Is there a Role for Anti-IL-5 Therapies in Eosinophilic Fasciitis?

Introduction

Eosinophilic Fasciitis (EF) is a rare disease, originally proposed as "diffuse fasciitis with eosinophilia" by Shulman in 1974. Symptoms of EF include peripheral eosinophilia accompanied by symmetrical inflammation of the subcutaneous fascia and muscle, usually locating in the upper arms or thighs. There is no approved standard of care treatment.

Methods

Taking into account that eosinophils may be pathogenetically involved in EF, we performed a review on Medline focusing on anti-Interleukin-5 (IL-5) therapies in EF.

Results

Only one case of a patient with EF has been reported who was successfully treated with reslizumab, an anti-IL-5 therapy. The patient had EF refractory to the commonly used immunosuppressive treatment but when reslizumab was added, the patient experienced remission of her symptoms.

Discussion

The exact aetiology of EF is still unclear, and many therapeutic approaches have been tested. Commonly used immunosuppressive agents, such as corticosteroids are not always effective and associate with significant side effects. Eosinophils seem to have a role in the pathogenesis of the disease; anti-eosinophilic therapies targeting IL-5/IL-5 Receptor could be an attractive alternative for the treatment of the disease.

Vigorous exercise-induced unilateral eosinophilic fasciitis: rare and easily misdiagnosed subtype

The hallmark of eosinophilic fasciitis (EF) is painful symmetric skin stiffness and limb sclerosis with deep fascia inflammation. Two cases of unilateral EF have been reported in the literature but were not related to strenuous physical activity. In this report, a young female presenting with unilateral scleroderma-like skin changes, blood and tissue eosinophilia, and hypergammaglobulinemia proven to be EF after strenuous physical activity is described. This case represents the first case reported in the current literature of unilateral EF after vigorous exercise. A skin to muscle biopsy and magnetic resonance imaging (MRI) study indicated classic EF features. Cases of unilateral eosinophilic fasciitis are under-recognized and have rarely been described in the literature. EF requires a high index of suspicion to be diagnosed accurately and differentiated from another scleroderma variant, especially localized types. Early diagnosis and management of unilateral EF are very crucial because EF management and prognosis are completely different from other scleroderma mimics. EF heals rapidly in response to glucocorticoid or combination therapy. In the current case, corticosteroids alone failed to induce complete disease remission, but with the addition of methotrexate, complete resolution of both skin and systemic features was obtained. She is now in good health with no medication use. The current literature review indicates that this the first reported case of unilateral EF after vigorous exercise.

Eosinophilic fasciitis (Shulman's disease): review and comparative evaluation of seven patients

OBJECTIVES

Eosinophilic fasciitis (EF) was described in 1974 by Shulman as a rare fibrosing connective tissue disease of unknown etiology. An undetermined trigger is thought to lead to the degranulation of eosinophils that interact with fibroblasts and express fibrogenic cytokines including the transforming factor of tumor growth a and b and interleukins 1 and 6. The purpose of this study was to summarize seven cases of EF in a central hospital.

MATERIAL AND METHODS

This was a retrospective and descriptive study of a population with EF of a central hospital. All patients diagnosed with EF in a hospital unit were admitted to the study between January 1, 2005, and April 30, 2018.

RESULTS

A total of seven patients diagnosed with EF were analyzed. The median age of the population at the time of diagnosis was 56 years, and 57% of the patients were women. All patients had elevated peripheral eosinophilia and sedimentation rate, and only one patient had hypergammaglobulinemia. All patients had edema and cutaneous thickening of the limbs, 57% had constitutional symptoms, and 57% had inflammatory arthritis with joint contracture. Prednisolone (PDN) therapy was initiated in all patients, and only in two was the association of PDN with methotrexate (MTX) initially performed. In one patient triple therapy of PDN, MTX, and cyclosporine was required. At the time of this publication, only one patient maintains active disease, and tocilizumab has been initiated.

CONCLUSIONS

Recent studies show a more favorable response from the combination of PDN and MTX than from PDN alone. Considering the rarity of the disease, more long-term studies are needed regarding the etiopathogenetics, progression, recurrence of EF, and new effective therapies.