Complete remission of Psoriatic erythroderma using modified low dose etanercept in a HIV positive patient: A case report with review of literature

Abstract

Dear Editor, Psoriatic patients with HIV infection often present with a more severe and refractory disease course. Psoriasis has been seen at all stages of HIV infection, occasionally presenting as the initial manifestation. A 35-year-old diabetic female with a 1-year history of chronic plaque psoriasis without Psoriatic arthritis presented with an erythrodermic flare for one month. Initial evaluation 1 year ago had revealed HIV seropositivity and she is on antiretroviral therapy since. Prior treatment history for Psoriasis includes acitretin and cyclosporine. Cyclosporine was withdrawn after the patient developed diastolic hypertension. Prior to flare, the patient was on acitretin (25 mg) twice daily for the past 6 months with good disease control. On physical examination, the patient was obese (BMI: 32.2 kg/m). Cutaneous examination showed erythroderma with the Psoriasis assessment severity Index (PASI) of 34.7 (Figure 1A). Dermatology life quality index (DLQI) score was 24. Psoriatic erythroderma being an emergency, and considering the limited therapeutic options available, we chose an anti-TNFα blocker, Etanercept. Prior tuberculosis infection was excluded and baseline investigations were conducted; Chest X-Ray was normal; Tuberculin Skin test, TB Quantiferon Gold Assay, Hepatitis B and C serology were negative and CD4 count prior to therapy was 580 cells/μl. Considering financial restrictions and difficulty in commuting frequently, Etanercept dosing was modified to once-weekly subcutaneous injections of Inj.Etanercept (50 mg). Clinical improvement was noted from fourth week onwards with PASI being 3.3 at the end of six weeks of therapy (Figure 1B). Noting monetary issues, Etanercept had to be discontinued after sixth week, and sequential therapy with acitretin (25 mg) twice daily was started. CD4 count and DLQI post-treatment were 545 cells/μl and 5, respectively. No opportunistic infections were seen. Anti-TNFα therapy (Infliximab, Adalimumab, and Etanercept) is relatively contra-indicated in HIV infection, which is usually excluded before starting therapy. However, TNFα is also seen to be elevated in all stages of HIV infection, possibly responsible for fatigue, fever, and cachexia. Overall, limited experience of anti-TNF agents in HIV positive patients