Severe anaphylactic reaction during the second infusion of infliximab in a patient with psoriatic arthritis

A 33-yer-old woman with no history of atopy, diagnosed of psoriatic arthritis, received 200 mg I.V. infliximab, with previous oral administration of loratadine and betamethasone, that was well tolerated. Two minutes after a second infusion two weeks later, with the same pretreatment, the patients suffer dyspnea, laryngeal spasm, generalized tremor, vomiting, hypotension, sinusal tachycardia, anxiety and hyposemia. She recovered in 45 minutes, after the administration of I.V. hydrocortisone, chloropyramine, adrenaline and oxigene. Several reports of infliximab-induced anaphylactic reactions have been published, especially in patients with Crohn's disease, that have been attributed to a type I (acute or delayed) hypersensitivity reaction mechanism.

At present, the treatment of rheumatoid arthritis include drugs known as biological therapies. The action of these drugs usually is on the specific molecules involve in the inflammatory response of the disease. Infliximab is a molecule that acts on the tumor necrosis factor. Specific antibodies have been found after the administration by the usual intravenous way.

CLINICAL CASE

We report the case of a 33 year old woman with psoriatic arthritis refractory to methotrexate. She was not taking other medication except for valdecoxib, started 2 months before. No history of atopia was present. Pre-treatment antinuclear and anti-DNA antibodies were negative. We started treatment with infliximab. In the first infusion she received 200 mg intravenously with previous administration of loratadine plus betametasone without any adverse reaction. For the second infusion (200 mg, two weeks later) she was premedicated in the same manner. In the first 2 minutes after the begin of the infusion she developed dyspnea, laryngeal spasm, generalized tremor, vomit, hypotension (80/50 mmHg), sinusal tachycardia (160 bpm), anxiety and hypoxemia (oxygen saturation 82%). At the emergency room she received 2 separate doses of 500 mg of hydrocortisone, chloropiramine, adrenaline and oxygen. She recovered in the next 45 minutes and was observed for three hours. After this she was discharged from the hospital.

Several authors have reported anaphylactic reactions to infliximab in adults and children, specially in patients with Crohn´s disease. In these reports it is not clearly described if the adverse reaction ocurred in the first or in subsequent infusions. A type I (acute or delayed) hypersensitivity reaction mechanism is implicated. In the future severe anaphylactic reactions should be described concerning dose, if the reaction ocurred in the first or subsequent infusions, severity of symptoms and treatment in order to establish criteria for the prompt identification and treatment of this rare but life-threatening condition.

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