Generalized pustular psoriasis of pregnancy (GPPP) is a rare dermatological condition that significantly affects maternal health and pregnancy outcomes. The treatment of this disease might be very challenging, as only a limited number of effective therapeutic options are available. If the use of systemic drugs is considered, they should ideally effectively control the systemic inflammation without harming the fetus. Here, we report the successful treatment of a severe case of GPPP in a 28-year-old woman using the tumor necrosis factor-alpha inhibitor (TNFi) certolizumab pegol. Additionally, we review the existing literature on the use of this class of drugs for treating GPPP. To date, there are only 11 reported cases of this severe skin condition treated with a TNFi. We also discuss the pathogenesis of GPPP and the rationale behind using TNFi for its treatment.

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Merkel cell carcinoma (MCC) is a rare but deadly skin cancer, observed classically in the sun-damaged skin of older, white males. The cancer is characterized by rapid growth as well as high morbidity and mortality. In this article, we detail an atypical presentation of MCC in an African-American patient being treated with prednisone, methotrexate, and adalimumab for rheumatoid arthritis. Initially presenting as a subcutaneous nodule, the tumor in our patient was misdiagnosed first as an abscess and treated accordingly. Only after the subcutaneous mass failed to resolve with antibiotics as well as repeated incision and drainage was a biopsy performed, which yielded the final diagnosis. In the text, we detail the patient\'s symptomatology as well as steps that eventually lead to diagnostic confirmation. Our case demonstrates the importance of heightened clinical suspicion for MCC in immunosuppressed patients with unexplained subcutaneous nodules. Prompt diagnosis is crucial for positive outcomes; therefore, we aim to provide information that may aid in identification of MCC tumors in future patients. With the increasing use of biologic agents such as adalimumab to treat rheumatic disease, the literature is demonstrating an increasing incidence of previously \"rare\" malignancies such as MCC. It is crucial for physicians to convey these risks when initiating a patient on chronic immunosuppressive therapy and to provide routine surveillance for MCC and other complications.

Histoplasmosis commonly presents as an asymptomatic or self-limited infection in immunocompetent patients, but immunocompromised hosts may present with severe and disseminated disease. Herein, we present a 26-year-old male with history of ulcerative colitis receiving long-term TNF-alpha inhibitor therapy who presented with six months of diarrhea and recently fever and hematochezia. On admission, he was febrile and hypotensive, with initial workup revealing pancytopenia and imaging reporting pulmonary infiltrates, pancolitis, and enlarged mesenteric lymph nodes. Disseminated histoplasmosis was ultimately diagnosed after examination of the colonic biopsy. Bone marrow biopsy was also consistent with the diagnosis of histoplasmosis but also demonstrated hemophagocytic lymphohistiocytosis. The patient was ultimately treated with amphotericin B, intravenous immunoglobulin, etoposide, and corticosteroids.

With anti-PD-1 antibodies serving as a representative drug, immune checkpoint inhibitors (ICIs) have become the main drugs used to treat many advanced malignant tumors. However, immune-related adverse events (irAEs), which might involve multiple organ disorders, should not be ignored. ICI-induced myocarditis is an uncommon but life-threatening irAE. Glucocorticoids are the first choice of treatment for patients with ICI-induced myocarditis, but high proportions of steroid-refractory and steroid-resistant cases persist. According to present guidelines, tumor necrosis factor alpha (TNF-α) inhibitors are recommended for patients who fail to respond to steroid therapy and suffer from severe cardiac toxicity, although evidence-based studies are lacking. On the other hand, TNF-α inhibitors are contraindicated in patients with moderate-to-severe heart failure. This review summarizes real-world data from TNF-α inhibitors and other biologic agents for ICI-induced myocarditis to provide more evidence of the efficacy and safety of TNF-α inhibitors and other biologic agents.

Acne fulminans (AF) is a rare and highly inflammatory severe form of acne most commonly seen in adolescent males. Unlike acne vulgaris, AF presents with associated systemic manifestations including, but not limited to, malaise, myalgia, arthralgia, fever, anorexia, and weight loss. It is often an extremely painful condition of sudden onset and can occur years after mild or moderate acne vulgaris. While the inciting agent for this condition has been postulated to be an explosive hypersensitivity reaction to the bacterium Propionobacterium acnes, increased androgens, namely testosterone, have also been reported to play a role in the pathogenesis of this disease process. Additionally, environmental triggers such as air pollution and exposure to halogenated hydrocarbons during occupational activities in enclosed, high temperature settings have been identified as possible etiologies or exacerbating factors. AF is primarily a clinical diagnosis. Isotretinoin, in combination with systemic steroids, are generally the treatments of choice for this disease entity. A Caucasian male in his early 40\'s presented to the authors\' clinic with a chief complaint of painful acneiform nodules, cysts, papules, pustules, and abscesses on his back, chest, neck, shoulders, upper arms, and thighs for several months. This case report demonstrates a refractory case of AF with significant clinical improvement after six weeks of topical treatment with subcutaneous adalimumab in combination with oral doxycycline. This case provides evidence supporting the role of Adalimumab in the treatment of AF in addition to the other inflammatory conditions currently FDA approved for treatment with this tumor-necrosis factor (TNF) alpha inhibitor. These conditions include plaque psoriasis, Crohn\'s disease, hidradenitis suppurativa, psoriatic arthritis, and rheumatoid arthritis.

Preoperative TNF-AI use has been associated with increased rate of postoperative infections and complications in a variety of orthopedic procedures. However, the association between TNF-AI use and complications following spine surgery has not yet been studied.
The purpose of the present study was to assess the risk of reoperation in patients prescribed TNF-AI undergoing spinal fusion surgery.
This is a retrospective review.
A total of 427 patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018.
Reoperation within 1 year.
We retrospectively reviewed the records of patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018. There were three distinct cohorts of spine surgery patients under study: patients with TNF-AI use in 90 days before surgery, patients with non-TNF-AI DMARD medications use in the 90 days before surgery, and patients taking neither TNF-AI nor other DMARD medications in 90 days before surgery. The primary outcome of interest was reoperation for any reason within 1 year following surgery.
Our study included 90 TNF-AI, 90 DMARD, and 123 control patients. Reoperation up to 1-year postsurgery occurred in 19% (n=17) of the TNF-AI group, 11% (n=10) of the DMARD group, and 6% (n=7) of the control group. The reasons for reoperation for TNF-AI group were 47% (n=8) infection and 53% (n=9) other causes which included failure to fuse and adjacent segment disease. Reasons for reoperation at 1 year were 40% (n=4) infection and 60% (n=6) other causes for DMARD patients and 14% (n=1) infection with 86% (n=6) other causes for control patients. The cox-proportional hazard model of reoperation within 1 year indicated that the odds of reoperation were 3.1 (95% CI:1.4-7.0) and 2.2 (95% CI 0.96-5.3) times higher in the TNF-AI and DMARD groups, respectively, compared to the control group.
Patients taking TNF-AIs before surgery were found to have a significantly higher rate of reoperation in the 1 year following surgery compared to controls. The higher rate of reoperation associated with TNF-AI use before spinal fusion surgery represents the potential for higher morbidity and costs for patient which is important to consider for both surgeon and patient in preoperative decision making.

BACKGROUND: Antibody-based therapies that inhibit proinflammatory cytokine signaling are commonly used in dermatology. Paradoxically, these medications may induce or exacerbate inflammatory disorders.
OBJECTIVE: To summarize the spectrum of manifestations, incidence, timing, potential mechanisms of, and general management approaches to paradoxical cutaneous reactions induced by cytokine-targeted antibodies in dermatology.
METHODS: We performed a systematic review and analysis of published cases of cutaneous paradoxical reactions (PRs) reported in association with tumor necrosis factor α, interleukin (IL) 12/23 (p40), IL-17A/17R, IL-23 (p19), and IL-4Rα inhibitors.
RESULTS: We identified 313 articles reporting 2049 cases of PRs. Tumor necrosis factor α inhibitors resulted in 91.2% (1869/2049) of all cases, followed by IL-17/17R (3.5%), IL-4Rα (2.7%), IL-12/23 (2.4%), and IL-23 (0.01%) inhibitors. Psoriasiform and eczematous eruptions were the most commonly reported, but a wide spectrum of patterns were described. Phenotypically overlapping reaction patterns were common. Time to onset typically ranged from weeks to months but could occur more than a year later. Improvement or resolution upon discontinuation of the inciting drug was common.
CONCLUSIONS: This was a retrospective analysis.
CONCLUSIONS: Familiarity with the clinical features of PRs from cytokine-blocking antibodies may facilitate efficient recognition and management.

Tumor necrosis factor alpha (TNF-α) inhibitors are increasingly being used for treating refractory cardiac sarcoidosis. There is a theoretical risk, however, that these therapies can worsen heart failure, and reports on efficacy and safety are lacking.
We conducted a retrospective review of all cardiac sarcoidosis patients seen at Stanford University from 2009 to 2018. Data were collected on patient demographics, diagnostic testing, and treatment outcomes.
We identified 77 cardiac sarcoidosis patients, of which 20 (26%) received TNF-α inhibitor treatment. The majority were treated for progressive heart failure or tachyarrhythmia, along with worsening imaging findings. All TNF-α inhibitor treated patients demonstrated meaningful benefit, as assessed by changes in advanced imaging, echocardiographic measures of cardiac function, and prednisone use.
A large cohort (n = 77) of cardiac sarcoidosis patients has been treated at Stanford University. Roughly one-fourth of these patients (n = 20) received TNF-α inhibitors. Of these patients, none had worsening heart failure and all saw clinical benefit. These results help support the use of TNF-α inhibitors for the treatment of cardiac sarcoidosis based on real-world evidence and highlight the need for future prospective studies.

Cutaneous polyarteritis nodosa (CPAN) is a rare necrotizing vasculitis affecting small- to medium-sized arteries. Reported treatments include oral corticosteroids alone or in combination with non-steroidal antiinflammatory drugs, intravenous immunoglobulins, cyclophosphamide, azathioprine, colchicine, or dapsone. However, some patients with CPAN do not respond to such treatments and continue to experience exacerbations over prolonged periods. This series provides support for the use of TNF-α inhibitors in the treatment of recalcitrant CPAN in pediatric patients.