Sarcoid- Like Phenomenon - Ustekinumab Induced Granulomatous Reaction Mimicking Diffuse Metastatic Disease

A Case Report and Review of the Literature

Mohamed M. Gad; Najdat Bazarbashi; Manpreet Kaur; Amit Gupta

Disclosures

J Med Case Reports. 2019;13(257) 

In This Article

Discussion

We report a rare case of disseminated sarcoid-like reaction in a patient undergoing treatment with ustekinumab for refractory psoriasis. Ustekinumab has a long history of successfully controlling chronic inflammatory arthropathies such as psoriasis and psoriatic arthritis,[3] but significant unexpected sarcoid-like reactions with non-caseating giant cell granulomas have been reported in rare case reports. The overstimulation of cytokines, such as IL-12, IL-18, IL-27, and interferon (IFN)-gamma, has been postulated in lung sarcoidosis pathogenesis.[4]

On the contrary, our patient was prescribed ustekinumab, a human mAb which is an anti-IL-12 blocker and anti-IL-23 blocker, for the treatment of refractory psoriasis and developed multiple non-caseating granulomas in his lung, liver, spleen and bones as evidenced by serial PET scan. This phenomenon is not entirely understood given the induction of sarcoid-like lesions while blocking the Th1 pathway. Furthermore, our patient was not-adherent to ustekinumab for his psoriasis adding to the complexity of the diagnosis.

Steroid use improved the lesions in his right lung, but given its widespread side effects with long term use and concurrent hepatic derangement, an immunosuppressive agent, azathioprine, was initiated due to its safety profile and ability to reduce intracellular purine synthesis leading to a decreased number of circulating T lymphocytes in an attempt to control the sarcoid-like lesions.[5] Review of previous case reports showed the ability of ustekinumab to cause severe and harmful reactions. In addition to that, other similar immunosuppressive agents, like, adalimumab, have been implied in sarcoid-like reactions.[6]

It is of great importance to carefully select the appropriate biological therapies when treating chronic inflammatory diseases given their recent emergence, clinical benefit, and unexpected side effects, which are evident in this article.

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