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New Emirates Medical Journal

Volume 3, 2 Issues, 2022
ISSN: 0250-6882 (Online)
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Open Access Article

Serum Sickness Reaction to Rituximab with Positive Immediate Intradermal Skin Test: A Case Report

Laura Palomino-Lozano1, *, Blanca Noguerado-Mellado1, Jimena Crespo Quirós1, Melina Tejero-Alcalde1, Cristina Cuevas-Bravo1, Borja Bartolomé Zavala2, Patricia Rojas-Perez-Ezquerra1
1 Department of Allergy, Hospital General Universitario Gregorio Marañon, Madrid, Spain
2 Department of I+D, Roxall, Parque cient. y tecnol. de Bizkaia, edif. 401, 48170 Zamudio, BI, Spain



Rituximab is a chimeric murine/human monoclonal antibody against CD20. It can be used off-label in autoimmune diseases. Its administration can lead to several types of reactions; immediate infusional reactions and also delayed reactions like Serum Sickness Reaction (SSR).

Case Presentation:

This is a case study of a 48 years old woman diagnosed with rheumatoid arthritis/systemic lupus erythematosus who developed refractory immune thrombocytopenic purpura and received treatment with rituximab. After treatment, she developed erythematous-violet lesions accompanied with fever of 38ºC, dyspnea, joints arthralgia and edema. In the emergency department, hypotension, fever, dyspnea, and shivering were observed, for which, intramuscular epinephrine, intravenous corticosteroids, antibiotics and salbutamol nebulization were administered. In our allergy unit, we performed an intradermal test (IDT) with rituximab (1mg/ml), which was positive at immediate (20min) and late (48h) reading. Based on the clinical manifestations and test carried out, she was diagnosed with rituximab SSR. We also studied the molecular mass of the IgE-reactive proteins present in rituximab product by SDS-PAGE Immunoblotting method according to Laemmli, in reducing and non-reducing conditions, with high sensitivity and using three different polyvinylidene difluoride (PVDF) membrane blocking substances (skimmed cow's milk, fish collagen and egg white). We did not detect IgE-binding to rituximab product.


The pathogenesis of SSR is not well known. The patients after reinfusion can develop immediate reactions suggesting involvement of IgE hypersensitivity. Nevertheless, there are patients who tolerated reinfusion. Further studies and assays are needed for a better understanding of these reactions and to lead to a safer re-administration if needed.

Keywords: Hypersensitivity reaction , Rituximab, Antibody, Immune-complex, Autoimmune disease, Serum sickness reaction, CD20.

Article Information

Identifiers and Pagination:

Year: 2021
Volume: 2
Issue: 2
First Page: 143
Last Page: 154
Publisher Id: nemj-2-143
DOI: 10.2174/0250688202666210303123547

Article History:

Received Date: 4/10/2020
Revision Received Date: 6/01/2021
Acceptance Date: 7/1/2021
Electronic publication date: 27/7/2021
Collection year: 2021

© 2021 Palomino-Lozano et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at Department of Allergy, Hospital General Universitario Gregorio Marañon, Madrid, Spain; Tel: 0034915868089; Fax: 0034915868089; E-mail:


Abdullah Shehab
Emirates Cardiac Society
Emirates Medical Association
(United Arab Emirates)
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