Necrotizing group A streptococcal periorbital infection following adalimumab therapy for rheumatoid arthritis

OBJECTIVE: (1) To describe a case of necrotizing group A streptococcal periorbital infection in a patient receiving treatment with adalimumab (Humira, Abbott)-- a fully humanized monoclonal anti-TNF-α agent. (2) To identify bacterial species responsible for infection with different forms of biological therapy. DESIGN: Single interventional case report and literature review. CASE: A 57-year-old woman developed severe right-sided necrotizing periorbital infection whilst receiving treatment with adalimumab for rheumatoid arthritis (RA). Cultures grew Lancefield Group A Streptococcus pyogenes. An extensive literature search for reports of ocular infections associated with biological therapy was conducted. RESULTS: Adalimumab therapy was discontinued and the patient was admitted to an intensive care unit. The patient made a complete recovery after receiving appropriate antibiotic therapy. Overall Gram-positive cocci are the most common infection associated with use of biological therapy. CONCLUSIONS: Anti-TNF-α agents are powerful immune-modulating drugs with potentially serious side effects. This case is the first to link adalimumab to necrotizing periorbital infection. Resolved infection does not preclude reintroduction of anti-TNF therapy however, careful assessment of the risks versus benefits of therapy is required at the individual patient level.