11.kuycy serum sickness

7/29/2019 11.kuycy Serum Sickness

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Serum Sickness

Jill Tichy, M.D. PGY III


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Serum Sickness

What is it? Immunization of host (human) by

heterologous (non-human) serum proteins

caused by formation of immunecomplexes

A diagnosis made clinically and one of

exclusion


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Definition continued

Cardinal symptoms include rash, fever,polyarthralgias or polyarthritis

Malaise

Occurs one to two weeks after firstexposure to responsible agent

Resolves within a few weeks ofdiscontinuing the drug


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Type III or Immune Complex

Mediated HypersensitivityAntigens combine with host

immunoglobulins specific to those

antigens Resultant immune complexes are in

excess of phagocyte system

Deposit in tissues and trigger theinflammatory response


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Blame the heterologous proteins

Equine or Rabbit Antithymocyte Globulin (ATG)

Rituximab

Inflimixab

Venom Anti-toxins

Rabies Vaccine

Streptokinase

Penicillin

Cefaclor

Amoxicillin

Bactrim


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Supportive Physical Exam Findings

Pruritic Rash sparing the mucousmembranes

Rash can be serpiginous and macularwhich starts at the trunk and spreadsdistally

*Skin changes at the junction of thelateral aspect of palms and soles


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Joints commonly involved are: MCP,knees, wrists, ankles and shoulders

Spine and TMJ involvement is alsoreported

Joint pain typically occurs after rash has

started Myalgias also seen

Trismus


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Supportive Laboratory Data

Neutropenia with reactive lymphocytes

Mild Thrombocytopenia

Eosinophilia

Elevated CRP and ESR

Proteinuria (50% of patients) Elevations in creatinine


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Supportive Laboratory Data

Dermatopathology Histology varies

Typical is mild peri-vascular infiltrates with

lymphocytes and histiocytes withoutvessel necrosis


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Differential Diagnosis

Acute Rheumatic Fever

Disseminated gonococcemia and meningococcemia

Reactive Arthritis (Reiters Syndrome)

Rickettsial Diseases

Disseminated EBV/CMV

Stevens-Johnson Syndrome

Stills Disease

Kawasakis Disease

Viral Exanthems


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Treatment

Stop offending agent Mild symptoms self-limiting

Anti-histamines; NSAIDs

Severe symptoms (fever > 38.5; extensiverash, severe arthritis) give steroids

Avoid responsible drug in the future

Not clear if similar drugs should beavoided


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References

Lawley, TJ, Bielory, L, Gascon, P, et al. A prospectiveclinical and immunologic analysis of patients with serumsickness. N Engl J Med 1984; 311:1407

Bielory, L, Yancey, KB, Young, NS, et al. CutaneousManifestations of serum sickness in patients receivingantithymocyte globulin. J AM Acad Dermatol 1985;13:411

Snow, M, Cannella, A, Stevens, RB, Presumptive SerumSickness as a Complication of Rabbit-DerivedAntithymocyte Globulin Immunosuppression

Harrisons Textbook of Internal Medicine Uptodate photography

11.kuycy serum sickness

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