A case of tuberculosis in a patient on Efalizumab and Etanercept for treatment of refractory palmopustular psoriasis and psoriatic arthritis

We discuss a patient with a history of a positive tuberculin skin test, who presented with severe, recalcitrant palmoplantar pustular psoriasis with psoriatic arthritis whose symptoms did not resolve with monotherapy of etanercept (Enbrel®) or efalizumab (Raptiva®) alone, but did respond to a combination of both biologics. However, our patient was later found to have reactivation tuberculosis after long-term treatment. This case highlights many key points for treatment of psoriasis and psoriatic arthritis with biologics. Namely, that recalcitrant psoriatic skin lesions may have good clearing on one biologic, such as efalizumab, and arthritic symptoms can be well-controlled with etanercept, leading patients to be on two different biologics concurrently to control symptoms. However, it also highlights the importance of determining a patient's tuberculosis status, initiating prophylactic anti-tuberculosis therapy prior to starting treatment with etanercept, and setting up an adequate treatment regime if the patient develops active tuberculosis during therapy with etanercept.