Vedolizumab-Induced Pyoderma Gangrenosum in a Patient With Ulcerative Colitis

Vedolizumab is humanized monoclonal IgG1 antibody, which is an alpha-4-beta-7 integrin antagonist with gut specific effects on lymphocyte trafficking. Although effective for ulcerative colitis, its effects on extraintestinal manifestations in patients with inflammatory bowel disease have not been well described. We present a case of a patient with pan-ulcerative colitis who failed anti-TNF treatment and started on vedolizumab who developed de novo pyoderma gangrenosum. 43-year-old female with past medical history of pan ulcerative colitis initially diagnosed in 2010. She was managed on infliximab and azathioprine until end of 2015. She lost her insurance and did not receive medications for four months, then she developed symptoms of a flare. The patient was re-started on infliximab, however, she did not achieve remission with 10mg/kg every 4 weeks. The decision was made to switch her medication to vedolizumab in January 2017 and she received 4 doses. In April 2017, she developed a rash on her breast (Figure). Her gastrointestinal symptoms were improving with vedolizumab treatment with less frequent bowel movements. However, the rash became ulcerated and painful. The lesion was biopsied in May 2017 and the diagnosis of pyoderma gangrenosum was made. The patient was treated with high dose steroids and cyclosporine with improvement and was discharged with oral cyclosporine with a plan to transition to azathioprine. We hypothesize that integrins and adhesion molecules play a role in the interception of recirculating activated lymphocytes away from the gut. As a result, activated cells could easily drift across tissues in search of a landing as the overall survival of cells was not affected including skin, eyes, and joint. Dubinsky's abstract describes higher incidence of development of erythema nodosum, aphthous stomatitis, artrhopathy and primary sclerosing cholangitis in Crohn's patients who were on vedolizumab compared to anti-TNFs. In patients with ulcerative colitis, a higher incidence of episcleritis and pyoderma gangrenosum in vedolizumab treated group compared to anti-TNF group. However, larger cohort studies are necessary to provide information of underlying mechanism and true association with extraintestinal manifestation when using vedolizumab in IBD patients.Figure: Breast lesion, biopsy proven pyoderma gangrenosum.