Serum sickness

Definition

Serum sickness is a type of delayed allergic response, appearing four to 10 days after exposure to some antibiotics or antiserum, the portion of serum that contains antibodies, such as gamma globulin, which may be given to provide immunization against some diseases.

Description

Serum sickness is very similar to an allergic reaction. The patient's immune system recognizes the proteins in the drug or antiserum as foreign proteins, and produces its own antibodies to protect against the foreign proteins. The newly formed antibodies bind with the foreign protein to form immune complexes. These immune complexes may enter the walls of blood vessels where they set off an inflammatory reaction.

While other types of allergic reactions may produce a rapid response, the serum sickness reaction is delayed because it takes time for the body to produce antibodies to the new protein.

Causes and symptoms

The usual symptoms are severe skin reactions, often on the palms of the hands and soles of the feet. Fever, sometimes as high as 104o F, is always present and usually appears before the skin rash.

Joint pain may be reported in up to 50% of cases. This is usually seen in the larger joints, but occasionally the finger and toe joints may also be involved.

Swelling of lymph nodes, particularly around the site of the injection, is seen in 10-20% of cases. There may also be swelling of the head and neck.

Urine analysis may show traces of blood and protein in the urine.

Other symptoms may involve the heart and central nervous system. These may include changes in vision, and difficulty in movement. Breathing difficulty may occur.

Traditionally, antitoxins were the most common cause of serum sickness, but those reports date from a time when most antitoxins were made from horse serum. As many as 16% of the people who received antirabies serum derived from horses developed serum sickness. The risk of a reaction to antitoxins has dropped dramatically since manufacturers have started using human serum instead of horse serum to make their products.

Although antitoxins are the most common cause of serum sickness, a number of drugs have been reported to cause a serum sickness reaction. The following list is not complete, but indicates some of the drugs that have been associated with this type of reaction:

• allopurinol (Zyloprim)

• barbiturates

• captopril (Capoten)

• cephalosporin antibiotics

• griseofulvin (Fulvicin, Grifulvin)

• penicillins

• pehnytoin (Dilantin)

• procainamide (Procan SR, Procanbid, Pronestyl-SR)

• quinidine (Quinaglute, Quinidex, Quinora)

• streptokinase (Streptase, Kabikinase)

• sulfonamide antibacterial drugs

Of cases of serum sickness reported to the United States Food and Drug Administration, the drugs most commonly associated with the reaction have been the cephalosporin antibiotics, including cefaclor (Ceclor) and cefalexin (Keflex) and the sulfonamide combination trimethoprim-sulfamethoxazole (Bactrim, Septra.) This does not mean that these are high-risk drugs, since these drugs are very widely used, so that there are many people exposed to them.

In addition to these substances, allergenic extracts used for testing and immunization, hormones, and vaccines have been known to cause serum sickness.

Diagnosis

Diagnosis is made by observing the symptoms and reviewing the patient's medical and medication history. Although the symptoms of serum sickness may be similar to other conditions, patients who present with symptoms of serum sickness and who have a recent history of exposure to a drug or other product which may cause this type of reaction should be suspected of having serum sickness.

Treatment

The first step in treatment of serum sickness is always to discontinue the drug or other substance which is suspected of causing the reaction. After that, all treatment is symptomatic. Antihistamines, pain relievers, and corticosteroids may be given to relieve the symptoms. The choice of treatment depends on the severity of the reaction.

Prognosis

Most serum sickness reactions are mild, and disappear on their own after one or two weeks as long as the cause is removed. Sometimes, symptoms of pain and discomfort may continue for several weeks, even after all the observable reactions such as skin rash and protein in the urine have disappeared. In very rare cases, however, there can be severe reactions and permanent damage. In very rare but extreme cases, serum sickness can lead to shock, permanent kidney damage, and even death.

Prevention

The most effective method of prevention is simple avoidance of antitoxins that may cause serum sickness. If patients have had a reaction in the past, particularly if the reaction was to a commonly used drug, they should be made aware of it, and be advised to alert physicians and hospitals in the future. Patients who have had particularly severe reactions may be advised to wear identification bracelets, or use other means to alert health care providers.

When it is necessary to administer an antitoxin, skin tests may be used to identify people who are at risk of a reaction. If the situation does not allow enough time for skin testing, the antitoxin should be given along with an intravenous antihistamine. Other drugs, such as epinephrine, which may be needed for an emergency, should be available.

Key Terms

Allergy

Altered body reaction, usually hypersensitivity, as a response to exposure to a specific substance.

Antibody

Any of a large number of proteins that are produced after stimulation by an antigen and act specifically against the antigen in an immune response.

Antihistamine

A drug that inhibits the actions of histamine. Histamine causes dilatation of capillaries, contraction of smooth muscle, and stimulation of gastric acid secretion.

Antitoxin

An antibody that is capable of neutralizing the specific toxin (a specific cause of disease) that stimulated its production in the body and is produced in animals for medical purposes by injection of a toxin or toxoid with the resulting serum being used to counteract the toxin in other individuals.

Serum

The clear yellowish fluid that remains from blood plasma after fibrinogen, prothrombin, and other clotting factors have been removed by clot formation-called also blood serum.

Sulfonamide

A sulfa drug, one of a large group of drugs used to treat bacterial infections.

For Your Information

Books

• 1999 Year Book: Allergy and Clinical Immunology. Saint Louis: Mosby, Inc., 1999.

• Allergen Immunotherapy, 2nd ed. New York: Marcel Dekker, Inc., 1998.

• "Children at Rrisk from Medication Mistakes." Houston Chronicle, May 18, 2001.

• "Drug allergies." Pediatrics for Parents 18 (2000): 1.

• Fielding, Jonathan. "Our Health; Drug Reactions Differ From Side Effects." The Los Angeles Times, February 7, 2000

• "VA Hospitals Test Smart Cards for Patient I nformation." Computerworld (May 14, 2001).

• Action Against Allergy (AAA). PO Box 278, Twickenham Middlesex, Greater London TW1 4QQ, England.

• American Allergy Association (AAA). 3104 E Camelback, Ste. 459 Phoenix, AZ 85016.

Source: Gale Encyclopedia of Medicine, Published December, 2002 by the Gale Group

The Essay Author is Samuel D. Uretsky PharmD.

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