Hyperkeratotic lesions associated to natalizumab treatment for multiple sclerosis: case report and literature review

Address for correspondence: Arthur Cesário de Holanda (email: [e-mail]).

Abstract

Case Presentation: A 29-year-old female patient was referred to our service after 3 recurrent episodes of partial transverse myelitis during 1 year. Multiple sclerosis (MS) was diagnosed based on compatible clinical, MRI, and CSF data (Figure 1). She had no personal or family history of dermatologic or autoimmune diseases. Treatment with natalizumab was indicated, and shed had only a minor reaction (cervical pruritus) after the first infusion. A few days after the second infusion, however, she developed painful crusted erythematous plaques and vesicles in both hands (Figure 2A). A biopsy revealed spongiotic dermatitis with acanthosis and perivascular infiltrates (Figure 2B). The patient improved completely after oral and topical corticosteroids. The lesions recurred on the fifth day after the third dose, this time involving all limbs and the trunk. After a review of the case with Dermatology, she started a course of prednisone 20 mg per day from 2 days before until 3 days after each infusion. The subsequent infusions, three so far, were carried out without lesion recurrence (Figure 2C).

Discussion: Natalizumab has one of the safest profiles among high-efficacy disease-modifying therapies for MS. Although delayed allergic reactions are well recognized, other cutaneous abnormalities have been scarcely reported, as is the case of hyperkeratotic lesions (Table 1). Previous reports have suggested a relationship between natalizumab infusions and psoriasis development or worsening, and an increase in peripheral CD4+IL17+ lymphocytes has been postulated as a potential cause. Spongiotic dermatitis, in turn, has only been associated with natalizumab in one other case. Dysregulation of natural-killer cells by the drug has also been proposed as a mechanism.

Final Comments: The present report is the second to describe a possible relationship between natalizumab infusion and spongiotic dermatitis. Recognition of rare dermatologic complications of natalizumab and their adequate management are important, especially considering the role of natalizumab in MS treatment and the limitation to the prompt access to other high-efficacy options.

Publication History

Article published online:
02 October 2024