Severe Immediate and Delayed Hypersensitivity Reactions to Biologics in a Toddler With Systemic Juvenile Idiopathic Arthritis

• Type of Material: Article
• Authors: Diana Villacis Nunez, Emory University; Kassahun Bilcha, Emory University; Mary Spraker, Emory University; Kelly Rouster Stevens, Emory University; Anthony Cooley, Emory University
• Language: English
• Date: 2022-02-01
• Publisher: American Federation for Medical Research
• Publication Version: Final Published Version
• Copyright Statement: © 2022 American Federation for Medical Research
• License: Creative Commons Attribution-NonCommercial 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1177/23247096221077836
• Title of Journal or Parent Work: Journal of Investigative Medicine High Impact Case Reports
• Volume: 10
• Start Page: 23247096221077836
• End Page: 23247096221077836
• Grant/Funding Information: The author(s) received no financial support for the research, authorship, and/or publication of this article.
• Keywords: anaphylactoid reaction; Arthritis, Juvenile; Child, Preschool; Male; anakinra; drug reaction; Hypersensitivity, Delayed; Antirheumatic Agents; Macrophage Activation Syndrome; eosinophilia; Biological Products; Humans; Hypersensitivity; tocilizumab
• Research Categories: Health Sciences, Human Development; Health Sciences, Medicine and Surgery

Abstract

Many pediatric rheumatic diseases can be safely managed with biologic therapy. Severe allergic reactions to these medications are uncommon. We report the case of a 2-year-old male with systemic-onset juvenile idiopathic arthritis and secondary macrophage activation syndrome (MAS), whose treatment was complicated by severe allergic reactions to biologics, including drug reaction with eosinophilia and systemic symptoms (DRESS)/drug-induced hypersensitivity reaction (DIHR) likely due to anakinra, and anaphylactoid reaction to intravenous tocilizumab. These required transition to canakinumab, cyclosporine, and corticosteroids, with later development of interstitial lung disease and MAS flare needing transition from canakinumab to tofacitinib, which led to disease control. Whether lung disease is a manifestation of DRESS/DIHR to canakinumab remains unclear. High index of suspicion of hypersensitivity reactions for timely diagnosis and drug discontinuation is critical, especially in patients with active disease who might be at increased risk of these adverse events.