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Vol. 14. Issue 2.
Pages 113-114 (March - April 2018)
Vol. 14. Issue 2.
Pages 113-114 (March - April 2018)
Images in Clinical Rheumatology
DOI: 10.1016/j.reumae.2016.11.003
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Rapid Dactylitis Resolution in a Patient With Psoriatic Arthritis After Treatment With Ustekinumab
Rápida resolución de la dactilitis en un paciente con artritis psoriásica tras tratamiento con ustekinumab
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Alba Quesada Morenoa,b,
Corresponding author
a.quesada.moreno@gmail.com

Corresponding author.
, Olga Martínez Gonzáleza, Laura Pérez Garridoa, Carlos Montilla Moralesa,b
a Servicio de Reumatología, Hospital Universitario de Salamanca, Salamanca, Spain
b Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
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We report the case of a 51-year-old man diagnosed in 2011 with polyarticular psoriatic arthritis with nail involvement. The disease was refractory to treatment with nonsteroidal anti-inflammatory drugs (NSAID) and synthetic disease-modifying antirheumatic drugs (DMARD) (methotrexate at 25mg/week and salazopyrine at a dose of 500mg/8h). The decision was made to start biological therapy with tumor necrosis factor inhibitors (anti-TNF), following the recommendations of the European League Against Rheumatism.

Adalimumab was chosen as the first biological agent. However, after 2 years of treatment, the activity of the disease remained moderate (Disease Activity Score—erythrocyte sedimentation rate [DAS28-ESR=3.70]; 3 tender joints and 3 swollen joints: right 4th metacarpophalangeal [MCP] joint, left 3rd MCP and left knee). In addition, he had painful dactylitis in the 4th toe of right foot (Fig. 1). Thus, treatment was begun with etanercept. Nevertheless, after 6 months of treatment, he continued to have high inflammatory activity (DAS28-ESR=5.80; 4 tender joints and 4 swollen joints: right 4th MCP, left 3rd MCP and both knees). Therefore, treatment was started with certolizumab pegol, which he took for 6 months, although it failed to control the inflammatory activity (DAS28-ESR=4.89; 4 tender joints—right 4th MCP, left 3rd MCP, left 4th proximal interphalangeal [PIP] joint and left knee—and 3 swollen joints: right 4th MCP, left 3rd MCP and left knee), and the dactylitis was not resolved.

Fig. 1.

Dactylitis in 4th toe.

(0.11MB).

Given the therapeutic failure with 3 anti-TNF-α agents, the decision was made to initiate treatment with ustekinumab. After 2 doses of ustekinumab, he achieved complete resolution of the dactylitis, with a significant improvement in the nail involvement (Fig. 2), and better control of the joint inflammatory activity (DAS28-ESR=3.50; 2 tender joints and 2 swollen joints: left 4th PIP and left knee).

Fig. 2.

Resolution of dactylitis in 4th toe.

(0.09MB).

Ustekinumab is a monoclonal antibody that inhibits the p-40 subunit of interleukin (IL)-12/IL-23, that has been found to be effective in all of the domains of psoriatic arthritis.1–3

The importance of this case lies in the rapid resolution of the dactylitis with ustekinumab, despite the fact that it had been found to be refractory to treatment with 3 anti-TNF agents.4,5 This incredible improvement may corroborate the importance of IL-23 in the development of dactylitis and the relevance of its inhibition for the treatment of this domain.

Ethical DisclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflicts of Interest

The authors declare they have no conflicts of interest.

References
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C. Ritchlin, P. Rahman, A. Kavanaugh, I.B. McInnes, L. Puig, S. Li, PSUMMIT 2 Study Group, et al.
Efficacy and safety of the anti-IL-12/23 p40 monoclonal antibody, ustekinumab, in patients with active psoriatic arthritis despite conventional non-biological and biological anti-tumour necrosis factor therapy: 6-month and 1-year results of the phase 3, multicentre, double-blind, placebo-controlled, randomised PSUMMIT 2 trial.
Ann Rheum Dis, 73 (2014), pp. 990-999
[2]
I.B. McInnes, A. Kavanaugh, A.B. Gottlieb, L. Puig, P. Rahman, C. Ritchlin, PSUMMIT 1 Study Group, et al.
Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial.
[3]
A. Kavanaugh, L. Puig, A.B. Gottlieb, C. Ritchlin, S. Li, Y. Wang, et al.
Maintenance of clinical efficacy and radiographic benefit through two years of ustekinumab therapy in patients with active psoriatic arthritis: results from a randomized, placebo-controlled phase III trial.
Arthritis Care Res (Hoboken), 67 (2015), pp. 1739-1749
[4]
E.L. Siegel, A.M. Orbai, C.T. Ritchlin.
Targeting extra-articular manifestations in PsA: a closer look at enthesitis and dactylitis.
Curr Opin Rheumatol, 27 (2015), pp. 111-117
[5]
S. Elyoussfi, B.J. Thomas, C. Ciurtin.
Tailored treatment options for patients with psoriatic arthritis and psoriasis: review of established and new biologic and small molecule therapies.
Rheumatol Int, 36 (2016), pp. 603-612

Please cite this article as: Quesada Moreno A, Martínez González O, Pérez Garrido L, Montilla Morales C. Rápida resolución de la dactilitis en un paciente con artritis psoriásica tras tratamiento con ustekinumab. Reumatol Clin. 2018;14:113–114.

Copyright © 2016. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
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