CASE LETTER

Oral Hairy Associated With the Use of Adalimumab

Molly B. Kitley, MD; Timothy Devitt, DMD; Don-John Summerlin, DMD; Carrie L. Davis, MD

Administration for the treatment of rheumatoid arthritis, PRACTICE POINTS juvenile idiopathic arthritis,copy psoriatic arthritis, ankylosing • Workup for new-onset oral hairy leukoplakia should spondylitis, adult and pediatric Crohn disease, ulcerative include a comprehensive medication history. colitis, noninfectious uveitis, hidradenitis suppurativa, 7 • Oral hairy leukoplakia is an uncommon side effect and plaque psoriasis. We report a case of OHL associated of adalimumab. with the use of adalimumab. Anot 47-year-old woman initially presented with chronic plaque-type psoriasis. Her medical history was notable for bipolar disorder, migraines, hypertension, and tobacco To the Editor: use. The patient’s psoriasis initially was well controlled Oral hairy leukoplakia (OHL) is an Epstein-Barr on a regimen of topical steroids and methotrexate; (EBV)–mediated mucocutaneous disease that often involvesDo however, methotrexate was stopped after 2.5 years due the lingual . The lateral portions of the to a mildly elevated alanine aminotransferase level, as are the most commonly affected sites. The often well as an abnormal liver showing mildly active are described as asymptomatic, white, corrugated patches (grade 1 of 3) steatohepatitis with portal chronic inflam- or plaques that are unable to be scraped off.1 Oral hairy mation, pericellular fibrosis, and portal and focal periportal leukoplakia was first identified in 1984 and was considered fibrosis (stage 1-2 of 4). The patient and her dermatologist to be associated with AIDS.2 An association between the were uncomfortable continuing methotrexate with these presence of OHL and the degree of immunosuppression as findings. After baseline screening including a negative well as the severity of human virus (HIV) purified protein derivative skin test, adalimumab was ini- has been reported.3 Although OHL initially was considered tiated. A loading dose of 80 mg subcutaneously (SQ) was to be pathognomonic for HIV, it has since been described in given, followed by adalimumab 40 mg SQ 1 week later CUTIS4 multiple other immunosuppressive conditions. Numerous and 40 mg every other week as maintenance. medical conditions and combinations of immunosuppres- The patient’s psoriasis was well controlled with adali- sive medications have been associated with OHL in patients mumab for 22 months, but she then developed a thin who were HIV negative.5 white plaque on the right lateral tongue (Figure 1). An Adalimumab is an injectable human IgG1 recom- incisional biopsy of the tongue performed by an oral sur- binant antibody to tumor necrosis factor α (TNF-α).6 geon revealed with colonization It currently is approved by the US Food and Drug and viral cytopathic effect (Figure 2). An EBV DNA in situ

Dr. Kitley is from the Department of Dermatology, University of Minnesota, Minneapolis. Dr. Summerlin is from the Department of Pathology & Laboratory Medicine, Indiana University School of Medicine, Indianapolis. Dr. Devitt is from Bloomington Oral Surgery, Indiana. Dr. Davis is from the Dermatology Center of Southern Indiana, Bloomington, and the Indiana University School of Medicine, Bloomington. The authors report no conflict of interest. Correspondence: Carrie L. Davis, MD, 1200 S Rogers St, Bloomington, IN 47401 ([email protected]). doi:10.12788/cutis.0119

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FIGURE 1. Oral hairy leukoplakia. A corrugated white plaque on the A right lateral border of the tongue.

hybridization stain revealed focal positivity within these cells (Figure 3), leading to a diagnosis of OHL. Laboratory evaluation demonstrated a normal complete blood cell copy count with differential and liver panel as well as a nega- tive HIV test. The patient otherwise felt well and denied fevers, lymphadenopathy, and weight loss. We consulted with an infectious disease and immu- nodeficiency specialist regarding the patient’s case. Before not conducting further evaluation beyond HIV screening for immunodeficiency states, adalimumab was discontinued to see if the OHL would spontaneously resolve. Three months after discontinuation of adalimumab, the white B plaque on the right lateral tongue was notably improved.Do The OHL continued to disappear and was completely FIGURE 2. A, revealed hyperkeratosis containing resolved 1 year after discontinuation of adalimumab. Candida organisms (H&E, original magnification ×200). B, High- The patient’s psoriasis had subsequently remained well power view exhibited cells with nuclear chromatin margination and controlled with diet and weight loss, smoking cessation, inclusions in the superficial spinous layer (H&E, original magnifica- tion ×400). topical steroids, and apremilast without any recurrence of the OHL. Oral hairy leukoplakia is associated with upregulated EBV replication and EBV-encoded proteins such as latent membrane protein 1.2 It often presents as white or gray patches on the lateral lingualCUTIS margins with prominent folds and/or projections, giving a shaggy appearance. Oral hairy leukoplakia often is specific for HIV infection and rarely is associated with other .2 Prasad and Bilodeau5 performed a literature review of medical condi- tions and immunosuppressive medications associated with OHL in patients without HIV. Allogeneic transplant was associated with the highest incidence of OHL in HIV- negative patients (59.2% [45/76]).5 Various combinations of immunosuppressive medications (eg, prednisone, cyclo- sporine, azathioprine) also may be implicated in cases of HIV-negative patients with OHL. A case of OHL also has been reported with long-standing use of inhaled cortico- 6 FIGURE 3. Epstein-Barr virus (EBV) DNA in situ hybridization dem- steroids in an immunocompetent, HIV-negative patient. onstrated blue nuclei staining positively for EBV within the superficial Another case was reported with long-term use of the spinous layer (original magnification ×100). aromatic antiepileptic lamotrigine, which resolved once

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stopping the medication.8 Although EBV is an oncovirus as a class are , melanoma, nonmelanoma skin and has been associated with lymphoproliferative dis- cancer, reactivation of latent tuberculosis, congestive orders and nasopharyngeal carcinoma, OHL is not con- heart failure, autoimmunity, and hematologic toxicity.11 sidered to be a premalignant .7 Despite the strong This case demonstrates an association between adalim- association between OHL and HIV, our patient was umab and OHL in an HIV-negative patient. Although the HIV negative. The only immunocompromising factor in mechanism behind OHL and immunosuppression remains our patient was the use of adalimumab to treat psoriasis. to be elucidated, this association is important to keep in We did not conduct further testing for immunodeficiency mind when using adalimumab or other TNF-α inhibitors states because the OHL spontaneously resolved when for the treatment of psoriasis or other medical conditions. the adalimumab was discontinued. PubMed and Ovid searches of articles indexed for REFERENCES MEDLINE using the terms adalimumab and oral hairy 1. Triantos D, Porter SR, Scully C, et al. Oral hairy leukoplakia: clinico- leukoplakia as well as TNF-alpha inhibitor and oral hairy pathologic features, pathogenesis, diagnosis, and clinical significance. Clin Infect Dis. 1997;25:1392-1396. leukoplakia with humans and English language as limi- 2. Greenspan D, Greenspan JS, Conant M, et al. Oral “hairy” leucoplakia tations revealed that no cases have been reported in in male homosexuals: evidence of association with both papillomavirus the literature demonstrating an association between and a herpes-group virus. Lancet. 1984;2:831-834. OHL and adalimumab or any other TNF-α inhibitor. 3. Glick M, Muzyka BC, Lurie D, et al. Oral manifestations associated However, Cetkovska et al9 reported a case of EBV hepati- with HIV-related disease as marks for immune suppression and AIDS. Oral Surg Oral Med Oral Pathol. 1994;77:344-349. tis and subsequently chronic hepatitis as a complication of 4. Chambers AE, Conn B, Pemberton M, et al. Twenty-first-century oral infliximab used for the treatment of chronic psoriasis. hair leukoplakia—a non-HIV-associated entity. Oral Surg Oral Med Oral Because TNF-α and IFN-γ play an important role in Patho Oral Radiol. 2015;119:326-332. controlling viral infections, there is an increased risk for 5. Prasad JL, Bilodeau EA.copy Oral hairy leukoplakia in patients without HIV: reactivating a viral illness when depleting TNF through presentation of 2 new cases. Oral Surg Oral Med Oral Pathol Oral Radiol. 8 2014;118:E151-E160. pharmacologic measures (ie, adalimumab, infliximab). 6. Moffat M, Jauhar S, Jones ME, et al. Oral hairy leukoplakia in an HIV- Another case of EBV-associated plasmablastic lymphoma negative, immunocompetent patient. Oral Biosci Med. 2005;2:282-284. was reported after 1 year of adalimumab use in a patient 7. Greenspan JS, Greenspan D. Oral hairy leukoplakia: diagnosis and with Crohn disease. The plasmablastic lymphoma resolved management. Oral Surg Oral Med Oral Pathol. 1989;67:396-403. 10 8. notGordins P, Sloan P, Spickett GP, et al. Oral hairy leukoplakia in a patient after 4 rounds of chemotherapy. on long-term anticonvulsant treatment with lamotrigine. Oral Surg Oral The only contraindication for the use of adalim- Med Oral Pathol Oral Radiol Endod. 2011;111:E17-E23. umab is a known hypersensitivity to the drug. Relative 9. Cetkovska P, Lomicova I, Mukensnabl P, et al. Anti-tumour necrosis contraindications for use of adalimumab include active factor treatment of severe psoriasis complicated by Epstein-Barr tuberculosis, demyelinating disease, hematologic diseasesDo virus hepatitis and subsequently by chronic hepatitis. Dermatol Ther. (ie, thrombocytopenia, pancytopenia), lymphoma, 2015;28:369-372. 11 10. Liu L, Charabaty A, Ozdemirli M. EBV-associated plasmablastic hepatitis C, and hepatitis B. The most common adverse lymphoma in a patient with Crohn’s disease after adalimumab treat- effect of adalimumab is an injection-site reaction. ment. J Crohns Colitis. 2013;7:E118-E119. Additional reported adverse effects of TNF-α inhibitors 11. Humira [package insert]. North Chicago, IL: AbbVie Inc; 2018.

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