<div><b>Alemtuzumab‐induced petechiae and epistaxis in a patient with
relapsing remitting multiple sclerosis; A case report </b></div><div>Farhad Mahmoudi<sup>1*</sup>, Sayed Ali Emami<sup>1</sup>,
Farid Masaeli<sup>1</sup>, Najmeh Rayatpisheh<sup>2</sup></div><div><sup>1</sup> School of Medicine, Isfahan University of Medical
Sciences, Isfahan, Iran</div><div><sup>2</sup>School of Medicine, Shahrekord University of Medical
Sciences, Shahrekord, Iran</div><div>Corresponding author*</div><div>Farhad Mahmoudi</div><div>School of Medicine,</div><div>Isfahan University of Medical Sciences,</div><div>Isfahan, Iran</div><div>Email: farhad.mg116@gmail.com</div><div>Abstract:
This case report presents a 58-year-old woman
with Multiple Sclerosis (MS) who developed petechiae and epistaxis, rare
side effects following Alemtuzumab treatment. While these reactions are
infrequent, heightened awareness among healthcare providers is essential
as Alemtuzumab gains popularity in MS treatment. Recognizing and
managing such hypersensitivity reactions promptly is crucial for
improved patient
care.
1.Introduction
Multiple
Sclerosis (MS) is an autoimmune disease that affects the central nervous
system. The course of the disease varies among individuals, leading to a
wide range of symptoms and patterns of presentation. Additionally, there
are other conditions, such as radiologically isolated syndrome, which
can progress to MS(1). While there is no curative therapy for this
condition, certain drugs can modify the course of the disease and
improve the prognosis and quality of life for patients.</div><div>Disease-modifying treatments (DMTs) are the preferred treatment option
for patients with MS. Alemtuzumab is an intravenously administered DMT
drug that has been available since 2014 for the treatment of patients
with multiple sclerosis who have not responded adequately to two or more
DMTs. It is a recombinant DNA-derived humanized monoclonal antibody that
selectively binds to the CD52 antigen on B and T lymphocytes, depleting
them from the bloodstream. This drug has been described as a safe and
effective treatment with minimal side effects for patients with
relapsing-remitting multiple sclerosis.(2)</div><div>While there are few studies on the cutaneous adverse effects of
Alemtuzumab, in this study, we report the first case of an MS patient
treated with Alemtuzumab who developed drug-induced petechiae and
epistaxis.</div><div>2. Case presentation</div><div>A 58-year-old Caucasian woman with relapsing-remitting multiple
sclerosis, who had no previous medical conditions, presented to the
emergency department due to muscle spasms and stiffness in her right
foot. Neurological examination revealed weakness in her right lower limb
with 3/5 muscle strength. She was diagnosed with MS at the age of 26
through an MRI and had previously been on weekly Interferon-beta (IFNb)
treatment. During acute MS attacks, she received intravenous
corticosteroids. Despite being on disease-modifying therapies (DMTs),
she experienced more relapses in the last year, and her Expanded
Disability Status Scale (EDSS) was 3. During the current
hospitalization, the patient underwent brain and cervical spinal MRI,
which revealed the appearance of new periventricular white active
plaques in addition to previous black old lesions.</div><div>Considering the progression of her disease condition, she was started on
treatment with Alemtuzumab at a dose of 12mg/day IV. There were no drug
reactions, and after completing the treatment, her muscle spasms and
stiffness resolved, and the patient was discharged from the hospital.</div><div>The day after, the patient came to the hospital to receive the second
dose of the drug. While receiving the treatment, her condition remained
stable, and she did not experience any notable symptoms. However, one
day after finishing the first dose, the patient started to experience a
gradual appearance of petechiae on her upper and lower limbs, chest,
shoulders, and back. Moreover, a few minutes later, she developed
epistaxis. Her blood pressure and heart rate were 127/73 and 87,
respectively. The patient denied any previous history of eczema, skin
issues, or respiratory allergies.</div><div>Dermatology was consulted to investigate the possible causes of
petechiae, and ENT was consulted to manage and evaluate the epistaxis.
Despite applying pressure to the nostrils and placing ice on the
forehead, the epistaxis did not cease. Consequently, the patient
underwent posterior nasal packing, which successfully halted the
bleeding.</div>