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serum sickness; serum sickness-like reaction

Etiology: - foreign serum, non-human serum proteins - rabbit anti-thymocyte globulin - drugs (serum sickness-like reaction, amoxicillin, Augmentin) [3] - chimeric pharmaceutical monoclonal antibodies containing murine light & heavy chain variable regions & human constant region [2] -infliximab, rituximab Pathology: - systemic immune complex formation after administration of drug or foreign serum to patient (type 3 hypersensitivity) - mediated mainly by IgG - vascular, cutaneous, cardiac, renal & joint immune complex deposition may result Clinical manifestations: 1) symptoms may occur from days to 3 weeks after administration of offending agent - generally occurs within 7-14 days after administration of offending agent 2) fever 3) lymphadenopathy 4) splenomegaly (unlikely with serum sickness-like reactions) 5) pruritic rash, urticaria - described as 'serpinginous maculopapular eruptions' (NEJM) [5] 6) arthralgias 7) myalgias 8) serum sickness-like reactions less severe than serum sickness * typically 1-2 weeks for amoxicillin & Augmentin [2] Complications: 1) glomerulonephritis 2) hepatitis (uncommon) Differential diagnosis: - type B drug reaction - anthralgia uncommon - unlikely to occur with 1-2 weeks of drug administration [2] - delayed type hypersensitivity reaction: no fever or arthralgia [5] - pyrogenic reaction to antivenom - due to pyrogen contamination in manufacturing - occur within 1st hour of antivenom administration [5] Management: 1) symptomatic 2) glucocorticoids

General

type 3 hypersensitivity; immune complex hypersensitivity adverse drug reaction (ADR)

References

  1. Taber's Cyclopedic Medical Dictionary, FA Davis, Philadelphia, 1977
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 19. American College of Physicians, Philadelphia 1998, 2021
  3. NEJM Knowledge+ Question of the Week. Jan 31, 2017 http://knowledgeplus.nejm.org/question-of-week/1250/ - Lin B, Strehlow M. Images in emergency medicine. Serum sickness-like reaction to amoxicillin. Ann Emerg Med. 2007 Sep;50(3):350, 359. PMID: 17709052
  4. McNamara K, Hughes OB, Strowd LC. Cutaneous drug eruptions including serum sickness-like reaction, symmetrical drug-related intertriginous and flexural exanthema, and drug-induced lupus. Clin Dermatol. 2020 Nov - Dec;38:641-647. PMID: 33341198
  5. NEJM Knowledge+