Title:Serum Sickness Reaction to Rituximab with Positive Immediate Intradermal Skin Test: A Case Report
Volume: 2
Author(s): Laura Palomino-Lozano*, Blanca Noguerado-Mellado, Jimena Crespo Quirós, Melina Tejero-Alcalde, Cristina Cuevas-Bravo, Borja Bartolomé Zavala and Patricia Rojas-Perez-Ezquerra
Affiliation:
- Department of Allergy, Hospital General Universitario Gregorio Marañon, Madrid,Spain
Keywords:
Hypersensitivity reaction , Rituximab, Antibody, Immune-complex, Autoimmune disease, Serum sickness reaction, CD20.
Abstract: Background:
Rituximab is a chimeric murine/human monoclonal antibody against CD20. It can be used off-label in autoimmune diseases. Its administration can
lead to several types of reactions; immediate infusional reactions and also delayed reactions like Serum Sickness Reaction (SSR).
Case Presentation:
This is a case study of a 48 years old woman diagnosed with rheumatoid arthritis/systemic lupus erythematosus who developed refractory immune
thrombocytopenic purpura and received treatment with rituximab. After treatment, she developed erythematous-violet lesions accompanied with
fever of 38ºC, dyspnea, joints arthralgia and edema. In the emergency department, hypotension, fever, dyspnea, and shivering were observed, for
which, intramuscular epinephrine, intravenous corticosteroids, antibiotics and salbutamol nebulization were administered. In our allergy unit, we
performed an intradermal test (IDT) with rituximab (1mg/ml), which was positive at immediate (20min) and late (48h) reading. Based on the
clinical manifestations and test carried out, she was diagnosed with rituximab SSR. We also studied the molecular mass of the IgE-reactive
proteins present in rituximab product by SDS-PAGE Immunoblotting method according to Laemmli, in reducing and non-reducing conditions,
with high sensitivity and using three different polyvinylidene difluoride (PVDF) membrane blocking substances (skimmed cow's milk, fish
collagen and egg white). We did not detect IgE-binding to rituximab product.
Conclusion:
The pathogenesis of SSR is not well known. The patients after reinfusion can develop immediate reactions suggesting involvement of IgE
hypersensitivity. Nevertheless, there are patients who tolerated reinfusion. Further studies and assays are needed for a better understanding of these
reactions and to lead to a safer re-administration if needed.
