With great interest, we read the article by Roos and coworkers entitled “Necrotizing group A streptococcal periorbital infection following adalimumab therapy for rheumatoid arthritis (Citation1)”. We congratulate the authors for the management of their case and for the extremely useful review of the literature of cases of eye infections following the administration of biological agents. We would take the opportunity to discuss some more key points on this rare disease and point out the presence in the literature of a case of ocular and adnexal infections occurred after treatment with a further monoclonal antibody, Rituximab.
Rituximab has been the first monoclonal antibody to be approved for therapeutic use (Citation2). It is a chimeric monoclonal antibody targeted against the pan-B-cell marker CD20. It is indicated for the treatment of patients with relapsed or refractory CD20-positive follicular non-Hodgkin’s lymphoma and in combination with fludarabine and cyclophosphamide, for the treatment of patients with previously untreated and previously treated CD20-positive chronic lymphocytic leukemia (CLL). Finally, Rituximab in combination with methotrexate is indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies.
Recently, we have managed a case of periorbital necrotizing fasciitis (NF) caused by Pseudomonas aeruginosa in a 49-year-old patient with a history of CLL that had been treated previously with four complete cycles of chemotherapy (fludarabine, cyclophosphamide, Rituximab) waiting for an autotransplant (Citation3). The patient was immediately started on large dose intravenous (i.v.) broad-spectrum antibiotics, and after the cultural results, the patient was started on high doses of meropenem (2 g every 8 h) and i.v. ciprofloxacin (400 mg every 8 h). In addition, he received daily cycles of oxygen hyperbaric treatments and underwent repeated surgical consecutive debridements. The coverage of the lesion was provided with a microsurgical free flap followed by eyelid reconstruction once the wounds were stable. Although the defect has been almost completely restored and eyelid functionality has been in great measure recovered, residual disfigurement with partial loss of definition of the normal contours of left eyelids still persists.
This unusual event (Citation3) might be related to deterioration of humoral immunity caused by Rituximab, and to our knowledge, this is the first case of bacterial periorbital NF following this type of monoclonal antibodies use. As already described by Roos and colleagues (Citation1), several further biological agents administration may be followed by bacterial infection of eye and periorbita. Physicians should be aware of these complications in patients receiving biological agents even when no prior history of trauma is reported, thus being early recognition of signs and symptoms followed by early onset of systemic antibiotics predicated to achieve favorable outcomes.
Declaration of interest
There are no financial conflicts or interests to report in association with the contents of this paper.
References
- Roos JC, René C, Ostor AJ. Necrotizing group A streptococcal periorbital infection following adalimumab therapy for rheumatoid arthritis. Cutan Ocul Toxicol 2010. (In Press.)
- Smith MR. Rituximab (monoclonal anti-CD20 antibody): Mechanisms of action and resistance. Oncogene 2003;22:7359–7368.
- Lazzeri D, Lazzeri S, Figus M, Tascini C, Bocci G, Colizzi L et al. Periorbital necrotising fasciitis. Br J Ophthalmol 2010;94:1577–1585.