Case Conference. K. Myra Lalas PGY 3. CC: rash and joint pain. History of Present Illness. 2 days PTA, (+) itchy, reddish wheals on back then spread to torso, chest, and extremities Went to PMD and was prescribed Benadryl and Hydrocortisone, which gave some relief.
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K. Myra Lalas
CC: rash and joint pain
History of Present Illness
2 days PTA, (+) itchy, reddish wheals on back then spread to torso, chest, and extremities
Went to PMD and was prescribed Benadryl and Hydrocortisone, which gave some relief
On the day of admission, (+) swelling, redness, warmth, and pain of both knees ( R > L), ankles (R > L), L elbow
No morning stiffness, nails don’t turn funny colors when cold
Review of Systems
No cough or runny nose
No sick contacts
No recent travel
Past Medical History
Staghorn calculus s/p removal of stones in the right kidney 3/2010
No lupus, no JIA, no scleroderma
No childhood leukemia
Gen awake, alert, no acute distress
HEENT PERRL, oropharynx clear, no LAD, TM’s normal
Lungs clear to auscultation
Heart Normal S1/S2, no murmurs
Abdomen soft, nontender, no organomegaly
Ext L knee: (+) effusion, limited ROM secondary to pain
R knee: limited ROM secondary to pain
B/L ankles: erythema over lateral malleoli, no swelling, FROM
No nail changes
Skin multiple erythematous, pruritic papules on back, buttocks with some excoriations
Other drug reactions
Steven Johnson's Sydrome
Parvovirus B19 IgG and IgM (normal)
ASLO normal (25)
C4 28 C3 148
Lyme Ab titer 0.2 (normal)
CBC WBC 13.9 Hgb 12 Hct 35.4 platelets 429 N 52 L 43
Blood Culture negative
Urine culture negative
Na 136 K hemolyzed Cl 102 HCO3 20 BUN 9 Creatinine 0.6
glucose 117 Ca 9.8
albumin 4.1 TP 6.7
ALT hemolyzed AST 11
Alk phos 145
TB 0.2 DB 0
First described by von Pirquet and Schick. They described an illness that developed in some patients after they were given horse serum antitoxin for diphtheria and Scarlet fever. The illness developed a few weeks after administration of horse serum antitoxin.
Cardinal features: rash, fever, and polyarthralgias or polyarthritis, which begin 1-2 weeks after exposure to the responsible agent.
Type III Hypersensitivity Reaction
1. Immune complex formation
2. Complement activation
3. Complement- independent mechanisms
Immune complexes in tissues can react directly with Fc gamma receptors on neutrophils, mast cells, and phagocytes, leading to release of cytokines, histamine, and other inflammatory mediators even without complement.
May be caused by drugs, viral infections
Has different pathophysiology than serum sickness
Levels of circulating immune complexes and serum complement are often unaffected
Commonly implicated drugs: Cefaclor Penicillin (amoxicillin) Trimethoprim-sulfamethoxazole
Metabolites toxic to lymphocytes. The predisposing drug metabolism is genetically influenced.
May be caused by drug-specific immune complexes, not complexes with heterologous serum proteins.
Fever, when present, is typically low-grade.
Acute onset of joint pain, often leading to inability to walk
Discontinuation of the offending agent
Antihistamines for urticaria
Nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis, arthralgia, or both
Steroids (Prednisone or Methylprednisolone)- Patients with higher fever (eg, temperature >38.5ºC), more severe arthritis and arthralgias, or more extensive rashes including extensive vasculitic rashes may be treated with short courses of glucocorticoids.
Brucculeri, M. et al. Serum sickness-like reaction associated with cefazolin. BMC Clin Pharmacol. 2006; 6: 3.
Hay Jr., W. et al. Current Pediatric Diagnosis and Treatment, 15th ed. McGraw-Hill. 2001: pp. 958-960.
A. A patient should not receive a second dose of epinephrine unless a clinician is presentB. Epinephrine reaches higher peak plasma concentrations if injected into the thigh rather than the armC. Families should keep one epinephrine autoinjector in the car in case a reaction occurs after schoolD. Skin manifestations (eg, flushing, itching, urticaria) are rare in severe anaphylaxisE. Subcutaneous injection of epinephrine is preferable to intramuscular injection
In the past, outpatient administration of epinephrine was subcutaneous, but research has demonstrated that intramuscular injection, specifically in the thigh, is the preferred route and location due to higher and faster peak plasma concentration. If epinephrine is administered, parents or school should call emergency services to evaluate the child and transport him or her to the ER for further evaluation. The effects of a single dose of epinephrine typically last for 5 to 15 minutes; up to 20% of individuals experiencing anaphylaxis may require a second epinephrine dose. When symptoms persist, a second (or third) dose should be administered, even if the parent or school professional still is awaiting the ambulance.