Transcript Serum Sickness in El Salvador

Serum Sickness in
El Salvador
• 12/07 Wal-Mart added Lamisil
(terbinafine) to its $4 list lowering in the
price of a 3 month course of Rx for
toenail fungal disease to $27.
• Post physical, I started 250 mg daily
and had normal LFT’s at three weeks.
• En route to El Salvador I developed
diffuse hives, erythema and swelling of
hands and feet with intense pruritis;
stopped Lamisil.
• Went to grocery store in San Salvador
and found chlorpheniramine. Traveled
to central El Salvador for project.
Benadryl and Ibuprofen for increasing
periarthritic pains.
• 2 days of increased malaise , chills,
fever, intense periarthralgias, hives and
edema of hands poorly controlled by
antihistamines and Ibuprofen 800mg tid.
• Day 4 began prednisone and stopped
the other meds.
• Gradual improvement over one month
• Turbinafine - 1/2 life of 36 hours. Terminal
elimination from serum takes 200-400 hours.
• 1-10% rate of hives,dermatitis, arthralgia,
myalgia
• <1% rate of angioedema, drug induced lupus,
toxic epidermal necrolysis, liver failure and
and Stevens-Johnson syndrome.
• Serum sickness;
• Rash fever, polyarthritis, poly arthralgias after
2 weeks of exposure to a medicine or foreign
protein
• Remission one to two weeks post D/C of
exposure.
• First described with Horse Serum use in
1905.
• Type III antigen-antibody complex disease
with complement activation.
• IgM IgG IgE IgA - time course favors IgM
• Resolution when antigen is completely
removed from serum - (?nails)
• Recurrent exposure causes illness within 36
hours
• Serum sickness like illness - not
antigen-antibody and mostly urticaria
and fever, arthralgias. Ceclor, antiseizure meds, sulfas, strept and viral
infections.
• Urticaria-arthralgia syndrome. Drugs act
as a hapten and invoke direct antibody
response while present without
complement activation.
• 85% of pts given antithymocyte antibodies for
bone marrow failure.
• 40-80% of pts given anti venom for snake bite
• 1.5% of pts given diphtheria antitoxin have
serum sickness.
• Remicade 25% if long delay between
infusions. 3% if continuous.
• DDx - viral - more oral lesions
•
- hypersensitivity and urticarial vasculitis
- vasculitic and low C
• - Rheumatic Fever - more joint swelling and other
features
• DGI and Meningococcemia - pustular lesions
• Reactive arthritis - more joint and mucous membrane
• E multiforme - palms and soles, target lesions
• Stevens-Johnson and toxic epidermal necrolysis vesicular lesions
• Still’s disease - rash
• Kawasaki’s - hand and foot swelling; more mucosal
• Personal observations on medicines:
• Prednisone is short acting; interferes
with sleep; more effective than
ibuprofen for systemic sx. Visual
hallucinations?
• Benadryl causes lethargy and spaced
feeling.