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Acute myelogenous leukemia in a patient receiving etanercept for psoriasis

2006; Elsevier BV; Volume: 56; Issue: 1 Linguagem: Inglês

10.1016/j.jaad.2006.06.032

1097-6787

Claude Bachmeyer, Brigitte Thiolière, Kiarash Khosrotehrani, E. Cattan,

Psoriasis: Treatment and Pathogenesis

To the Editor: A 40-year-old man with a medical history of obesity, hyperlipidemia, obstructive sleep apnea, and cellulitis of the left leg sought medical advice in December 2005 for a severe plaque psoriasis evolving for 10 years and treated previously with topical agents, phototherapy, and acitretin with poor efficacy. On physical examination, the patient was healthy with weight of 120 kg and height of 1.70 m. Plaque psoriasis involved the trunk and lower aspect of limbs. Blood cell count showed a hemoglobin level of 13.4 g/dL, a white cell count of 5.1 × 109/L with 59% neutrophils and 29% lymphocytes, and a platelet count of 395 × 109/L. C-reactive protein, serum lactate dehydrogenase activity, and liver function tests revealed normal results, but γ-glutamyl transferase level was 774 U/L (normal < 45). Chest radiograph findings were normal and tuberculin skin testing produced negative results. Treatment with etanercept was started on December 19, 2005, at a dose of 25 mg twice a week subcutaneously. One month later, routine laboratory examination showed a leukocyte cell count of 3.8 × 109/L with 45% neutrophils and 45% lymphocytes. At his visit on April 25, 2006, the patient was fatigued. Dramatic improvement of psoriatic plaques was observed on the trunk whereas a few plaques were still present on his thighs. Otherwise, physical examination was unchanged. Blood cell count showed a hemoglobin level of 11 g/dL; a white cell count of 1.7 × 109/L with 0.05% neutrophils, 80% lymphocytes, and 3% blasts; and a platelet count of 268 × 109/L. The remainder of the laboratory examination was unchanged. Bone-marrow smear disclosed 43% blasts. Diagnosis of acute myelogenous leukemia (AML)-M2 was established. Tumor necrosis factor-α inhibitors such as etanercept are an interesting alternative to traditional therapies in patients with chronic moderate to severe plaque psoriasis.1Krueger G. Callis K. Potential of tumor necrosis factor inhibitors in psoriasis and psoriatic arthritis.Arch Dermatol. 2004; 140: 218-225Crossref PubMed Scopus (83) Google Scholar, 2Gottlieb A.B. Leonardi C.L. Goffe B.S. Ortonne J.P. van der Kerkhof P.C. Zitnik R. et al.Etanercept monotherapy in patients with psoriasis: a summary of safety, based on an integrated multistudy database.J Am Acad Dermatol. 2006; 54: S92-S100Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar The safety profile of these drugs seems to be favorable although adverse drug reactions are well known including mainly infections, both common and opportunistic, demyelinating disease, lupuslike syndromes, congestive heart failure, and malignancies.1Krueger G. Callis K. Potential of tumor necrosis factor inhibitors in psoriasis and psoriatic arthritis.Arch Dermatol. 2004; 140: 218-225Crossref PubMed Scopus (83) Google Scholar, 2Gottlieb A.B. Leonardi C.L. Goffe B.S. Ortonne J.P. van der Kerkhof P.C. Zitnik R. et al.Etanercept monotherapy in patients with psoriasis: a summary of safety, based on an integrated multistudy database.J Am Acad Dermatol. 2006; 54: S92-S100Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar We report here a case of AML in a patient with severe plaque psoriasis that developed within 4 months of etanercept therapy, suggesting a possible responsibility of the drug on the development of the hematologic condition. Hematologic toxicity of etanercept is unusual.3Kuruvilla J. Leitch H.A. Vickars L.M. Galbraith P.F. Li C.H. Al-Saab S. et al.Aplastic anemia following administration of a tumor necrosis factor-α inhibitor.Eur J Haematol. 2003; 71: 396-398Crossref PubMed Scopus (63) Google Scholar According to the product monograph, "rare cases of pancytopenia including aplastic anemia, some fatal" have been reported, but "a causal relationship to etanercept is unclear."4Enbrel [US product monograph]. Thousand Oaks, Calif: Immunex Corporation, Amgen/Wyeth Pharmaceuticals; 2006.Google Scholar Interestingly, a case of AML has been described in a patient with ankylosing spondylitis 4 months after the initiation of etanercept therapy.5Bakland G. Nossent H. Acute myelogenous leukemia following etanercept therapy.Rheumatology. 2003; 42: 900-901Crossref PubMed Scopus (36) Google Scholar In contrast with this patient, ours did not receive any concomitant drug and no leukopenia was present before beginning etanercept therapy that should have alerted the physician. Of course, a fortuitous association cannot be ruled out. Perhaps the patient had a latent AML at the time etanercept therapy was started. However, we consider close monitoring of blood cell count in patients under antitumor necrosis factor-α to be warranted, converse to what is indicated in the product monograph.4Enbrel [US product monograph]. Thousand Oaks, Calif: Immunex Corporation, Amgen/Wyeth Pharmaceuticals; 2006.Google Scholar