Serum Sickness in El Salvador

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Serum Sickness in El Salvador
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• 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 LFTs at three weeks.

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• 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.

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• 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

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• Turbinafine - 1/2 life of 36 hours. Terminal
  elimination from serum takes 200-400 hours.
• 1-10 rate of hives,dermatitis, arthralgia,
  myalgia
• lt1 rate of angioedema, drug induced lupus, toxic
  epidermal necrolysis, liver failure and and
  Stevens-Johnson syndrome.

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• 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.

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• 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

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• Serum sickness like illness - not
  antigen-antibody and mostly urticaria and fever,
  arthralgias. Ceclor, anti-seizure meds, sulfas,
  strept and viral infections.
• Urticaria-arthralgia syndrome. Drugs act as a
  hapten and invoke direct antibody response while
  present without complement activation.

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• 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.

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• 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
• Stills disease - rash
• Kawasakis - hand and foot swelling more mucosal

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• 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.

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