolizumab pegol (CZP) is a pegylated, humanized,
tumor necrosis factor (TNF)-alpha inhibitor that differs from other TNF-alpha inhibitors by being solely
composed of a Fab fragment and lacking the Fc portion
of the IgG antibody (1, 2). By lacking the Fc portion, CZP
cannot activate complement nor mediate antibody-dependent
cell-mediated cytotoxicity; theoretically, this should reduce the
potential for CZP to have Fc-mediated eﬀects. While the other
TNF-alpha antagonists have been cited to cause leukocytoclastic vasculitis (LCV), we believe this is the ﬁrst report of CZP
causing LCV.

CASE PRESENTATION
A 28-year-old woman with Crohn's disease and ankylosing
spondylitis presented for evaluation of a rash on her bilateral
lower legs, feet, palms of hands, and plantar surface of her feet
6 months after beginning CZP. At age 26, she was diagnosed
with severe ankylosing spondylitis; 6 months after diagnosis,
she was placed on CZP as sole therapy. She received 400 mg of
subcutaneous CZP every 4 weeks for approximately 1 year. She
initially developed a rash after being on CZP for 6 months and
remained on the CZP for an additional 6 months, due to the
eﬀective control of ankylosing spondylitis. Initially, many pruritic inﬂammatory macules and papules involved the patient's
Proc (Bayl Univ Med Cent) 2017;30(2):213-214

the initial presentation, the eruption extended to the patient's
trunk and scalp, with the scalp lesions appearing as sebopsoriasis. The eruption progressed to include a folliculitis-like rash on
the patient's thighs and arms. The patient additionally reported
lower extremity edema with prolonged standing and lower leg
muscle soreness.
The patient had documented intolerance for TNF-alpha
inhibitors previously. At the initial diagnosis of Crohn's disease, she was treated with adalimumab but had intolerable side
eﬀects including alopecia, scalp psoriasis, severe hidradenitis
of the groin and axillae, and vesicular eruption on her palms
and soles. Adalimumab was thus discontinued and the patient
subsequently underwent subtotal colectomy.
The patient underwent a punch biopsy of her left foot and
right leg. Microscopic evaluation of the left foot demonstrated an
unremarkable epidermis overlying dermal inﬁltrates, composed
mostly of neutrophils and scattered eosinophils. Chemotaxis
of neutrophils leading to vessel wall injury, ﬁbrin deposition,
and erythrocyte extravasation along with fragmented neutrophils were also noted. Microscopic evaluation of the right leg
From the University of Texas Dell Medical School, Austin, Texas (Woody); Baylor
Scott & White, Marble Falls, Texas (Warren); and Westlake Dermatology, Austin,
Texas (Speck, Jackson).
Corresponding author: Meghan Woody, MD, MPH, University of Texas Dell
Medical School, Austin, TX (e-mail: mwoody@seton.org).
213

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