Fuzeon-Induced Collagenophagic Granuloma: A Peculiar Granulomatous Injection Site Reaction to Fuzeon- A Case Report and Review of Literature

Abstract

Enfuvirtide (ENF, T-20, or Fuzeon [Hoffman-La Roche Inc, Nutley, NJ, and Trimeris, Inc, Durham, NC]) is an HIV-1 fusion inhibitor and is the only injectable antiretroviral drug available. Injection site reactions (ISRs) are the most frequently reported adverse events, occurring in about 98% of patients. A granuloma annulare—like granulomatous ISR has been reported. We report a granulomatous ISR that is different from granuloma annulare and granuloma annulare—like reaction because it is rich in multinucleated giant cells engulfing altered collagen. We call this type of ISR a collagenophagic granuloma. Most previous reports—with the exception of 1 report—about ISRs with ENF treatment have used punch biopsies, which lack the depth to analyze the reticular dermis and subcutaneous tissue and, therefore, may have missed ISRs, which look like granuloma annulare, and the collagenophagic granulomatous reaction.

Keywords

enfuvirtide granuloma collagenophagic injection site reaction granuloma annulare Fuzeon

Get full access to this article

View all access options for this article.

References

Lalezari JP , Henry K. , O’Hearn M. , et al. ENF, an HIV-1 fusion inhibitor, for drug-resistant HIV infection in North and South America. N Engl J Med. 2003;348:2175-2185.

Oldfield V. , Keating GM , Plosker G. ENF: a review of its use in the management of HIV infection. Drugs. 2005;65: 1139-1160.

Hardy H. , Skolnik PR Enfuviride, a new fusion inhibitor for therapy of human immunodeficiency virus infection. Pharmacotherapy. 2004;24:198-211.

Zapor MJ , Cozza KL , Wynn GH , Wortmann GW , Armstrong SC Antiretrovirals, Part II: focus on non-protease inhibitor antiretrovirals (NRTIs, NNRTIs, and fusion inhibitors). Psychosomatics. 2004;45:524-535.

Luther J. , Glesby MJ Dermatologic adverse effects of antiretroviral therapy: recognition and management . Am J Clin Dermatol. 2007;8:221-233.

Lazzarin A. , Clotet B. , Cooper D. , et al. Efficacy of ENF in patients infected with drug-resistant HIV-1 in Europe and Australia. N Engl J Med. 2003 ;348:2186-2195.

Trottier B. , Walmsley S. , Reynes J. , et al. Safety of ENF in combination with an optimized background of antiretrovirals in treatment-experienced HIV-1-infected adults over 48 weeks . J Acquir Immune Defic Syndr. 2005;40:413-421.

Ball RA , Kinchelow T. ; ISR Substudy Group. Injection site reactions with the HIV-1 fusion inhibitor ENF. J Am Acad Dermatol. 2003;49:826-831.

Reynes J. , Arastéh K. , Clotet B. , et al. TORO: ninety-six-week virologic and immunologic response and safety evaluation of ENF with an optimized background of antiretrovirals. AIDS Patient Care STDS. 2007;21:533-543.

10.

Maggi P. , Ladisa N. , Cinori E. , Altobella A. , Pastore G. , Filotico R. Cutaneous injection site reactions to long-term therapy with ENF. J Antimicrob Chemother. 2004; 53:678-681.

11.

Ghadially R. , Sibbald RG , Walter JB , Haberman HF Granuloma annulare in patients with human immunodeficiency virus infections. J Am Acad Dermatol. 1989; 20(2, pt 1):232-235.

12.

McGregor JM , McGibbon DH Disseminated granuloma annulare as a presentation of acquired immunodeficiency syndrome (AIDS). Clin Exp Dermatol . 1992;17:60-62.

13.

Myers SA , Selim AA , McDaniel MA , et al. A prospective clinical and pathological examination of injection site reactions with the HIV-1 fusion inhibitor ENF. Antivir Ther. 2006;11: 935-939.

14.

Umbert P. , Winkelmann RK Histologic, ultrastructural and histochemical studies of granuloma annulare . Arch Dermatol. 1977;113:1681-1686.

15.

Morse C. , Maldarelli F. ENF antiviral activity despite rebound viremia and resistance mutations: fitness tampering or a case of persistent braking on entering? J Infect Dis. 2007;195:318-321.

16.

Clotet B. , Raffi F. , Cooper D. , et al. Clinical management of treatment-experienced, HIV-infected patients with the fusion inhibitor ENF: consensus recommendations. AIDS. 2004;18:1137-1146.