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Serum Sickness

Serum Sickness. Jill Tichy, M.D. PGY III. Serum Sickness What is it?. Immunization of host (human) by heterologous (non-human) serum proteins caused by formation of immune complexes A diagnosis made clinically and one of exclusion. Definition continued….

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Serum Sickness

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  1. Serum Sickness Jill Tichy, M.D. PGY III

  2. Serum SicknessWhat is it? • Immunization of host (human) by heterologous (non-human) serum proteins caused by formation of immune complexes • A diagnosis made clinically and one of exclusion

  3. Definition continued… • Cardinal symptoms include rash, fever, polyarthralgias or polyarthritis • Malaise • Occurs one to two weeks after first exposure to responsible agent • Resolves within a few weeks of discontinuing the drug

  4. Type III or Immune Complex Mediated Hypersensitivity • Antigens combine with host immunoglobulins specific to those antigens • Resultant immune complexes are in excess of phagocyte system • Deposit in tissues and trigger the inflammatory response

  5. Blame the heterologous proteins • Equine or Rabbit Antithymocyte Globulin (ATG) • Rituximab • Inflimixab • Venom Anti-toxins • Rabies Vaccine • Streptokinase • Penicillin • Cefaclor • Amoxicillin • Bactrim

  6. Supportive Physical Exam Findings • Pruritic Rash sparing the mucous membranes • Rash can be serpiginous and macular which starts at the trunk and spreads distally • *Skin changes at the junction of the lateral aspect of palms and soles

  7. Supportive Physical Exam Findings

  8. Supportive Physical Exam Findings • Joints commonly involved are: MCP, knees, wrists, ankles and shoulders • Spine and TMJ involvement is also reported • Joint pain typically occurs after rash has started • Myalgias also seen • Trismus

  9. Supportive Laboratory Data • Neutropenia with reactive lymphocytes • Mild Thrombocytopenia • Eosinophilia • Elevated CRP and ESR • Proteinuria (50% of patients) • Elevations in creatinine

  10. Supportive Laboratory DataDermatopathology • Histology varies • Typical is mild peri-vascular infiltrates with lymphocytes and histiocytes without vessel necrosis

  11. Differential Diagnosis • Acute Rheumatic Fever • Disseminated gonococcemia and meningococcemia • Reactive Arthritis (Reiter’s Syndrome) • Rickettsial Diseases • Disseminated EBV/CMV • Stevens-Johnson Syndrome • Still’s Disease • Kawasaki’s Disease • Viral Exanthems

  12. TreatmentStop offending agent • Mild symptoms self-limiting • Anti-histamines; NSAIDs • Severe symptoms (fever > 38.5; extensive rash, severe arthritis) give steroids • Avoid responsible drug in the future • Not clear if similar drugs should be avoided

  13. References • Lawley, TJ, Bielory, L, Gascon, P, et al. A prospective clinical and immunologic analysis of patients with serum sickness. N Engl J Med 1984; 311:1407 • Bielory, L, Yancey, KB, Young, NS, et al. Cutaneous Manifestations of serum sickness in patients receiving antithymocyte globulin. J AM Acad Dermatol 1985; 13:411 • Snow, M, Cannella, A, Stevens, RB, Presumptive Serum Sickness as a Complication of Rabbit-Derived Antithymocyte Globulin Immunosuppression • Harrison’s Textbook of Internal Medicine • Uptodate photography

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