Sir,

Hidradenitis suppurativa (HS) is an inflammatory disease with chronic acneiform infection of the cutaneous apocrine glands. Etanercept, an anti-tumor necrosis factor-α (TNF-α) agent, is effective in the management of HS.1 Infectious complications have been described following treatment with etanercept,2 including uveitis.3

Case report

A 48-year-old woman was referred to our department because of bilateral blurred vision and floaters for 2 days. She had been hospitalized 35 days before due to a secondary amyloidosis after 8 years of HS, which was being treated with prednisone 5 mg daily and subcutaneous 25-mg etanercept injections every 4 days for 3 months. During the hospitalization, she developed a superficial phlebitis in her left arm (where she had a catheter) followed by a septicemia, with positive cultures for Candida albicans in the catheter and in the hemocultives. She was treated with caspofungine and etanercept removal.

Baseline visual acuity was 20/60 in the right eye and 20/40 in the left eye. Ophthalmic exploration showed one yellow-white chorioretinal yuxtafoveal lesion with perilesional hemorrhage in both eyes and a similar parafoveal lesion in the left eye, with neither vitreous haze nor cells (Figure 1a). Chest X-ray, tuberculin skin test, and serologic tests were normal or negative. The association of these ocular and microbiologic findings drove us to the diagnosis of Candida chorioretinitis, which improved after systemic fluconazol, with no active chorioretinal lesions after 3 weeks (Figure 1b). Final visual acuity was 20/30 in both eyes.

Figure 1
figure 1

Both eye retinographies showing active chorioretinal lesions due to Candida on the baseline visit (a) and chorioretinal scars after treatment (b).

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Comment

TNF-α is a proinflammatory cytokine, which plays an important role in the pathogenesis of inmune-mediated diseases and in the immune mechanisms against infection. The use of TNF-α inhibitors has been associated with an increased rate of intracellular infections.4 Even so, there is little evidence about Candida infections among patients treated with etanercept. Wallis et al4 cited a rate of 7.1 Candida infections (no reference to ocular affectation) per 100 000 patients who received etanercept. Its use, associated to chronic corticosteroid treatment and intravenous catheter, led to a fungal septicemia in our patient, which was followed by the bilateral chorioretinitis. In conclusion, we should consider Candida species as a possible etiology of chorioretinitis in patients taking etanercept.