Serum sickness-like reaction to D-supplement: a case report.

BACKGROUND: Serum Sickness-Like Reaction (SSLR) is an immune response characterized by rash, polyarthralgias, inflammation, and fever. Serum sickness-like reaction is commonly attributed to antibiotics, anticonvulsants, and anti-inflammatory agents. CASE PRESENTATION: A 16-year-old female with a history of overactive bladder and anemia presented with a diffuse urticarial rash, headaches, joint pain, and swelling for three days. Her medications included oral contraceptive pills, iron, mirabegron, UQora, and a probiotic. Physical examination revealed a diffuse urticarial rash, and her musculoskeletal exam revealed swelling and tenderness in her wrists. She was evaluated by her pediatrician and started on a 7-day course of prednisone, as well as antihistamines. Her CBC, basic metabolic panel, liver function panel, Lyme titers, and urinalysis were all within normal limits. With concern for hypersensitivity reaction to medication, all medications were discontinued. Nine days after symptom onset, the patient was evaluated by an allergist, who confirmed her presentation was consistent with serum sickness-like reaction. Her symptoms resolved, and her medications were re-introduced sequentially over several months. Restarting UQora, however, triggered a recurrence of her symptoms, and it was identified as the culprit medication. Consequently, UQora was permanently discontinued, and the patient has remained symptom-free. CONCLUSIONS: This case report describes the first documented case of serum sickness-like reaction caused by UQora (active ingredient D-mannose). D-mannose is a monosaccharide, and it is frequently promoted to prevent urinary tract infections. While the clinical features and timeline in this case were typical of serum sickness-like reaction, UQora as the trigger was highly unusual. Clinicians should be aware of the diverse triggers of serum sickness-like reaction and the importance of prompt identification and management to enhance patient safety. Further research is necessary to better understand the potential therapeutic applications of D-mannose, as well as the potential risks and interactions.

Case Report: Use of Obinutuzumab as an Alternative Monoclonal Anti-CD20 Antibody in a Patient With Refractory Immune Thrombocytopenia Complicated by Rituximab-Induced Serum Sickness and Anti-Rituximab Antibodies.

Management of refractory immune thrombocytopenia frequently involves rituximab, a chimeric anti-CD20 monoclonal antibody, to target B cells and induce remission in most patients. However, neutralizing antibodies to rituximab that nullify therapeutic response and may lead to serum sickness have been rarely reported. Here, we present a case of a young adult woman with Evans syndrome treated with rituximab, complicated by the development of serum sickness, acute respiratory distress syndrome, and platelet refractoriness presumed secondary to neutralizing antibodies to rituximab. She was successfully treated with the humanized anti-CD20 monoclonal antibody, obinutuzumab, with subsequent symptom resolution. Additionally, a review of 10 previously published cases of serum-sickness associated with the use of rituximab for idiopathic thrombocytopenic purpura (ITP) is summarized. This case highlights that recognition of more subtle or rare symptoms of rituximab-induced serum sickness is important to facilitate rapid intervention.

Serum sickness reaction to obinutuzumab in a patient with chronic lymphocytic leukaemia.

Serum sickness (SS) is a known phenomenon; however, it is commonly missed due to vague symptoms, and is usually confounded by other aetiologies that present similarly. Obinutuzumab is a novel anti-CD20 antibody agent that has been approved for chronic lymphocytic leukaemia (CLL) treatment. At the time of approval, it was not linked to SS; however, this phenomenon has been recognised with other anti-CD20 agents like rituximab. SS remains a rare entity, but it is important to be recognised accurately and quickly in the appropriate circumstances, so that effective treatment with corticosteroids can be initiated to alleviate inflammatory symptoms. Here we present a patient with CLL who developed maculopapular rash, fever and polyarthritis and elevated inflammatory markers consistent with serum sickness triggered by obinutuzumab and was effectively treated with corticosteroids.

Serum sickness induced by alemtuzumab in a kidney-pancreas transplant recipient.

Serum sickness is an immune-complex-mediated hypersensitivity reaction that was first noted in the early 1900s in patients receiving heterologous antisera, such as horse antitetanus or antidiphtheria serum. This condition is primarily self-limited; however, in its acute state, it can cause severe symptoms of fever, rash, polyarthritis, or polyarthralgias. In solid organ transplantation, this condition is frequently reported in association with the use of rabbit anti-thymocyte globulin and chimeric murine monoclonal antibodies such as rituximab. Alemtuzumab, designed as a humanized monoclonal antibody against CD52, is expected to be less immunogenic. Here, we report a case of serum sickness associated with alemtuzumab induction therapy in a kidney-pancreas dual-organ recipient.

Rituximab-induced serum sickness and anaphylaxis in a child with nephrotic syndrome.

BACKGROUND: Rituximab is effective for treatment of children with refractory nephrotic syndrome (NS). However, the drug may cause serum sickness characterized by fever, rash, and arthralgia 10-14 days after primary antigen exposure or within a few days after secondary antigen exposure. Rituximab may also lead to anaphylaxis. It is important to recognize rituximab-induced serum sickness (RISS) clinically, as it may mimic various infectious or vasculitic diseases. CASE: A six-year-old male with NS treated with rituximab presented with diffuse arthralgia and myalgia eight days after the first dose. He developed an urticarial rash and arthralgia one week after the second dose, while he had swelling of lips and periorbital regions, choking sensation and erythematous rash in whole body within minutes after the third dose of rituximab. The first two reactions resemble typical serum sickness whereas the third reaction seem to be an anaphylaxis/anaphylactoid reaction. CONCLUSIONS: Although rituximab-induced serum sickness is typically self-limited, further infusions of rituximab should be avoided as it may provoke more severe symptoms. Most of the previous reported cases of RISS are patients with autoimmune or hematologic disorders. We present the first pediatric case with membranous nephropathy and RISS. The patient also developed anaphylactoid reaction during the third rituximab infusion.

Rituximab-induced serum sickness in a 6-year-old boy with steroid-dependent nephrotic syndrome.

Rituximab (RTX) is a murine-human chimeric monoclonal antibody against CD20 that has been proven effective for preventing relapse in frequently-relapsing or steroid-dependent nephrotic syndrome (NS). Serum sickness, a type-3 hypersensitivity reaction resulting from injection of foreign proteins, has been reported in patients treated with RTX. Herein, we describe a case of RTX-induced serum sickness (RISS) in a 6-year-old boy with steroid-dependent NS. He presented to the hospital with fever and polyarthralgia at 10 days after his fourth dose of RTX. Although he was started on empiric intravenous antibiotics, there was no evidence of septic arthritis and his symptoms resolved over the course of 4 days. He was diagnosed with RISS based on the chronology of RTX administration and the acute-onset self-limiting course of the polyarthritis. His serum human anti-chimeric antibody (HACA) level on day 53 exceeded the limit of quantification (5000 ng/mL). The pathogenesis of RISS and the role of HACAs remain unclear. It is important for clinicians to recognize RISS, because further infusions of RTX may cause more severe reactions in patients with a history of RISS.

Antivenin-associated serum sickness in a dog.

OBJECTIVE: To describe a case of documented serum sickness in a dog following administration of a single dose of a novel antivenin crotalidae polyvalent. CASE SUMMARY: A 4-year-old female neutered mixed breed dog developed recurrent signs of hypersensitivity (swelling, edema, urticaria/hives, gastrointestinal signs, vasculitis) at 1 and 2 weeks following administration of a single unit of a novel antivenin crotalidae polyvalent plasma product. Both episodes were treated with antihistamines and glucocorticoids and signs improved rapidly, with a prolonged course of glucocorticoids and antihistamines administered following the second occurrence. Diagnosis of serum sickness was based on clinical appearance of delayed hypersensitivity following exposure to novel biologic product, absence of other inciting cause of hypersensitivity, complement testing, and skin biopsies confirming vasculitis. NEW OR UNIQUE INFORMATION PROVIDED: This case documents the first report of delayed hypersensitivity with a novel antivenin plasma product. This is the only case report of serum sickness to a single unit of antivenin. Additionally, the dog developed recurrence of hypersensitivity following the initial episode at 1 week; appropriate identification and prolonged treatment could have prevented recurrence and additional hospitalization. Cost and benefit analysis should be considered with antivenin administration.

Rituximab-induced serum sickness is more frequent in autoimmune diseases as compared to hematological malignancies: A French nationwide study.

INTRODUCTION: Rituximab induced serum sickness (RISS) is a rare delayed hypersensitivity reaction. The aim of this study was to describe the epidemiological and clinical characteristics of the RISS cases reported in France. METHOD: Serum sickness cases involving rituximab were identified from the French PharmacoVigilance Database from 1998 to 2016. RESULTS: We analyzed 37 cases of RISS. Rituximab was prescribed for an autoimmune disease in 78% of cases. Serum sickness occurred mainly after the first injection (54%) with a median time to onset of 12 days. The most frequent manifestations were rheumatologic symptoms (92%), fever (87%), and skin lesions (78%). The incidence was significantly higher when rituximab was used for autoimmune diseases than for a hematological malignancies. Taking into account the existence of a Systemic Lupus Erythematosus (SLE) as the indication of rituximab or as a comorbidity, the incidence of RISS in patients with SLE was even higher. DISCUSSION: We report on the largest series of RISS studied to date and confirm that this reaction preferentially occurs in patients with autoimmune disease, especially SLE. This may be due to B-cell lysis, leading to the release of intracellular antigens into the serum and subsequent antigen-antibody complex formation, especially in patients with elevated autoantibody production. This could also explain why RISS often occurred after a single injection. CONCLUSION: Patients generally recovered from RISS rapidly without obvious benefit from corticosteroid therapy. The risk of recurrence should prompt clinicians to question the use of rituximab after an episode of RISS.

Efficacy and safety of etanercept for postoperative pyoderma gangrenosum after infliximab serum sickness.

Non-peristomal postoperative pyoderma gangrenosum (PPG) is a rare subtype of pyoderma gangrenosum that occurs in the early postoperative period at surgical incisions, most commonly after breast surgery. Early diagnosis and treatment is essential to prevent severe scaring. TNF-alpha inhibitor infliximab was reported to be efficient in treatment of PPG refractory to systemic corticosteroids. However infliximab can be not well tolerated. We report the first case of etanercept efficacy in post-plastic breast surgery pyoderma gangrenosum after infliximab serum sickness.

[Urticaria multiforme: difficult to distinguish from other skin conditions]. / Urticaria multiforme.

BACKGROUND: Urticaria multiforme is a rare clinical variant of urticaria that occurs specifically in children. CASE DESCRIPTION: A boy aged 11 months was presented at the Emergency Department with acute onset of itching urticarial skin weals and acral oedema. This picture is consistent with the diagnosis of urticaria multiforme. CONCLUSION: The diagnosis of urticaria multiforme can be made on the basis of the clinical picture. Treatment is symptomatic and in most cases this condition resolves spontaneously within two weeks. It is often confused with erythema exsudativum multiforme, urticarial vasculitis, a serum sickness-like reaction or acute haemorrhagic oedema of infancy (AHOI syndrome). As each of these clinical presentations involves specific treatment and prognosis, it is important to be able to distinguish between them.

Demographic and clinical characteristics of patients with serum sickness-like reaction.

In this study, we aimed to review the demographic, clinical, and laboratory characteristics of patients who were followed up and treated with the diagnosis of serum sickness-like reactions (SSLR) in our pediatric rheumatology clinic retrospectively and emphasize the importance of early diagnosis and treatment. The files of 29 patients who were hospitalized in the pediatric rheumatology clinic between September 2016 and March 2017 with the diagnosis of type 3 hypersensitivity reaction were reviewed retrospectively. Patient records including C-reactive protein, erythrocyte sedimentation rate, serum electrolytes, blood glucose, urea, and liver function were recorded by using the computerized patient database. The gender, age, length of hospital stay, accompanying clinical findings, family history of atopy, preceding infection, and drug usage data were obtained from the files of the patients. Twenty-nine patients with the diagnosis of type 3 hypersensitivity reaction were evaluated. Fifteen (51.7%) of the patients were male and 14 (48.3%) were female. The male to female ratio was 1.07. The age distribution of patients ranged from 18 to 192 months (mean ± SD 100.66 ± 53.75 months). The hospitalization duration was 3-16 days (mean ± SD 5.14 ± 3.20 days). The use of many drugs, especially antibiotics, has increased even in the treatment of viral upper air way infections. As a result, side effects have also increased. The most important of these is SSLR. However, this disease is not well recognized by clinicians.

Presumed serum sickness following thymoglobulin treatment of acute cellular rejection of a cardiac allograft.

Serum sickness is a hypersensitivity reaction to proteins in antiserum derived from nonhuman animal sources and can be seen in patients being treated with antiserum to prevent transplant rejection. Serum sickness may display variable clinical presentations. Because cutaneous findings may be the initial symptom in some cases, it is important for dermatologists to be able to recognize this condition given its potentially life-threatening symptoms. We present a case of a 35-year-old man with presumed serum sickness after receiving thymoglobulin for the treatment of acute cellular rejection of a heart transplant. The clinical presentation, laboratory findings, and treatment options are reviewed.