DeClue Cory E, Phillips Elizabeth J, Prieto-Granada Carlos, Bao Shichun
Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee.
Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee.
AACE Clin Case Rep. 2024 Apr 16;10(4):140-143. doi: 10.1016/j.aace.2024.04.002. eCollection 2024 Jul-Aug.
BACKGROUND/OBJECTIVE: Allergic reactions to insulin have decreased significantly since the introduction of human insulin preparation, but up to 2.4% of insulin-treated patients can still be affected. Rituximab is a monoclonal antibody against the surface antigen CD20 on B lymphocytes, and it is largely used to treat lymphoproliferative and rheumatological conditions. In a very few published case reports, rituximab has been used as an investigational drug to treat severe insulin allergy refractory to conventional therapy. Here, we present an unusual case of a 40-year-old woman with T1DM and severe insulin allergy that was successfully treated with rituximab.
The patient was diagnosed with T1DM at age 37. Three years later, skin reactions developed at insulin administration sites. These consisted of pruritic and painful erythema and wheals that appeared within 1 to 4 h of insulin administration, followed by induration, subcutaneous nodules, and surrounding lipodystrophy that lasted several days with spontaneous resolution in 1 to 2 weeks. Extensive immunologic evaluation suggested the reaction was related to insulin allergy. Skin biopsy revealed sublobular panniculitis. After failed conventional treatment with antihistamines, glucocorticoid, and various insulins, rituximab infusion as an investigational approach was initiated. This was very successful, leading to prolonged remission of her insulin allergy.
First-line management of insulin allergy should focus on second-generation antihistamines and switching insulin preparation. In refractory cases, systemic immunotherapy with rituximab can be a viable option.
Practitioners should be aware that in patients with insulin allergy who fail conventional treatment, immunotherapy with rituximab can be a viable option.
背景/目的：自人胰岛素制剂问世以来，对胰岛素的过敏反应已显著减少，但仍有高达2.4%接受胰岛素治疗的患者可能受到影响。利妥昔单抗是一种针对B淋巴细胞表面抗原CD20的单克隆抗体，主要用于治疗淋巴增殖性疾病和风湿性疾病。在极少数已发表的病例报告中，利妥昔单抗已被用作研究性药物来治疗对传统疗法难治的严重胰岛素过敏。在此，我们报告一例不寻常的病例，一名40岁1型糖尿病合并严重胰岛素过敏的女性患者成功接受了利妥昔单抗治疗。
该患者37岁时被诊断为1型糖尿病。三年后，胰岛素注射部位出现皮肤反应。这些反应包括在胰岛素注射后1至4小时内出现的瘙痒性疼痛性红斑和风团，随后是硬结、皮下结节以及周围脂肪营养不良，持续数天，1至2周内自行消退。广泛的免疫学评估表明该反应与胰岛素过敏有关。皮肤活检显示小叶下脂膜炎。在用抗组胺药、糖皮质激素和各种胰岛素进行传统治疗失败后，开始采用利妥昔单抗输注作为一种研究性方法。这非常成功，使她的胰岛素过敏得到了长期缓解。
胰岛素过敏的一线管理应侧重于第二代抗组胺药和更换胰岛素制剂。在难治性病例中，使用利妥昔单抗进行全身免疫治疗可能是一种可行的选择。
从业者应意识到，对于传统治疗失败的胰岛素过敏患者，使用利妥昔单抗进行免疫治疗可能是一种可行的选择。
