Presentation and Skin Biopsy Findings in Delayed Type Hypersensitivity Reactions to Facilitated Subcutaneous Immunoglobulin Replacement
Saturday, March 3, 2018
South Hall A2 (Convention Center)
Kara B McNamara, MD, Jim M. Fernandez, MD PhD, Lily Pien, MD FAAAAI, Dawn M. Zacharias, MD
RATIONALE: Immunoglobulin replacement therapy is an important treatment option for patients with primary immunodeficiency. There are currently multiple immunoglobulin replacement products varying in formulation, route of administration, rate and frequency of administration. Due to these differences, the tolerability of each of these products can vary as well. A better understanding of the adverse reactions associated with individual products would be beneficial for future clinical care.

METHODS: The charts of 4 patients with suspected delayed type hypersensitivity reactions to hyaluronidase-facilitated subcutaneous immunoglobulin were reviewed. Skin biopsies were performed in 2 cases and slides were reviewed by a dermatopathologist.

RESULTS: The dermatologic exam of the 4 patients revealed multiple cutaneous manifestations including erythema, swelling, scaly plaques, and papules. Among the 4 cases reviewed, 2 patients underwent subsequent skin biopsy. The biopsies collectively showed spongiotic dermatitis and superficial perivascular lymphocytic infiltrate. In all 4 cases, the rash gradually resolved with discontinuation of the facilitated subcutaneous immunoglobulin along with medical therapy ranging from antihistamines to steroids. Two of the patients subsequently tolerated IV immunoglobulin and one tolerated standard subcutaneous immunoglobulin.

CONCLUSIONS: Facilitated subcutaneous immunoglobulin replacement is typically well tolerated by most patients, however adverse cutaneous reactions have been documented. It is unclear whether this represents a hypersensitivity to the hyaluronidase, the immunoglobulin or the combination. We present the examination and histological findings in several cases. Characterization of these findings can help clarify the nature of these adverse reactions and should assist physicians in their choice of treatment and alternative options in such instances.