Paradoxical Reaction to Golimumab: Tumor Necrosis Factor α Inhibitor Inducing Psoriasis Pustulosa
A female, 50-year-old, black patient with rheumatoid arthritis, followed-up by the Rheumatology Sector, was forwarded to the Dermatology Ambulatory as an emergency case due to complaints of sudden onset of pustular lesions in the palms and soles (fig. , fig. ), and erythematous-desquamating plaques with pustules in the limbs, chest and dorsum (fig. ). During anamnesis, we found that the patient had recently begun the use of golimumab, a TNF-α inhibitor, and that she was on her fourth monthly dose of the medication. The clinical picture began soon after administration of this last dose and she was also using methotrexate concurrently. The patient had no previous personal or familial history of psoriasis. A skin biopsy was carried out with clinical suspicion of pustular psoriasis by paradoxical effect, since there are literature reports of similar adverse events with other TNF-α inhibitors. We decided to suspend the medication, given the extension of the cutaneous picture. Histopathology showed abundant neutrophilic infiltrate (Munro's abscess), acanthosis, presence of Kogoj's spongiform pustule, and dilation of papillary dermal capillaries (fig. , fig. ). The clinical-histopathologic correlation confirmed the diagnosis of pustular psoriasis. We continued treatment with methotrexate 15 mg for a week, in an attempt to treat the cutaneous-articular manifestations. The patient is undergoing ambulatory follow-up, but, after over 12 months of suspension of the drug, she still has skin lesions, with periods of exacerbation and appearance of new lesions, providing evidence of triggering a new disease caused by the use of the medication.