Serum sickness-like reaction to cefuroxime: a case report and review of the literature

Journal of Drugs in Dermatology, July, 2007 by Rajani Katta, Vijayalaxmi Anusuri

Abstract

We report a case of a 34-year-old woman who received cefuroxime, a second-generation cephalosporin, as treatment for mastitis. She subsequently developed a serum sickness-like reaction (SSLR) with a generalized pruritic rash, joint pains, and fever. She improved upon treatment with systemic steroids. SSLR is well-described to cefaclor, a second-generation cephalosporin. However, there is a paucity of reports of SSLR to other cephalosporins such as this case.

Case Report

A 34-year-old Caucasian woman presented to the dermatology clinic with a 2-week history of mastitis. The patient was breast-feeding following delivery of her sixth child 7 weeks earlier. She had no other significant past medical history. She was treated with 500 mg of oral cefuroxime (Ceftin[R]) twice daily and had completed the 10-day prescribed course. Six days into the course of treatment, she developed a rash on the scalp, which generalized over a 5-day time span to involve extensive areas of the trunk, arms, legs, and face. The rash was very pruritic, and individual lesions, which lasted less than 24 hours, were migratory. The patient also complained of intermittent fevers to 101[degrees]F and joint pains of the elbows, knees, and smaller joints of the hands. She specifically denied wheezing or shortness of breath. Her other current medications included prenatal vitamins. At the time of her delivery, 7 weeks previous, she had received pain medications, but no antibiotics. Acetaminophen and diphenhydramine, which she had tolerated well in the past, were taken orally as needed for the rash. Her reported allergies included tetracycline, penicillin, and erythromycin, all of which had caused skin rashes. As the rash continued to worsen in extent and severity, even after the antibiotic was completed, she was treated with oral methylprednisolone for 3 days, then one dose of oral prednisone 30 mg without improvement. She was then referred to the dermatology clinic.

The patient was a thin woman who scratched frequently, but otherwise was in no apparent distress. Skin examination revealed multiple confluent and extensive blanching urticarial plaques with dermatographism on the arms, legs, trunk, and face. No mucosal erosions were present, and there was no edema of the face or extremities. No cervical, occipital, axillary, or inguinal lymphadenopathy was noted. Pulmonary and cardiac examination was unremarkable. She had no swelling or erythema of the joints. The elbows, knees, and joints of the hands exhibited full range of motion. Laboratory studies, including a complete blood count, comprehensive metabolic panel, urinalysis, erythrocyte sedimentation rate, and C3, C4, and CH50 were all within the normal limits.

She was diagnosed with a serum sickness-like reaction (SSLR) to cefuroxime and admitted for 100 mg of intravenous methylprednisolone daily and oral antihistamines. Her symptoms and rash improved within 24 hours, and she was discharged on an extended tapering dose of prednisone starting at 40 mg daily, in addition to oral hydroxyzine, oral doxepin, and topical emollients. She experienced slow but steady resolution of her symptoms over the following 4 weeks.

Discussion

SSLR is a specific type of drug reaction so named because of its clinical similarity to serum sickness. True serum sickness is a type III hypersensitivity reaction in which clinical signs and symptoms result from deposition of immune complexes in the skin, joints, and other organ systems. In contrast, SSLR is not associated with demonstrable circulating immune complexes. The reaction is acute, self-limited, and has been described in association with a variety of different medications. Although many drugs have been reported to cause SSLR, antibiotics are the major group of offending agents, particularly beta-lactam and sulfonamide antibiotics. (1,2)

In most cases, signs and symptoms appear about a week after initiation of therapy. (3) The most frequent finding is cutaneous involvement, typically in the form of erythema and urticarial lesions that are often migratory. In the series reported by Hebert et al, many of the urticarial wheals had dusky to purple centers, which were morphologically suggestive of erythema multiforme (EM). (3)

The other primary clinical feature is joint involvement. Pain and swelling of the joints is a typical finding, and is usually polyarticular. Affected joints commonly include wrists, ankles, hips, and knees, (2,3) which can become so severe that patients are unable to walk. (2)

Although fever may occur, other systemic findings are less common. In contrast to true serum sickness, renal and hepatic involvement is rare.

Despite the impressive cutaneous findings and joint symptoms, a hallmark of SSLR is the benign outcome, although some patients do require hospitalization due to their severe symptoms. Treatment is typically symptomatic, usually with antihistamines and analgesics. The use of systemic corticosteroid treatment has been described in retrospective medical record reviews (4) and in a number of case reports, although there is no accepted standardized therapy. Reports of SSLR describe benign outcomes with no sequelae. (2,3,5)