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SERUM SICKNESS

Prof DR Dr Ariyanto Harsono SpA(K)

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Difinition• Serum sickness is a hypersensitivity vasculitis due to

foreign objects.

Etiology• Which often is the cause of horse serum proteins, for

example, is ADS and ATS. In addition to the foreign serum proteins (horse serum), allergy medications such as penicillin, amoxicillin, cefachlor, insect stings, human gamma globulin, although rarely can cause "serum sickness-like" syndrome.

Pathogenesis

Serum sickness is a classic example of the type III hypersensitivity. Antigen-antibody complexes are formed, occurs in a state of excess antigen are trapped in small blood vessels.

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• Small size of immune complexes circulating in the blood without any harm, big immune complexes were drived into RES later destroyed, while the medium having deposits in blood vessels. These deposits cause tissue damage through the activation of complement and granulocytes. C5, 6,7 causes neutrophil chemotaxis and adherence on deposit. Mast cells activated by IgE serum that is formed against foreign protein and anafilaktosin (C3a). Tissue injury occurs due to proteolytic enzymes and oxygen radicals from neutrophils.

Type III Hypersensitivity

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Clinical Manifestations

• Clinical symptoms arise 7-12 days after the injection of foreign serum, in some cases it can occur after 3 weeks. Faster initial symptoms occur when there is exposure prior to the beginning of the same serum previously. A few days before the general symptoms arise, body temperature elevates, swollen and erythema at the injection site occur. Itching and rashes such as urticaria and skin morbili-form rash is a prominent symptom.

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Erythema was also found on the dorsum of the foot-plantar dorsolateral border. In some patients the erythema turned into petechiae, echimosis, probably due to hrombocytopenia.

Other symptoms: swollen, myalgia, lymphadenopathy, especially the area around

the injection, some joint pain, stomach-ache, nausea diarrhea, and melena. Before it gets better, the symptoms often get

worse. These symptoms are self-limited in 1-2 weeks.

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First sign is rash

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More erythema and rashes develop over the body

Followed by stiffness of joints, red eyes, ulcers in the mouth

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Day 3. Symptoms worsen, erythema turned into petechiae, echimosis, probably due to

thrombocytopenia.

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Day 4. Symptoms is dramatically improved.

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Complication

Although rare, can occur:CarditisGNAGBSPeripheral neuritis

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Examination/Diagnosis

In the peripheral bloodimmune complexes are found in 10-12 days.C3, C4 decreasedC3a increasedLED increasesthrombocytopenia

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UrineproteinuriaHaemoglobinuriamicroscopic hematuria

ImmunologyEliza: IgG, IgM, IgA, IgE specific to foreign serumImunoflorescense: IgM, IgA, IgE, C3

Management

Supportive:Antihistamines: Antihistamines such as

generation 1 diphenhidramin 1 mg / kg / time, generation 2 for example Cetirizin <6 years ½ tablet,> 6 years 1 tablet

AnalgesicIn severe cases use high doses of corticosteroids

and then lowered the optimal dose. Methylprednisolone dose ranged from 0.8 to 1.1 mg / kg / hr.

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Prevention

The use of human serum, such as botulinum immune globuline for Botulism.

If there is no human serum, skin testing should be performed prior to administration.

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How to do skin test: use liquid histamine and saline controls. Perform

serum injection solution 1: 1000 by subcutan maximum dose 0.2 ml. If negative it is safe to anaphylaxis, but can not guarantee to Serum Sickness. When the skin test positive at any dose, the serum granting the rapid desensitization, starting with a dose of 0.1 ml with dilution 1:100-1:100.000. 2X fold increased dose every 15-20 minutes. After 4-6 hours of rest serum to be given at once. Serum sickness can not be prevented with methylprednisolone premedication.

Prognosis• Most serum sickness reactions are mild, and

disappear on their own after one or two weeks as long as the cause is removed. Sometimes, symptoms of pain and discomfort may continue for several weeks, even after all the observable reactions such as skin rash and protein in the urine have disappeared. In very rare cases, however, there can be severe and permanent damage reactions. In very rare but extreme cases, serum sickness can lead to shock, permanent kidney damage, and even death.

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