Paradoxical pulmonary event under tocilizumab treatment for systemic sclerosis-associated usual interstitial pneumonia

We read with interest, the results of the faSScinate trial1 suggesting tocilizumab had a good safety profile in the treatment of systemic sclerosis-associated interstitial lung disease (SSc-ILD). SSc-ILD is, however, a heterogeneous condition classified according to radiological and histopathological findings. Usual interstitial pneumonia (UIP) is much less frequent than non-specific interstitial pneumonia (approximately 10% and 75% respectively), with no difference in prognosis and survival reported between these two main entities.2 An earlier report in tocilizumab-treated patients with severe SSc-lung fibrosis reported respiratory function stabilisation in two but slight deterioration in one of the patients.3 Based on this evidence, we treated one patient in breast cancer remission, with clinical and functional respiratory deterioration and a UIP pattern of SSc-ILD, with off-label tocilizumab. We, hereby, report a reversible life-threatening episode of acute alveolitis that led to treatment discontinuation. In June 2009, a previously healthy 43-year-old female smoker of Portuguese ancestry experienced Raynaud phenomenon (RP). Three months later, an oestrogen-receptor-positive ductal breast carcinoma was diagnosed and treated by tumorectomy, axillary lymphadenectomy, radiotherapy and tamoxifen. Twelve months after the onset of RP, she developed severely pruritic and diffusely progressive skin thickening, dyspnoea, gastro-oesophageal reflux, recurrent digital ulceration and large joint arthritis. By July 2010, the modified …