[The effect of on-demand glucocorticoid strategy on the occurrence and outcome of p-ALG-associated serum sickness in aplastic anemia]

Objective: To investigate the effect of on-demand glucocorticoid strategy on the occurrence and outcome of porcine anti-lymphocyte globulin (p-ALG) -associated serum sickness in aplastic anemia (AA) . Methods: The data of AA patients who received in the Anemia Diagnosis and Treatment Center of Haematology Hospital, CAMS & PUMC from January 2019 to January 2022 were collected. Among them, 35 patients were enrolled in the on-demand group, with the glucocorticoid strategy adjusted based on the occurrence and severity of serum sickness; 105 patients were recruited in the usual group by matching the age and disease diagnosis according to 1∶3 ratio in patients who received a conventional glucocorticoid strategy in the same period. The incidences, clinical manifestations, treatment outcomes of serum sickness, and glucocorticoid dosage between the two groups were analyzed. Results: The incidences of serum sickness in the on-demand group and the usual group were 65.7% and 54.3% (P=0.237) , respectively. The median onset of serum sickness was the same [12 (9, 13) d vs the 12 (10, 13) d, P=0.552], and clinical symptoms and signs, primarily joint, and/or muscle pain, fever, and rash were similar. Severity grades were both dominated by Grades 1-2 (62.8% vs 51.4%) , with only a few Grade 3 (2.9% vs 2.9%) , and no Grades 4-5. No significant difference in the serum sickness distribution (P=0.530) . The median duration of serum sickness was the same [5 (3, 7) d vs 5 (3, 6) d, P=0.529], and all patients were completely cured after glucocorticoid therapy. In patients without serum sickness, the average dosage of prophylactic glucocorticoid per patient in the usual group was (469.48 ±193.57) mg (0 in the on-demand group) . When compared to the usual group, the average therapeutic glucocorticoid dosage per patient in the on-demand group was significantly lower [ (125.91±77.70) mg vs (653.90±285.56) mg, P<0.001]. Conclusions: In comparison to the usual glucocorticoid strategy, the on-demand treatment strategy could significantly reduce glucocorticoid dosage without increasing the incidence of serum sickness; in addition, the duration of serum sickness and the incidence of above Grade 2-serum sickness were similar.

Serum Sickness-Like Reaction in an Adolescent Taking Minocycline for Acne

We report a case of serum sickness-like reaction (SSLR) in a 14-year-old male taking minocycline for acne. The patient presented with urticarial rash, arthralgia/arthritis, and tender lymphadenopathy. Symptoms resolved with discontinuation of minocycline and treatment with prednisone, cetirizine, and ibuprofen. SSLR is a rare complication of minocycline treatment that may go unrecognized and underreported.

Adrenal insufficiency is a contraindication for omalizumab therapy in mast cell activation disease: risk for serum sickness

Omalizumab is an effective therapeutic humanized murine IgE antibody in many cases of primary systemic mast cell activation disease (MCAD). The present study should enable the clinician to recognize when treatment of MCAD with omalizumab is contraindicated because of the potential risk of severe serum sickness and to report our successful therapeutic strategy for such adverse event (AE). Our clinical observations, a review of the literature including the event reports in the FDA AE Reporting System, the European Medicines Agency Eudra-Vigilance databases (preferred search terms: omalizumab, Xolair®, and serum sickness) and information from the manufacturer’s Novartis database were used. Omalizumab therapy may be more likely to cause serum sickness than previously thought. In patients with regular adrenal function, serum sickness can occur after 3 to 10 days which resolves after the antigen and circulating immune complexes are cleared. If the symptoms do not resolve within a week, injection of 20 to 40 mg of prednisolone on two consecutive days could be given. However, in MCAD patients whose adrenal cortical function is completely suppressed by exogenous glucocorticoid therapy, there is a high risk that serum sickness will be masked by the MCAD and evolve in a severe form with pronounced damage of organs and tissues, potentially leading to death. Therefore, before the application of the first omalizumab dose, it is important to ensure that the function of the adrenal cortex is not significantly limited so that any occurring type III allergy can be self-limiting.

Serum sickness (Like Reaction) in a patient treated with alemtuzumab for multiple sclerosis: A case report

BACKGROUND

Alemtuzumab is a monoclonal antibody approved for relapsing-remitting multiple sclerosis (RRMS). The only report of Serum Sickness (SS) in a MS patient occurred during treatment with natalizumab. Non-protein drugs, such as some antibiotics, may induce "SS-like" reactions (SSLR), whose clinical and laboratory features may partially overlap with the traditional SS.

OBJECTIVE

To report a case of SS/SSLR in a RRMS patient treated with alemtuzumab.

CASE REPORT

A 42-year-old-woman with RRMS developed SS/SSLR in the first week after the first alemtuzumab treatment. Concomitant medications included trimethoprim-sulfamethoxazole at low dose. Intravenous methylprednisolone therapy led to clinical resolution and normalization of serum inflammatory markers.

CONCLUSION

SS/SSLR should be considered in patients treated with alemtuzumab developing delayed fever, rash and arthralgia and differentiated with Infusion Associated Reactions (IARs) and infections.

Adverse reactions to snake antivenom, and their prevention and treatment

Antivenom is the mainstay of treatment of snakebite envenoming. However, adverse reactions to snake antivenom that is available are common in many parts of the world where snakebite is prevalent. Both acute (anaphylactic or pyrogenic) and delayed (serum sickness type) reactions occur. Acute reactions are usually mild but severe systemic anaphylaxis may develop, often within an hour or so of exposure to antivenom. Serum sickness after antivenom has a delayed onset between 5 and 14 days after its administration. Ultimately, the prevention reactions will depend mainly on improving the quality of antivenom. Until these overdue improvements take place, doctors will have to depend on pharmacological prophylaxis, where the search for the best prophylactic agent is still on-going, as well as careful observation of patients receiving antivenom in preparation for prompt management of acute as well as delayed reactions when they occur.

Serum sickness following treatment with rituximab

Serum sickness, an illness characterized by fever, rash, and arthralgias, can occur in patients who receive chimeric monoclonal antibody therapy. Rituximab, a B cell-depleting chimeric anti-CD20 monoclonal antibody, has been used with increasing frequency in the treatment of rheumatologic illnesses such as rheumatoid arthritis and systemic lupus erythematosus. Serum sickness has only rarely been reported following rituximab therapy. All prior reported cases have been in patients with autoimmune conditions. We describe a case of serum sickness in a patient treated with rituximab for mantle cell lymphoma. We also review the literature of rituximab-induced serum sickness.

Serum sickness and hepatitis B vaccine including review of the literature

HB vaccine is one of the most widely administered vaccines in the world. Its efficacy approaches 95 per cent. The majority of adverse reactions are generally mild, although there have been individual case reports of serious reactions since the vaccine has become commercially available. Here, a patient with a serum sickness-like reaction after her second HB immunization is reported. Review of the literature for reports of serious adverse reactions to the vaccine was also carried out.

Cyclosporin A reduces expression of adhesion molecules in the kidney of rats with chronic serum sickness

Treatment with cyclosporin A (CsA) improves proteinuria and reduces renal cellular infiltration in chronic serum sickness (CSS). We examined if these effects were associated with a reduced renal expression of CD54 and its ligands, interferon-gamma (IFN-gamma), tumour necrosis factor-alpha (TNF-alpha) and MHC class II molecules. We studied two groups of rats in which CSS was induced by daily injections of ovalbumin (OVA): a group treated with CsA (OVA.CsA group, n = 11) and a group that received no treatment (OVA.CSS group, n = 11). An additional group of five rats (control group) received only phosphate buffer. Immunostaining techniques were used to follow CSS and to study the expression of CD54, CD18, CD11b/c, IFN-gamma, TNF-alpha and MHC class molecules. Proteinuria (mg/24 h) was reduced from 248.2 +/- 73.1 (OVA.CCS group) to 14.5 +/- 13.1 with CsA treatment (P < 0.0001). The renal expression of CD54 and its ligands (CD18 and CD11b/c) was reduced by 50% to 75%. Correspondingly, there was a 60% to 85% reduction in the number of infiltrating leucocytes. The number of cells expressing TNF-alpha, IFN-gamma and MHC II molecules was also reduced. CsA reduces expression of CD54 and its ligands. This effect is associated with a reduction of cellular infiltration, IFN-gamma, TNF-alpha-producing cells and with MHC II expression in the kidney. These findings suggest that expression of adhesion molecules plays a critical role in CSS and underline the importance of cellular immunity in this experimental model.

Selection of treatment of cefaclor-associated urticarial, serum sickness-like reactions and erythema multiforme by emergency pediatricians: lack of a uniform standard of care

BACKGROUND

Serum sickness-like reactions (SSLR) and erythema multiforme are common adverse effects of cefaclor therapy and can be associated with significant morbidity. No standardized evidence-based protocol for the optimal treatment of drug-induced SSLR exists.

OBJECTIVES

To define the standard of care used by physicians treating adverse reactions associated with cefaclor.

METHODS

A retrospective review of the medical records of children discharged from a pediatric emergency room with a diagnosis of adverse events to cefaclor was conducted. Charts of patients were reviewed to determine which therapy was prescribed.

RESULTS

During the study period, 74 cases of adverse events attributed to cefaclor presented to the emergency department. SSLR were the most common pattern of adverse events seen (31 cases, 42%), followed by urticarial reactions (26 cases, 35%) and erythema multiforme (17 cases, 23%). An antihistamine was the treatment most often prescribed (88%) for erythema multiforme. Significantly more children with SSLR than with erythema multiforme or urticaria were treated with prednisone, either alone or in combination (P<0.05).

CONCLUSIONS

The treatment most often prescribed for serious cefaclor-associated erythema multiforme was an antihistamine. In the case of SSLR, an antihistamine and prednisone were most commonly used. Prospective randomized, controlled trials are needed to define the role of various therapeutic agents and to determine the optimal therapy for SSLR and other serious adverse drug reactions.

Serum sickness secondary to ciprofloxacin use

Although serum sickness-like reactions are uncommon, various drugs have recently been implicated to manifest the reaction. The following case report is of a possible serum sickness-like reaction secondary to ciprofloxacin use, a commonly prescribed antibiotic in the US. A 62-y-old female developed polyarthralgias, myalgia and a generalized urticarial rash following 5 d use of ciprofloxacin. On admission to the hospital, patient was placed on cefazolin and gentamicin for suspected bacteremia. However, the regimen was discontinued after 72 h because of worsening clinical condition. Patient was placed on iv methylprednisolone therapy, and within 18 h a significant improvement was noted in her myalgias and rash. Over the next 72 h the steroid therapy was changed to a po regimen and the patient became asymptomatic 5 d after the initiation of steroid therapy. Patient was discharged on day 9 of hospital admission. Though serum sickness-like reactions have been reported with various drugs, only 1 case has been reported implicating ciprofloxacin. Clinicians should be aware of this potential adverse event secondary to ciprofloxacin use.

The three week sulphasalazine syndrome

We report a 53-year-old man with sero-negative rheumatoid arthritis who developed a fever, rash and hepatitis 3 weeks after starting sulphasalazine therapy. This was associated with a T cell lymphocytosis, eosinophilia and evidence of classical complement pathway activation. He responded to high dose corticosteroids. This is a rare but characteristic reaction which is likely to be encountered by rheumatologists more frequently with the increasing use of sulphasalazine. It should be recognized promptly as it may be fatal and can be confused with other systemic diseases.

The effect of cyclosporin A on disease progression in proliferative immune complex glomerulonephritis

In rats with the proliferative immune complex glomerulonephritis of chronic serum sickness, kidney function deteriorates in three discrete and readily distinguishable stages: Mild, Moderate, and Severe. The mononuclear cell composition of glomerular inflammation is also different in each stage. The immunosuppressive drug, cyclosporin A, was administered to rats with chronic serum sickness in order to investigate the relationship between glomerular immunopathology and pathophysiology in proliferative immune complex nephritis. When introduced after the onset of proteinuria, daily treatment with cyclosporin A failed to prevent the progression from Moderate to Severe nephritis, which is characterized by the abnormal differentiation and local proliferation of glomerular macrophages, as well as grave deterioration in kidney function. In contrast, when cyclosporin A therapy started before the onset of proteinuria, the course of proliferative glomerulonephritis was altered significantly. Although the levels of proteinuria and macrophage accumulation that are characteristic of the Moderate stage of nephritis were not reduced, progression to Severe nephritis did not occur. The number of glomerular macrophages appeared to increase in two separate phases in this chronic serum sickness model of proliferative immune complex glomerulonephritis. The first phase, which coincided with the onset of proteinuria, did not require T cells and culminated only in moderate hypercellularity and proteinuria. The second increase in the number of glomerular macrophages, which was accompanied by the expression of abnormal macrophage phenotypes, was closely linked to the development of severe kidney insufficiency. The protective effect of cyclosporin A therapy was consistent with, although not conclusive proof for, the hypothesis that local T cell activation may contribute to the progression of proliferative immune complex glomerulonephritis. Since cyclosporin A can also directly influence the responses of macrophages and mesangial cells, the effect of the drug on the course of nephritis in this model might not be related to its immunosuppressive action.

Chronic serum sickness glomerulonephritis: heparin enhances the removal of glomerular antigen

Chronic serum sickness glomerulonephritis was induced in rats using 125I-labelled cationic bovine serum albumin as antigen. During the recovery period the animals were given protamine or polyethyleneimine (PEI), both of which are cationic, or heparin, which is anionic. A control group received saline. The cationic molecules were not shown to influence the rate of removal of antigen from the glomeruli, but heparin increased removal. In subsequent experiments this effect of heparin was confirmed, and a similar effect was demonstrated using low molecular weight heparin. These results indicate that large doses of heparin can enhance the removal of antigen from well-established glomerular deposits. Fibrin is not detectable in the glomeruli in this model, so this effect of heparin may be independent of its anticoagulant properties.

Complications of Crotalidae antivenin therapy

Polyvalent antivenin is the mainstay of treatment of serious snake envenomation. Its use, however, has been challenged as being unnecessary in minor envenomations and potentially hazardous due to allergic complications. Our institution routinely uses antivenin, and this report focuses on the allergic complications of this therapy. Forty patients with Crotalidae snake bites were evaluated and treated over a 7-year period. Twenty-six patients received a total of 507 vials of antivenin, the dose correlating with the clinical severity of envenomation. All patients were skin tested. Immediate hypersensitivity reactions occurred in six patients (23%). Cutaneous manifestations alone occurred in three of these patients, while systemic anaphylaxis occurred in three. Twenty patients were available for followup, and ten (50%) developed serum sickness. Skin testing was not reliable in predicting the development of immediate (anaphylaxis) or delayed (serum sickness) hypersensitivity reactions. Treatment of antivenin allergic reactions was uniformly effective, with no mortality, minimal morbidity, and no chronic sequelae.

Eastern massasauga rattlesnake bites

The Eastern massasauga rattlesnake is native to many Midwestern states. Although this rattlesnake is smaller in size than many other pit vipers, envenomation can still produce significant morbidity, particularly in children. Children bitten by Eastern massasauga rattlesnakes appear to do well with treatment programs consisting primarily of antivenom and blood component replacement.

Significant envenomation from a preserved rattlesnake head (in a patient with a history of immediate hypersensitivity to antivenin)

We present a case of significant envenomation from a severed, preserved rattlesnake head in a 22-year-old man. The patient was treated successfully with 15 vials of Crotalidae polyvalent antivenin despite a history of severe immediate hypersensitivity reaction to antivenin. The patient developed a mild case of serum sickness five days after antivenin infusion that was treated successfully with a course of steroids. The patient experienced complete recovery. This case demonstrates the hazard of even preserved snake heads and fangs.

Serum sickness syndrome

Numerous agents are known to cause serum sickness reactions. Although generally a benign disorder, serum sickness must be distinguished from various rheumatic and infectious disorders. The causative agent must be identified in order to avoid subsequent reactions. With the introduction of new drugs and biotechnically produced hormones and antibodies, new causes of serum sickness reactions are likely.

Severe systemic vascular necrosis in cyclosporin-treated rabbits with acute serum sickness

Rabbits given acute serum sickness (ASS) and treated with cyclosporin A (CyA) developed a severe, systemic vascular injury, which was not similar to that normally seen in ASS. Thirty-three NZW rabbits received a single intravenous injection of 250 mg/kg bovine serum albumen (BSA) with or without endotoxin (5 micrograms/kg), on day 0. Groups of rabbits were given intramuscular CyA as follows: 15 mg/kg/day from day -2 to +8, or 25 mg/kg/day from day -2 to +3 or day 0 to 5. Muscular arteries of the heart and splanchnic organs developed an arterial injury in which there was extensive fibrinoid necrosis of the vessel wall but little or none of the mononuclear cell reaction that is normally associated with the arteritis of ASS. A microvascular injury also occurred which led to interstitial haemorrhage in the gastric mucosa and multi-focal necrosis in the heart and liver. These lesions were seen with equal frequency in all groups of rabbits with serum sickness who received CyA, irrespective of whether they also received endotoxin. We suggest that CyA altered the host inflammatory response to the injury initiated by the BSA-anti-BSA immune complexes and this led to enhanced vascular injury. The inhibition by CyA of the perivascular cellular reaction suggests that this reaction may be mediated by T lymphocytes. This model should provide further insight into the pathogenesis of arteritis, as well as the mechanisms of cyclosporin toxicity.

Glomerular thrombosis and cortical infarction in cyclosporin-treated rabbits with acute serum sickness

Rabbits given acute serum sickness (ASS) and treated with cyclosporin A (CyA) developed glomerular capillary thrombosis and cortical infarction, lesions not seen in unmodified ASS. Thirty-three NZW rabbits received a single intravenous injection of 250 mg/kg bovine serum albumen (BSA) with or without endotoxin (5 micrograms/kg) on day 0. Groups of rabbits were given intramuscular CyA as follows: 15 mg/kg from day -2 to +8, or 25 mg/kg/day from day -20 to +3 or day 0 to 5. Signs of this renal injury were haematuria, transient proteinuria, glycosuria and oliguria and they occurred during the rapid phase of antigen elimination when immune complexes were being formed. Seventeen of the 33 rabbits developed glomerular capillary thrombi and 11 of 17 also had glomerular and tubular infarction. Electron microscopic examination showed that these lesions were associated with severe endothelial injury and platelet-fibrin-leucocyte thrombi. These changes were more severe in the groups given 25 mg/kg. The lesions were not seen in untreated rabbits and ASS, nor in normal rabbits given equivalent doses of CyA alone. A strikingly similar renal lesion has been seen in patients receiving CyA following bone marrow transplantation, and also in the haemolytic uraemic syndrome. The model we describe may be valuable for the study of the mechanisms of endothelial injury and thrombosis in the kidney.

Venomous snakebite in a patient allergic to horse serum

The management of snake envenomation is a clinical challenge. The definitive therapy, antivenin, is potentially harmful and should not be used indiscriminately. However, the morbidity and mortality from the envenomation usually outweigh any adverse reactions to the antivenin therapy. Most reactions can be divided into two general categories: type I (immediate hypersensitivity) reaction, which may be life-threatening, and the more common type III (immune complex) reaction characterized by serum sickness. It is vital to evaluate the patient's potential for developing adverse reactions from antivenin and to be prepared to provide appropriate therapy. The administration of epinephrine and antihistamines can be lifesaving in type I reactions, while steroids and antihistamines can ameliorate type III reactions.

Prolongation of the prodrome to acute hepatitis B infection by corticosteroids

A 56-year-old woman had rash, arthralgia, and lymphadenopathy. Prednisone therapy caused the symptoms to abate but not disappear. Medication was continued for almost eight weeks, during which time the symptoms persisted. While the patient was receiving therapy, serologic evidence of hepatitis B infection was noted. When prednisone therapy was stopped, the patient rapidly passed from the prodrome to typical, acute, icteric hepatitis. Prednisone may have suppressed normal immunologic responses to the hepatitis virus, resulting in persistence of the serum sickness-like state. Corticosteroids are not indicated in the treatment of the prodrome to hepatitis B infection.

Effects of high-dose i.v. steroid (pulse) therapy on acute serum sickness in rabbits

We investigated the effect of high doses (50 mg/kg/day) of i.v. methylprednisolone ("pulses") on a model of acute serum sickness in rabbits, using bovine serum albumen as antigen and endotoxin as an adjuvant. The pulses were given on 2 consecutive days at one of the following times during antigen elimination: Days 1 and 2, Days 5 and 6, and Days 8 and 9. Methylprednisolone did not alter antibody production, or the size of circulating immune complexes. Pulses given at any period inhibited the fibrinoid necrosis associated with arteritis, but did not otherwise lessen the histopathological changes. Pulses given on Days 1 and 2 or at the end of immune elimination on Days 8 and 9 increased proteinuria and haematuria, and tended to increase histopathological changes, whereas pulses given at the onset of immune elimination on Days 5 and 6 in contrast reduced haematuria, but had a variable effect on proteinuria and organ damage. In this model high-dose steroids produced no consistent amelioration of the disease, apart from reduced fibrinoid necrosis, and at some times there was a tendency for the disease to be exacerbated.

Prostaglandin E1 therapy of murine chronic serum sickness

We studied the effect of PGE1 in pharmacologic doses on immune complex-induced glomerulonephritis produced by daily intraperitoneal injections of apoferritin. Mice received one of the following injection schedules: apoferritin 4 mg/day, apoferritin 4 mg/day plus PGE1 200 microgram twice daily, saline, or PGE1 200 microgram twice daily. Administration of apoferritin alone resulted in mesangial cell proliferation in all 14 mice with crescent formation in nine. Evidence of subepithelial and mesangial immune complex deposition and a significant increase in urine protein excretion was found. Treatment with PGE1 resulted in a mild increase in mesangial cells in six of 14 mice. No mice developed crescents on this regimen. In addition, proteinuria was prevented, and there was a marked diminution of immune complex deposition. Antiapoferritin antibody was detected in the sera of mice from both groups. No alteration in lymphocyte response to mitogen or in vitro PGE1 suppression of blastogenesis was detected. Our results indicate that PGE1 therapy alters immune complex glomerulonephritis in this model of murine chronic serum sickness by reducing glomerular immune complex deposition. However, no difference in specific or nonspecific immunologic responses was detected.

The effects of defibrination with ancrod in experimental allergic glomerular injury

Quantitative studies of the effects of defibrination (with ancrod) have been undertaken in two forms of allergic glomerular damage, nephrotoxic serum nephritis and acute serum sickness in rabbits. No differences in intrarenal fixation of nephrotoxic antibody, complement activation or host antibody response were detected between defibrinated and untreated rabbits with nephrotoxic serum nephritis. Defibrination prevented intraglomerular fibrin deposition in this disease; but some glomerular damage as shown by a rise in blood urea and endothelial proliferation still occurred in defibrinated animals. No differences in immune elimination of BSA, circulating immune complex formation or intrarenal localization of immune complexes were noted in defibrinated animals with acute serum sickness. No intraglomerular fibrin deposition was detected in treated or untreated animals in this disease model. It is concluded that the protective effects of ancrod are directly related to defibrination, and not to any other modification of allergic events.