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Assistant Professor of Pharmacology, Pharmacovigilance Unit, National Research Institute of Tuberculosis and Lung Disease, Shaheed Beheshti University of Medical Sciences, Tehran, Iran
Assistant Professor of Clinical Pharmacy, Clinical Pharmacy Department, School of Pharmacy, Shaheed Beheshti University of Medical Sciences, Pharmacovigilance Unit, National Research Institute of Tuberculosis and Lung Disease, Shaheed Beheshti University of Medical Sciences, Tehran, Iran, fax 98 21 22678090, fahimi{at}nritld.ac.ir
Professor of Medicine, Division of Infectious Disease and Clinical Immunology, National Research Institute of Tuberculosis and Lung Diseases, Shaheed Beheshti University of Medical Sciences
Published Online, June 19, 2007. www.theannals.com, DOI 10.1345/aph.1K146
Case Report. A 47-year-old woman who presented with fever, heart rate 117 beats/min, weakness, lymphadenopathy, pruritic erythematous skin rash, swelling of the lips and tongue, and respiratory distress was admitted to our hospital. Ten days prior to the onset of these symptoms, the patient had been treated with oral cefuroxime and intramuscular ceftriaxone for suspected infection. Previous medications included ergotamine, propranolol, and diclofenac as needed for migraine headache. She had no known drug allergies. Multiple courses of cefuroxime had been taken previously by the patient without prescription or physician's order. The patient was a dentist and had access to cefuroxime.
Laboratory evaluation revealed slight elevation of alanine aminotransferase to 84 U/L (reference range 10-40). Blood cultures were negative. Chest X-ray showed bilateral alveolar infiltration in both lower lobes. Cardiac, pelvic, and abdominal exams (echocardiography and sonography) were unremarkable. An extensive rheumatologic and infectious disease workup was performed, and the results were found to be negative. The impression was that the patient had experienced an SSLR to cephalosporins. All drugs were discontinued and intravenous dexamethasone 8 mg, intravenous furosemide 20 mg, and oral loratadine 20 mg were administered. The next day, she was found to be febrile with respiratory distress. Intravenous dexamethasone and furosemide were increased to 8 mg 3 times daily and 40 mg once daily, respectively. On day 3, all clinical symptoms, including low-grade fever, weakness, lymphadenopathy, and pruritic skin rash, were resolved.
The patient was discharged with a prescription for 3 days of dexamethasone 8 mg daily. At follow-up 4 weeks later, her clinical symptoms were resolved and liver function values returned to baseline. Laboratory data showed white blood cell count 5.0 x 103/µLwith 39% polymor-phonuclear leukocytes, 42% lymphocytes, 9% monocytes, and 10% eosinophils. Serum complement level was within the normal range. Serum immunoglobulin E level was 54 IU/mL (reference range 0-200).
Discussion. Serum sickness is a type III hypersensitivity reaction caused by an immune complex-mediated reaction to heterologous antisera and other foreign proteins.3 Typical manifestations of SSLR include fever, malaise, and lymphadenopathy.2 Dyspnea with or without pulmonary infiltrates is a rare symptom.3 SSLR was suspected in our patient due to use of cefuroxime and/or ceftriaxone. Although the patient had been on other medications in the past, only cephalosporins have been associated with SSLR.4 The Naranjo probability scale indicated a probable relationship between the cephalosporin therapy and the development of SSLR in our patient.5
Multiple courses of antibiotics have been shown to be a risk factor and may increase the frequency of SSLR.2 Although no specific laboratory criteria are universally present or conclusively diagnostic of SSLR, liver transaminase levels may be transiently elevated.3 The patient's elevated liver enzymes may be a part of the drug reaction. The noncardiogenic pulmonary edema that developed and responded to steroid therapy was a rare and interesting clinical manifestation.
Footnotes
We thank Rocsanna Namdar PharmD BCPS, Assistant Professor of Clinical Pharmacy, University of New Mexico, for helpful assistance in the preparation of this manuscript.
References
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