title: Necrotizing group A streptococcal periorbital infection following adalimumab therapy for rheumatoid arthritis.
abstract: 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.
  
  
  METHODS
  Single interventional case report and literature review.
  
  
  METHODS
  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.
authors.affiliation: Department of Medicine, University of Cambridge, Cambridge, UK. jonathanroos@cantab.net
authors.forename: Jonathan C P
authors.initials: JC
authors.lastname: Roos
authors.forename: Cornelius
authors.initials: C
authors.lastname: René
authors.forename: Andrew J K
authors.initials: AJ
authors.lastname: Ostor
mesh_terms: D000068879:Adalimumab; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000009:adverse effects* / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D008875:Middle Aged; D009336:Necrosis / Q000209:etiology / Q000473:pathology; D054517:Orbital Cellulitis / Q000188:drug therapy / Q000382:microbiology* / Q000473:pathology; D013290:Streptococcal Infections / Q000188:drug therapy / Q000382:microbiology* / Q000473:pathology; D013297:Streptococcus pyogenes
chemical_list: D000900:Anti-Bacterial Agents; D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D007166:Immunosuppressive Agents; D000068879:Adalimumab