Serum sickness is a type III hypersensitivity reaction caused by foreign antigens like horse serum proteins. It occurs when antigen-antibody complexes form in blood vessels, activating the complement system and causing tissue damage. Clinical symptoms appear 7-12 days after antigen exposure and include rashes, joint pain, fever, and organ involvement. Diagnosis involves detecting immune complexes, complement activation, and organ-specific markers. Treatment focuses on supportive care with antihistamines and corticosteroids to reduce symptoms. Prevention emphasizes human serum use and desensitization protocols when exposure is necessary.

1. Prof DR Dr Ariyanto Harsono SpA(K) 1
SERUM SICKNESS
Prof DR Dr Ariyanto Harsono SpA(K)

2. Prof DR Dr Ariyanto Harsono SpA(K) 2
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.

3. 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.
3Prof DR Dr Ariyanto Harsono SpA(K)

4. Prof DR Dr Ariyanto Harsono SpA(K) 4
• 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.

5. Type III Hypersensitivity
Prof DR Dr Ariyanto Harsono SpA(K) 5

6. 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.
6Prof DR Dr Ariyanto Harsono SpA(K)

7. Prof DR Dr Ariyanto Harsono SpA(K) 7
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.

8. 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.
Prof DR Dr Ariyanto Harsono SpA(K) 8

9. Prof DR Dr Ariyanto Harsono SpA(K) 9
First sign is rash

10. Prof DR Dr Ariyanto Harsono SpA(K) 10
More erythema and rashes develop over the body

11. Followed by stiffness of joints, red eyes, ulcers in the mouth
Prof DR Dr Ariyanto Harsono SpA(K) 11

12. Day 3. Symptoms worsen, erythema turned into
petechiae, echimosis, probably due to
thrombocytopenia.
Prof DR Dr Ariyanto Harsono SpA(K) 12

13. Day 4. Symptoms is dramatically improved.
Prof DR Dr Ariyanto Harsono SpA(K) 13

14. Complication
Although rare, can occur:
Carditis
GNA
GBS
Peripheral neuritis
14Prof DR Dr Ariyanto Harsono SpA(K)

15. Examination/Diagnosis
In the peripheral blood
immune complexes are found in 10-12 days.
C3, C4 decreased
C3a increased
LED increases
thrombocytopenia
15Prof DR Dr Ariyanto Harsono SpA(K)

16. Prof DR Dr Ariyanto Harsono SpA(K) 16
Urine
proteinuria
Haemoglobinuria
microscopic hematuria
Immunology
Eliza: IgG, IgM, IgA, IgE specific to foreign serum
Imunoflorescense: IgM, IgA, IgE, C3

17. 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
Analgesic
In 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.
17Prof DR Dr Ariyanto Harsono SpA(K)

18. 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.
18Prof DR Dr Ariyanto Harsono SpA(K)

19. Prof DR Dr Ariyanto Harsono SpA(K) 19
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.

20. 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.
20Prof DR Dr Ariyanto Harsono SpA(K)

21. Prof DR Dr Ariyanto Harsono SpA(K) 21
Thank you