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- Serum Sickness -
9/21/04 re: Delayed react ion to insect sting My wife was stung by a honeybee on the foot about 4 days ago. She initially developed the usual local reaction of erythema, pruritis, and swelling in the immediate area of the envenomation. Yesterday she awoke with a slightly pruritic, erythemetous, maculopapular rash with areas of confluence migrating throughout her trunk and extremities. She also has some palmar erythema and swelling of her hands as well as polyarthritis. Today she has complained of worsening malaise, some nausea and GI discomfort, and the rash appears to be worsening. We have not noted any fever. The references that I have read state that delayed reactions tend to occur 10 to 14 days following the envenomation and are usually accompanied by fever. She has been stung by bees several times in the past but has never experienced any systemic symptoms from them. Are these symptoms likely to be the result of the bee sting? If so, would oral steroids be indicated? Your description sounds like an atypical serum sickness reaction to me. Although serum sickness reactions typically start 7-10 days after the stimulus, it is conceivable that your wife's prior insect stings may have altered her immune responses to insect stings so that she started reacting a bit sooner. A mac-papular rash is not the typical skin manifestation of serum sickness (most commonly urticaria/angioedema). However, her rash could be part of a serum-sickness like reaction.
I see two issues that require attention:
1) Symptomatic treatment to control her present symptoms. I had sent word to you that the clinical picture you described would suggest the need for a 10-14 day tapered dose course of oral steroids (starting about 30-40 mg prednisone/day depending on her body size).
2) Determination in about 4-6 weeks after the recent sting whether she has IgE antibodies to any of the various hymenoptera venom allergens. This can be done by appropriate skin testing by a qualified allergist. However, if her recent sting reaction was severe, it may be preferable to obtain serum for in vitro testing for the IgE antibodies. Although such in vitro tests are now done in a number of commercial labs, my personal preference is the DACI labs under the auspices of Johns Hopkins Medical Institutions.
If your wife does have IgE antibodies against hymenoptera venom, I think that she would be at increased risk for an immediate anaphylactic-type reaction to a subsequent sting in the future. Therefore, appropriate avoidance measures, always carrying an up-to-date Epipen auto-injector syringe (instructed in its use) and strong consideration for treatment with venom immunotherapy would be appropriate. Your allergist consultant can assist in such an evaluation and treatment.
8/9/97 re: false diagnosis of serum sickness like syndrome A 9 month old atopic infant receiving Ceclor for a febrile upper respiratory infection developed a few urticarial and papular rashes around the knees after a week to 10 days. The parent got worried and took to several Pediatricians and Emergency room from where the infant was admitted to the hospital. The infant received an antihistamine, oral prednisone and tylenol. Also had a workup for infection. There was no immunological work up done. There was no history or finding of arthritis or arthralgia. Infant was in the hospital for a couple of days being observed and was described as playful and active. However, at the end of the hospitalization, a diagnosis of probable serum sickness was made. Is it a valid diagnosis? Is it proper to make a diagnosis of serum sickness in every case of urticaria if the child happens to be taking ceclor? The questioner raises several very important points. Over the years, I have seen many teen-agers and adults previously labeled as "penicillin-allergic" based upon a history similar to that described by the questioner. I agree that, in most cases, the rash described is most likely associated with the underlying viral infection. One would hope that education of primary care physicians and pediatricians about this situation would reduce the frequency of such "loose statements" about penicillin allergy as a cause of the rash. However, some practitioners may feel obliged to raise the possibility of an allergic reaction because they cannot prove that the rash was viral infection -related. Fortunately, allergists with appropriate skin testing materials can determine with fair certainty at a later date whether an individual has IgE antibodies against penicillin antigens and is at an increased risk of an immediate IgE-mediated reaction following treatment with penicillin
agents. Unfortunately, some of the skin testing materials (the "minor determinant" antigens) are not yet available for general clinical use. AThose allergists using them have "home-made" supplies. I suggest that you obtain consulatation with a certified allergist in your region, if needed. If you wish, you can obtain names of such allergisy-immunologists by calling the American Academy of Allergy, Asthma, and Immunology Executive Office at 1-800-822-2762.
