Spondylarthritis presenting with an allergic immediate systemic reaction to adalimumab in a woman: a case report

We report the case of a 61-year-old Caucasian woman who was treated with adalimumab for spondylarthritis and developed injection site reactions after the sixth dose. After a two-month suspension, she recommenced therapy and experienced two systemic reactions. The first occurred after one hour with itching of the palms and soles and angioedema of the tongue and lips. Thirty minutes after the next dose the patient had itching of the palms and soles with diffusion to her whole body, angioedema of the lips, dizziness and visual disturbances. A skin-prick test and intra-dermal tests with adalimumab gave strong positive results at the immediate reading. However, serum-specific immunoglobulin E (IgE) to adalimumab were not detectable by using Phadia solid phase, especially harvested for this case, in collaboration with our Immunology and Allergy Laboratory Unit. Her total IgE concentration was 6.4 kU/L.We describe what is, to the best of our knowledge, the first reported case of immediate systemic reaction to adalimumab studied with a skin test giving positive results and a serum-specific IgE assay giving negative results. The mechanism of the reaction must be immunologic but not IgE-mediated.Adalimumab (Humira; Abbott Laboratories, Abbott Park, IL, USA) is a fully human recombinant immunoglobulin G1 (IgG1) monoclonal antibody with specificity for human tumor necrosis factor α (TNF-α). Adalimumab binds to soluble and membrane-bound TNF-α, leading to the blockade of activity of TNF. Apoptosis of cells with membrane-bound TNF occurs. Adalimumab was initially approved for the treatment of rheumatoid arthritis. It was subsequently approved for treatment of psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, plaque psoriasis, Crohn's disease and uveitis. The recommended dosage for adults with spondylarthritis is a subcutaneous dose of 40 mg every other week.The most frequent adverse reactions to adalimumab are injection site reactions. They occur in 6.6%