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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Supportive Physical Exam Findings
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Supportive Physical Exam Findings
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