The most common treatment based on the literature involves cessation of the offending agent. They blanch with pressure and may display a central purplish or dusky hue. ), Tanriover, B, Chuang, P, Fishbach, B. Skin lesion; List of cutaneous conditions; References Fever develops in almost all patients with serum sickness, preceding skin rash in 10-20% of cases. These findings should prompt consideration for Stevens-Johnson syndrome, a potentially fatal hypersensitivity reaction and (in my experience) the one reason for a Dermatologist to come in at night. Another course of steroids can halt these symptoms. Registration is free. Article also reviewed treatment for serum sickness with steroids and plasmapheresis. Home » Decision Support in Medicine » Dermatology. Gonococcemia can have septic arthritis with swelling, and organisms can be detected from joint aspirate. there are no respiratory symptoms. ), (Five case reports of renal transplant patients who developed serum sickness after polyclonal antibody treatment with severe symptoms that persisted even after starting systemic steroids, and had subsequent resolution of symptoms ater one to two courses of therapeutic plasma exchange.). 0.5-2mg/kg by mouth per day, divided once, twice, or four times per day. -Neurologic: Rarely there are peripheral neuritis, brachial plexus neuritis, optic neuritis, cranial nerve palsies, Guillaine-Barre syndrome, myelitis. 10-15mg/kg by mouth four to six times per day. It is mistaken most often for erythema multiforme and, occasionally, for a serum-sickness … ), (Three case reports of severe serum sickness-like reactions in adults after receiving oral penicillin and symptom resolution occuring within 24 hours of starting therapy with oral prednisone 40 to 60mg daily. In one study looking at antirabies serum, serum sickness was more common in patients older than 15 years. The condition is sometimes mistaken for other ring-shaped disorders — most often, erythema multiforme and less commonly, serum-sickness–like reactions. Serum sickness, vasculitis, erythema multiforme, interstitial nephritis: IV (delayed) T cell mediated: 2-4 days (or more) Maculopapular exanthema, delayed urticaria, fixed … No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. Tapering of these agents should be from one to two weeks as the symptoms resolve. 2014, Brad Sobolewski, MD, MEd. Once the offending agent is identified, it should be avoided to prevent recurrences in the future. This process is immune complex mediated and results in the development a polymorphous, sometimes pruritic rash that starts in the trunk and spreads peripherally. Viral infections can often have mucosal and pharyngeal lesions which are not often seen in serum sickness. Serum sickness is a type III hypersensitivity reaction from the administration of foreign protein, serum or nonprotein medications. Splenomegaly can also be found. Pruritus and erythema … ), Finger, E, Scheinberg, M. “Development of serum sickness-like symptoms after rituximab infusion in two patients with severe hypergammaglobuinemia”. Antirabies serum is associated with a higher likelihood of serum sickness than with tetanus antitoxin. What is erythema multiforme?. A short course of prednisone should be used orally, and in the more acutely ill patient, intravenous methylprednisolone can be used. Arthritis and arthralgia (10-50%): Joint involvement occurs after the rash has started and resolves before the rash resolves. Spine and temporamandibular joint pain have also been described. - Full-Length Features ), (Single case report of corticosteroids being used to treat severe and prolonged serum sickness reaction to intramuscular penicillin depot injection. When seen in adults, it usually occurs between the ages of 20 and 40, although it can happen to people of any age. No standardized evidence-based protocol for the optimal treatment of drug-induced SSLR exists. Skin rashes of reactive arthritis differ from that of serum sickness and include circinate balanitis with gyrate white plaques on the glans penis, and the typical keratoderma blenorrhagica that resembles kertatotic plaques on the palms and soles.]. Patients often develop a combination of urticarial lesions and a serpinginous macular rash that starts in the axillary and groin region and later spreads to involve other parts of the body. - Evidence-Based Guidance Serum sickness like reactions are heterogeneous and the pathogenetic mechanism(s) are not well defined. ), Tatum, AJ, Ditto, AM, Pattterson, R. “Severe serum sickness-like reaction to oral penicillin drugs: three case reports”. ... erythema simplex, or erythema multiforme are less common. <12 years old: 5-10mg/kg by mouth four to six times per day. There have been very rare cases of progressive glomerulonephritis, neurologic damage, and even death linked to serum sickness. -Renal: More commonly seen are proteinuria, hematuria, and oliguria. Who is at Risk for Developing this Disease? ], -Systemic lupus erythematosus [SLE can have nonspecific fever, arthragias, and rash, however, that also include serologic testings consistent with automimmune disease (eg, positive ANA, dsDNA) that serum sickness lacks.]. Copyright © 2017, 2013 Decision Support in Medicine, LLC. 659-60. It has been our experience that erythema multiforme is incorrectly diagnosed in many patients with an urticarial drug eruption because the edema from the urticaria can result in some surrounding pallor and some central pallor or duskiness, which can mimic a type of targetoid pattern. The Licensed Content is the property of and copyrighted by DSM. This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. Findings on physical examination can include a skin rash, fever, arthralgia/arthritis, and other less common manifestations including renal, cardiovascular, pulmonary, neurologic, and gastrointestinal systems. 325-650mg by mouth four to six times per day. The patient failed methylprednisolone, methothrexate, and azathioprine so repeated plasmaphoresis with fresh frozen plasma was used. Similarly, in another study when the the offending agent could not be discontinued (an insulin injection used in a type I diabetic patient), it caused a serum sickness reaction. The most common and earliest feature is a pruritic rash. -Edema: at site of injection or of the face and neck. You may still encounter this today in sheep-derived Fab snake antivenom, heterologous immunomodulators containing murine components (rituximab and infliximab), streptokinase and the human diploid cell rabies vaccine. Symptoms develop 1 to 2 weeks after initial introdution to the antigen (as this primary immunization causes IgM antibodies to develop around 7-14 days later, and IgG antibodies appear a few days after IgM). Liver Transp. Fun fact: What was described today is actually serum sickness-like reaction. Classically serum sickness was in response to administration of a non-human species (horse) protein antigen. 26. Acute annular urticaria is a common and benign cutaneous hypersensitivity reaction seen in children that manifests with characteristic annular, arcuate, and polycyclic urticarial lesions in association with acral edema. : 130 See also. All That Forms Rings Is Not Erythema Multiforme. Serum sickness is a self-limiting disorder, and these symptoms resolve within a few weeks of discontinuation of the responsible agent. We hope you’re enjoying the latest clinical news, full-length features, case studies, and more. ... erythema simplex, or erythema multiforme are less common. here. Serum sickness-like reaction is most commonly seen in young children (< 6 years of age) following the use of cefaclor (an antibiotic). Fever (10-20%): Fever higher than 38.5°C can precede the rash. Acute annular urticaria (ring-shaped hives) is a benign cutaneous hypersensitivity reaction that occurs frequently in childhood. Repeated exposure leads to a more rapid (within 12-36 hours) and more florid response. The differential diagnosis includes: You can generally make the diagnosis clinically in most cases. Treatment consists of stopping the offending agent, NSAIDs for pain, and antihistamines for itching. Serum creatinine can be elevated above baseline, but often resolves in a few days. ), (Two case reports of patients developing serum sickness-like reactions after placement of sirolimus-eluting stents, and resolution of symptoms after oral prednisone treatment. Classical serum sickness is caused by the injection of heterologous serum proteins such as horse serum. -Pulmonary: Dysnea, wheezing, and cyanosis, and rarely, pleuritis can be seen. Specific antigen type: In one study looking at antithymocyte globulin (ATG), 85% developed serum sickness. She has no involvement of her eyes or mouth. 1-2mg/kg intravenous per day divided into once to twice per day dosing. Serum sickness-like reactions have some clinical signs and symptoms in common with serum sickness. Lab abnormality of eosinophilia and elevated liver function test is often seen. Most patients develop remittent fever without temporal spikes. ], -Still’s disease [Still’s disease, also known as systemic onset juvenile rheumatoid arthritis, can have similar fever, arthralgias, arthritis, and a rash. “Severe serum sickness reaction to oral and intramuscular penicillin”. 8–11 The rash may include urticaria or erythema multiforme, or be morbilliform. Adults often require higher dosing, which can be a factor; however serum sickess itself is unusual in children overall. vol. 2 The overall incidence of skin rash of probable or unknown association was 1.2%. -Reactive arthritis [Reactive arthritis can have fever and joint pain, however, also includes symptoms of urethritis and conjunctivitis. ), Lundquist, AL, Chari, RS, Wood, JH. 98. Patients should initially be evaluated and be admitted to inpatient care if comorbidities exist such as extreme ages of young or old, immunocompromised, severe symptoms, or hemodynamic instability. BACKGROUND: Serum sickness-like reactions (SSLR) and erythema multiforme are common adverse effects of cefaclor therapy and can be associated with significant morbidity. 80. 0.2-2mg/kg by mouth per day, divided by once, twice, or four times per day dosing. An excess of this soluble immune complexes can deposit in tissues and cause an inflammatory response through activation of the complement cascade. There is no involvement of the mucous membranes or eyes. Serum sickness-like reactions (SSLR) are caused by various medications, especially antibiotics including cefaclor, penicillin, amoxicillin, and bactrim, and also following infections (Hepatitis B and endocarditis) and vaccines. Age: Adults are at higher likelihood of developing serum sickness. Most patients develop remittent fever without temporal spikes. Swelling and erythema of joints are rare. Urticarial erythema multiforme is an unusual reaction virtually always associated with antibiotic ingestions, characterized by skin lesions that consist of urticarial papules and plaques, some of which clear centrally forming annular lesions, but with no true urticarial lesions. Serum sickness is characterized by rash, fever, arthralgia or arthritis. This hasn’t limited her ability to walk, run or jump. In patients with a history of receiving antiserum in the past, or a history of allergy to horse dander, skin testing, including prick and intradermal, can help identify individuals at risk for developing anyphylaxis for future administration of antiserum. Diabet Med. The rash appeared this morning and seemed to begin on her torso, later spreading to her limbs. Nonsteroidal antiinflammatory drugs (NSAIDS) such as aspirin or ibuprofen can have analgesic, antiinflammatory, and antipyretic properties.
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