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Refractory Takayasu arteritis with recurrent pyoderma gangrenosum: a therapeutic challenge with case-based review

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Abstract

Takayasu arteritis (TA) is an uncommon chronic granulomatous large-vessel vasculitis affecting the aorta and its branches. Pyoderma gangrenosum (PG) is a chronic neutrophilic dermatosis characterized by rapidly developing painful ulcers. The association of PG with TA is relatively uncommon. We report a case of a 22-year-old lady with a history of recurrent pyoderma lesions for 4 months following which she developed right upper limb claudication. She underwent contrast-enhanced magnetic resonance angiography of the aorta and its branches and was initially diagnosed with type IIb TA. She was put on prednisolone and methotrexate but had a major relapse with new-onset lower limb claudication despite an appropriate course of immunosuppression. She was planned for tocilizumab infusion 8 mg/kg intravenous every 4 weeks. Following the first dose of tocilizumab, her vascular symptoms improved but she had a flare of PG. This was followed by another flare after the second dose. She was switched to tofacitinib which led to sustained remission of her TA activity and healing of her skin lesions, and the prednisolone dose could be reduced to 5 mg daily over the next 1 year. Various immunosuppressives were used to date for treating PG in TA. However, tofacitinib is being reported for the first time in literature for treating PG and controlling TA activity. The paradoxical flare of PG with tocilizumab is quite uncommon and is also reported in our case with literature review.

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Authors and Affiliations

  1. Department of Clinical Immunology and Rheumatology, Institute of Post Graduate Medical Education and Research, Kolkata, India

    Kaustav Bhowmick, Rashmi Roongta, Soumya Dey, Sonali Dey, Sumantro Mondal, Pradyot Sinhamahapatra, Parasar Ghosh & Biswadip Ghosh

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Contributions

KB: diagnosis and management of case, writing—original draft, literature search. RR: diagnosis and management of case, collection of image, review and editing. SouD: diagnosis and management of case, review and editing. SonD: diagnosis and management of case, review and editing. SM: diagnosis and management of case, review and editing. PS: diagnosis and management of case, review and editing. PG: review and editing of the case. BG: diagnosis and management of case, review and editing. All co-authors take full responsibility for the integrity and accuracy of all aspects of the work.

The paper has not been submitted to another journal and has not been published in whole or in part elsewhere previously.

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Correspondence to Biswadip Ghosh.

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Bhowmick, K., Roongta, R., Dey, S. et al. Refractory Takayasu arteritis with recurrent pyoderma gangrenosum: a therapeutic challenge with case-based review. Clin Rheumatol 42, 1469–1477 (2023). https://doi.org/10.1007/s10067-023-06506-x

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