Prof DR Dr Ariyanto Harsono SpA(K) 1SERUM SICKNESSProf DR Dr Ariyanto Harsono SpA(K)
Prof DR Dr Ariyanto Harsono SpA(K) 2Difinition• Serum sickness is a hypersensitivity vasculitis due toforeign objects.Etiology• Which often is the cause of horse serum proteins,for example, is ADS and ATS. In addition to theforeign serum proteins (horse serum), allergymedications such as penicillin, amoxicillin,cefachlor, insect stings, human gamma globulin,although rarely can cause "serum sickness-like"syndrome.
PathogenesisSerum sickness is a classic example of the typeIII hypersensitivity. Antigen-antibodycomplexes are formed, occurs in a state ofexcess antigen are trapped in small bloodvessels.3Prof DR Dr Ariyanto Harsono SpA(K)
Prof DR Dr Ariyanto Harsono SpA(K) 4• Small size of immune complexes circulating in theblood without any harm, big immune complexeswere drived into RES later destroyed, while themedium having deposits in blood vessels. Thesedeposits cause tissue damage through theactivation of complement and granulocytes. C5, 6,7causes neutrophil chemotaxis and adherence ondeposit. Mast cells activated by IgE serum that isformed against foreign protein and anafilaktosin(C3a). Tissue injury occurs due to proteolyticenzymes and oxygen radicals from neutrophils.
Type III HypersensitivityProf DR Dr Ariyanto Harsono SpA(K) 5
Clinical Manifestations• Clinical symptoms arise 7-12 days after the injectionof foreign serum, in some cases it can occur after 3weeks. Faster initial symptoms occur when there isexposure prior to the beginning of the same serumpreviously. A few days before the generalsymptoms 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.6Prof DR Dr Ariyanto Harsono SpA(K)
Prof DR Dr Ariyanto Harsono SpA(K) 7Erythema was also found on the dorsum of thefoot-plantar dorsolateral border. In somepatients the erythema turned into petechiae,echimosis, probably due tohrombocytopenia.
Other symptoms:swollen,myalgia,lymphadenopathy, especially the area aroundthe injection,some joint pain,stomach-ache,nausea diarrhea, and melena.Before it gets better, the symptoms often getworse. These symptoms are self-limited in 1-2weeks.Prof DR Dr Ariyanto Harsono SpA(K) 8
Prof DR Dr Ariyanto Harsono SpA(K) 9First sign is rash
Prof DR Dr Ariyanto Harsono SpA(K) 10More erythema and rashes develop over the body
Followed by stiffness of joints, red eyes, ulcers in the mouthProf DR Dr Ariyanto Harsono SpA(K) 11
Day 3. Symptoms worsen, erythema turned intopetechiae, echimosis, probably due tothrombocytopenia.Prof DR Dr Ariyanto Harsono SpA(K) 12
Day 4. Symptoms is dramatically improved.Prof DR Dr Ariyanto Harsono SpA(K) 13
ComplicationAlthough rare, can occur:CarditisGNAGBSPeripheral neuritis14Prof DR Dr Ariyanto Harsono SpA(K)
Examination/DiagnosisIn the peripheral bloodimmune complexes are found in 10-12 days.C3, C4 decreasedC3a increasedLED increasesthrombocytopenia15Prof DR Dr Ariyanto Harsono SpA(K)
Prof DR Dr Ariyanto Harsono SpA(K) 16UrineproteinuriaHaemoglobinuriamicroscopic hematuriaImmunologyEliza: IgG, IgM, IgA, IgE specific to foreign serumImunoflorescense: IgM, IgA, IgE, C3
ManagementSupportive:Antihistamines: Antihistamines such asgeneration 1 diphenhidramin 1 mg / kg / time,generation 2 for example Cetirizin <6 years ½tablet,> 6 years 1 tabletAnalgesicIn severe cases use high doses of corticosteroidsand then lowered the optimal dose.Methylprednisolone dose ranged from 0.8 to 1.1mg / kg / hr.17Prof DR Dr Ariyanto Harsono SpA(K)
PreventionThe use of human serum, such as botulinumimmune globuline for Botulism.If there is no human serum, skin testingshould be performed prior to administration.18Prof DR Dr Ariyanto Harsono SpA(K)
Prof DR Dr Ariyanto Harsono SpA(K) 19How to do skin test:use liquid histamine and saline controls. Performserum injection solution 1: 1000 by subcutanmaximum dose 0.2 ml. If negative it is safe toanaphylaxis, but can not guarantee to SerumSickness. 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 15-20minutes. After 4-6 hours of rest serum to be givenat once. Serum sickness can not be prevented withmethylprednisolone premedication.
Prognosis• Most serum sickness reactions are mild, anddisappear on their own after one or two weeks aslong as the cause is removed. Sometimes,symptoms of pain and discomfort may continue forseveral weeks, even after all the observablereactions such as skin rash and protein in the urinehave disappeared. In very rare cases, however,there can be severe and permanent damagereactions. In very rare but extreme cases, serumsickness can lead to shock, permanent kidneydamage, and even death.20Prof DR Dr Ariyanto Harsono SpA(K)