Dexamethasone desensitization in type III hypersensitivity reaction and multiple myeloma

IntroductionMultiple myeloma (MM) is a hematologic cancer characterized by the accumulation of monoclonal plasma cells in the bone marrow. Dexamethasone is included in preferred regimens for primary therapy for both transplant-eligible and transplant-ineligible candidates. To date, type III hypersensitivity reactions to dexamethasone have not been previously reported.Case reportA 61-year-old man diagnosed with multiple myeloma received treatment with bortezomib and dexamethasone, achieving complete remission. In 2017, he experienced his first relapse and was managed with bortezomib, thalidomide, and dexamethasone. In 2019, his regimen was changed to carfilzomib, which was subsequently discontinued due to hematologic toxicity. In 2022, he presented with relapse and an ankle fracture, leading to the suspension of treatment. In 2023, carfilzomib and dexamethasone were restarted at lower doses. During intravenous and oral dexamethasone treatment, the patient developed skin lesions on his lower extremities, and, following evaluation by the Allergy and Immunology team, drug-induced vasculitis was diagnosed.Management and outcomeGiven the need to reintroduce dexamethasone due to the lack of alternative therapeutic options, a dexamethasone desensitization protocol was implemented. A 5-step delayed desensitization protocol was successfully performed, with no reactivation of vasculitic lesions.DiscussionAlthough desensitization is generally contraindicated in type III hypersensitivity reactions, no prior cases of successful desensitization in dexamethasone-induced vasculitis have been reported. This is the first reported case of successful desensitization in a patient with dexamethasone-induced vasculitis. A limitation of this case report is that the mechanisms underlying drug tolerance remain unknown.