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

Cutan Ocul Toxicol. 2011 Jun;30(2):160-2. doi: 10.3109/15569527.2010.533317. Epub 2010 Nov 15.


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.

Publication types

  • Case Reports

MeSH terms

  • Adalimumab
  • Anti-Bacterial Agents / therapeutic use
  • Antibodies, Monoclonal / adverse effects*
  • Antibodies, Monoclonal / therapeutic use
  • Antibodies, Monoclonal, Humanized
  • Arthritis, Rheumatoid / drug therapy*
  • Female
  • Humans
  • Immunosuppressive Agents / adverse effects*
  • Immunosuppressive Agents / therapeutic use
  • Middle Aged
  • Necrosis / etiology
  • Necrosis / pathology
  • Orbital Cellulitis / drug therapy
  • Orbital Cellulitis / microbiology*
  • Orbital Cellulitis / pathology
  • Streptococcal Infections / drug therapy
  • Streptococcal Infections / microbiology*
  • Streptococcal Infections / pathology
  • Streptococcus pyogenes*


  • Anti-Bacterial Agents
  • Antibodies, Monoclonal
  • Antibodies, Monoclonal, Humanized
  • Immunosuppressive Agents
  • Adalimumab