5,557

A Case with Psoriasis Vulgaris Discontinued due to Anaphylactic Shock During Ixekizumab Treatment

Fumio Kaneko, Ari Togashi, Tetsuo Nagatani

Fumio Kaneko, Ari Togashi, Tetsuo Nagatani, Dermatology, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Fumio Kaneko, Dermatology, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan.
Email: f.kaneko@mt.strins.or.jp
Telephone: +81-24-934-5322

Received: July 31, 2018
Revised: September 27, 2018
Accepted: September 29, 2018
Published online: October 1, 2018

ABSTRACT

A 38-year-old Chinese woman had suffered from psoriasis vulgaris (PV) for more than one year and developed to the disease severity of PASI 12. She visited our hospital requesting treatment by biologics. Clinical examination before beginning treatment with biologics, showed no abnormalities except for slight increase in red blood cells and an indurated cutaneous reaction to tuberculin test, but no sign of clinical tuberculosis. The patient was commenced on treatment with ixekizumab (IXE) 160 mg in divided injections at two sites of the abdomen, but reddish urticarious reactions appeared at the injected sites. No such reactions were reappeared after the 2nd time injections. During 5 times injection the psoriatic eruption almost cleared to PASI 90% (PASI90). However, she had itchy urticarial rashes on her whole body after 7 times self-injection of IXE and she developed anaphylactic shock, although anti-histamine and hydrocortisone were injected intravenously. Fortunately, she recovered from the shock after intramuscular injection of adrenalin. After this episode, we examined immunological tests including IgE cap to mouse, hamster and drug-lymphocyte stimulated test by IXE, but no abnormalities detected. In conclusion, we should be aware of the potential to develop anaphylaxis in a patient who develops urticarial reactions at the injection sites of biologics for PV treatment.

Key words: Anaphylactic shock; Biologics; IgE-cap; Ixekizumab; Psoriasis vulgaris

© 2018 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Kaneko F, Togashi A, Nagatani T. A Case with Psoriasis Vulgaris Discontinued due to Anaphylactic Shock During Ixekizumab Treatment. Journal of Dermatological Research 2018; 3(1): 144-146 Available from: URL: http://www.ghrnet.org/index.php/jdr/article/view/2116

INTRODUCTION

Recently, patients with psoriasis have been immunologically treated by biologics and good efficacy has been gained in safety[1-2]. Ixekizumab (IXE), which is an anti-interleukin-17A monoclonal antibody, is also reported to effect for the clinical management of moderate-to severe psoriasis[3-5]. However, we should carefully note risk of side effects such as easily acquired infections by microorganism[4-6]. In addition, the biologics may contain a few amino acids from mouse and Chinese hamster ovary cells which are utilized in their production process, even though the agents are a recombinant humanized monoclonal antibody. IXE is composed of frame regions and constant regions derived from human IgG4[6].

Here, we would like to report a patient with psoriasis vulgaris (PV) who developed anaphylactic shock after self-injection of IXE.

CASE REPORT

The patient was a 38-year-old Chinese woman who had suffered from PV more than one year. No other family members were involved with PV. In the past history, she experienced medically induced abortion. She has been treated with a type of steroid ointment by a medical practitioner, but new lesions continued to appear. On 4 September, 2017, she visited to our hospital clinic requesting treatment by biologics. The clinically severity score of psoriasis seemed to be PASI 12 (Figure 1 A-C). She was examined clinically before the trial of treatment with biologics. She showed no abnormalities except for slight increasing of red blood cells (530 × 104/μL, Hb: 15.6g/L, Ht: 46.3%) and a cutaneous indurated reaction to her tuberculin test (5 × 5mm/17 × 24mm). However, no sign of tuberculosis was found. Then, treatment for the patient was started with IXE 160mg in divided injections at two sites of her abdomen, but within 20min after injections, reddish urticarious reactions appeared at the injected sites (Figure 1D). The lesions were naturally disappeared in an hour and no such reactions were reappeared after the 2nd time injections. During 5 times injection psoriatic eruption almost disappeared and reached to the result of PASI90 (Figure 2A, B). Any disadvantages were not complained during these times. However, she developed itchy urticarious rushes on her whole body after 7 times self-injection of the biologic and visited us immediately in the afternoon of 8th February, 2018 (Figure 3E, F). Anti-histamine agent (Chlorpheniramine Maleate 5mg/mL) and 10mg of hydrocortisone were given intravenously for the widespread urticaria, but before long she developed anaphylactic shock with low blood pressure. An absent pulse was noted at the moment, but fortunately she recovered from the shock after intramuscular injection of 0.3 mg/1ml of adrenalin and application of an oxygen mask. She was admitted to ICU room for a day as a precautionary measure.

Figure 1 Clinical manifestations, psoriatic eruption exhibiting severity PASI 12. (a) abdomen; (b) back; (c) right arm, psoriatic patches scattered; (d) Within 20 min after self-injection of IXE, reddish urticarious erythema appeared.

Figure 2 After 5 times self-injection, psoriatic eruption completely disappeared and it seemed to reach PASI 90%. (A) abdomen, (B) back.

Figure 3 Before anaphylactic shock, the patient had urticarious erythema within 20 min after 7 times self-injection of IXE 160 mg. (A), urticarious erythema of the l-neck and cheek, (B) r-upper arm.

DISCUSSION

After the episode, we have commenced to investigate about her risk factors to anaphylactic shock, as reported before[7]. Anaphylactic shock due to the biologics is not reported before as a side effect except for some infections[1-7]. However, it may be possibility of allergic episodes was detected later in the patient’s history and investigations. Eosinophils in white blood cells were noted to be relatively increased after the episode, although serum IgE level was rather low (less than 170 IU/mL). The analysis of IgE cap by ELISA system revealed absence of antibodies to mouse, hamster and guinea pig but reactions to house dusts and Japanese cedars were positive and the patient had hay- fever in the season. High levels of serum histamine and triptase were not found, although it is reported to be found in mastocytosis which is one of the risk predictors for anaphylaxis[8]. We were refused to do a prick test with IXE for her fear. Regarding the immediate immune reactions, no abnormal reactions were found and drug-lymphocyte-stimulation test to IXE was also reported to be negative (SRL Co., Tokyo, Japan).

The only predicting signs may be is to find erythematous reactions at the initial injection sites of the biologics. Then, it may be danger sign if self-management of the patient is continued.

ACKNOWLEDGEMENTS

We deeply appreciate the Group of Drs. Keiichi Kan from Emergency Unit and Drs. Anne and Martin Black from St. John’s Institute of Dermatology, St. Thomas’ Hospital, London, UK for help with the manuscript.

REFERENCES

1. Feldman SR, Kruger GG. Psoriasis assessment tools in clinical trials. Ann Rheum Dis 2005; 64: ii65-68.

2. Kamata M, Tada Y. Safety of biologics in psoriasis. J Dermatol 2018; 45: 279-286.

3. Leonardi C, Matheson R, Zachariae C, Cameron G, Li L, Edson-Heredia E, Brown D, Banerjee S. Anti-interleukin-17 monoclonal antibody ixekizumab in chronic plaque psoriasis. N Engl J Med 2012; 1190-1199.

4. Saeki H, Nakagawa H, Nakajo K, Ishi T, Morisaki Y, Aoki T, Cameron GS, Osuntokun OO, for the Japanese Ikekizumab Study Group. Efficacy and safety of ixekizumab treatment for Japanese patients with moderate to severe plaque psoriasis, erythrodermic psoriasis and generalized pustular psoriasis: results from a 52-week, open-label, phase 3 study (UNCOVER-J). J Dermatol 2017; 44: 355-362.

5. Imafuku S, Torisu-Itakura H, Nishikawa A, Zhao F, Cameron GS, Japanese UNCOVER-1 Study Group. Efficacy and safety of ixekizumab treatment in Japanese patients with moderate-to-severe plaque psoriasis: subgroup analysis of a placebo-controlled, phase 3 study (UNCOVER-1). J Dermatol 2017; 44: 1285-1290.

6. HIGHLIGHTS OF PRESCRIBING INFORMATION TALZ(ixekizmab) injection subcutaneous use initial U.S. Approval:2016

7. Ryan C, Menter A, Guenther L, Blauvelt A, Bissonnette R, Meeuwis K, Sullivan J, Cather JC, Yosipovitch G, Gottlieb AB, Morela JF, Callis Duffin K, Fretzin S, Osuntokun OO, Burge R, Naegeli AN, Yang FE, Lin CY, Todd K, Potts Blaekman A, Ixora-Q Stuy Group. Efficacy and safety of ixekizumab in a randomized, double-blinded, placebo-controlled phase 3b study of patients with moderate-to-severe genital psoriasis. Br J Dermatol 2018

8. Worm W, Francuzik W, Renaudin JM, Bilo MB, Cardona V, Scherer Hofmeier K, Kohli A, Bauer A, Christoff G, Cichocka-Jaroz E, Hawaranek T, Hourihane JOB, Lange L, Mahler V, Muraro A, Papadopoulos NG, Plohler C, Pozimkowska-Gesicka I, Rueff F, Spinder T, Trendler R, Fernandes-Rivas M, Dolle S. Factors increasing risk for a severe reaction in anaphylaxis: An analysis of data from the European anaphylaxis registry. hettp://doi.org/10.1111/all.13380

Refbacks

  • There are currently no refbacks.