Severe Coagulopathy after Ingestion of "Snake Wine".

BACKGROUND: This report describes a patient who developed coagulopathy after ingesting snake wine, which is an alcoholic libation containing an entire venomous snake. CASE REPORT: A 68-year-old man was admitted to the hospital 19 h after ingesting snake wine. The laboratory features upon admission included unmeasurable activated partial thromboplastin (aPTT) values, prolonged prothrombin time (PT) values, increased fibrinogen levels, modestly elevated fibrin degradation product and D-dimer values, uncorrected aPTT and PT values after a mixing test, and normal levels of aspartate transaminase and alanine transaminase. No pesticides, warfarin, or superwarfarin in the patient's blood or urine were detected. His coagulation profile normalized on the 6(th) day after admission after antivenom treatment. He was discharged 10 days later without sequelae. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The physician should be aware that ingesting snake wine may lead to systemic envenomation. As for coagulopathy, which may develop by ingesting snake venom, related laboratory findings may differ from the features observed after direct envenomation by snakebite.

Intestinal mucosal permeability of children with cefaclor-associated serum sickness-like reactions.

Although the serum sickness-like reaction (SSLR) in children after the administration of cefaclor has long been recognized, the exact mechanism of cefaclor-associated SSLR remains unclear. This study aims to investigate the association between intestinal mucosal permeability and cefaclor-associated SSLR in children. A total of 82 pediatric patients with upper respiratory tract infection following the cefaclor therapy was divided into cefaclor-associated SSLR positive group and negative group based on the presence or absence of SSLR after taking cefaclor, and 30 healthy volunteers served as control group. Urinary lactulose/mannitol (L/M) ratios and serum diamine oxidase (DAO) levels were determined in all cases on days 7, 9, 11, 13, and 15 after oral administration of cefaclor. The children in the control group were given the same measurements after enrollment in this study. From days 7 to 13, the urinary L/M ratio of children with cefaclor SSLR gradually increased and reached to the highest level of 0.38 ± 0.14 on day 13. Compared with the cefaclor-associated SSLR negative group and control group, urinary L/M ratios increased significantly in the cefaclor SSLR positive group on days 7, 9, 11, 13, and 15 after taking cefaclor, and serum levels of DAO following the treatment of cefaclor increased significantly in children with cefaclor SSLR on days 9, 11, 13, and 15. No significant difference in urinary L/M ratios and serum levels of DAO between SSLR negative group and control group through the entire experiment was observed. In conclusion, administration of cefaclor may induce SSLR in children by increasing the intestinal mucosal permeability and/or affecting the integrity of the intestinal mucosa. Determinations of urinary L/M ratios and serum DAO levels may be helpful for observing or predicting the occurrence of SSLR after administration of cefaclor, which will encourage physicians to proceed with extreme caution when prescribing cefaclor for pediatric patients.

Serum sickness in a patient with follicular lymphoma after rituximab and radioimmunotherapy with ibritumomab tiuxetan.

A previously healthy 47-year-old woman was treated for follicular lymphoma, grade III, with cyclophosphamide, adriamycin, vincristine, prednisone with rituximab (CHOP-R) followed by ibritumomab tiuxetan and rituximab. She developed a serum sickness-like illness during immunotherapy with fever, myalgias, arthralgias, and pleural and pericardial effusions. Despite anti-inflammatory therapies her symptoms persisted for 10 months before ultimate resolution. Her clinical course and literature are reviewed.

Delayed allergic reaction to natalizumab associated with early formation of neutralizing antibodies.

BACKGROUND: Natalizumab is a new therapeutic option for relapsing-remitting multiple sclerosis. As with other antibody therapies, hypersensitivity reactions have been observed. In the Natalizumab Safety and Efficacy in Relapsing-Remitting Multiple Sclerosis (AFFIRM) trial, infusion-related hypersensitivity reactions developed in 4% of patients, usually within 2 hours after starting the infusion. OBJECTIVE: To report a significant, delayed, serum sickness-like, type III systemic allergic reaction to natalizumab. DESIGN: Case report describing clinical follow-up and the serial measurement of antinatalizumab antibodies. PATIENT: A 23-year-old man with relapsing-remitting multiple sclerosis developed a fever, arthralgias, urticarial exanthema, and a swollen lower lip during several days after his second infusion of natalizumab. RESULTS: The patient developed a delayed, serum sickness-like, type III systemic allergic reaction to natalizumab. Five weeks after initiation of this therapy, he tested positive for antinatalizumab antibodies and exhibited persistent antibody titers 8 and 12 weeks later. His symptoms completely resolved with a short course of oral glucocorticosteroids. CONCLUSION: Clinicians and patients should be alert not only to immediate but also to significantly delayed substantial allergic reactions to natalizumab.

Severe serum sickness reaction to oral and intramuscular penicillin.

Serum sickness is a type III hypersensitivity reaction mediated by immune complex deposition with subsequent complement activation, small-vessel vasculitis, and tissue inflammation. Although the overall incidence of serum sickness is declining because of decreased use of heterologous sera and improved vaccinations, rare sporadic cases of serum sickness from nonprotein drugs such as penicillins continue to occur. Drug-induced serum sickness is usually self-limited, with symptoms lasting only 1-2 weeks before resolving. We report an unusual case of a severe and prolonged serum sickness reaction that occurred after exposure to an intramuscular penicillin depot injection (probable relationship by Naranjo score) and discuss how pharmacokinetics may have played a role. Clinicians should be familiar with serum sickness reactions particularly as they relate to long-acting penicillin preparations. Accurate diagnosis in conjunction with cessation of drug exposure and prompt initiation of antiinflammatory treatment with corticosteroids can produce complete recovery

Serum sickness-like reaction associated with cefazolin.

BACKGROUND: Although rare, serum sickness-like reactions have been documented to occur following the administration of many antibiotics. Cefazolin, a first generation cephalosporin, is a commonly prescribed antibiotic which is considered to be generally safe and well tolerated. There have been no prior reports linking this drug with sickness-like reactions. We report a probable case of serum sickness-like reaction following a single dose of cefazolin. CASE PRESENTATION: A 23 year old man with no significant past medical history was admitted to undergo a laparoscopic donor nephrectomy as part of a living-related renal transplant. One gram of intravenous cefazolin was administered perioperatively. The surgery was completed without complication and the remainder of his hospital course was uneventful. Ten days following discharge the patient developed fevers, painful and swollen joints, and a cutaneous eruption overlying his trunk and extremities. There was no evidence of systemic vasculitis. These clinical findings were most consistent with a serum sickness-like reaction. A brief course of corticosteroids and antihistaminergic therapy was initiated, and complete resolution of the patient's symptoms followed. The Naranjo probability scale indicated that this adverse drug event was probable. CONCLUSION: Serum sickness-like reaction may be associated with cefazolin therapy.

Adverse skin and joint reactions associated with oral antibiotics in children: the role of cefaclor in serum sickness-like reactions.

OBJECTIVE: To review presentations to Princess Margaret Hospital Emergency Department (PMH ED) with adverse joint and skin reactions associated with the use of oral antibiotics, to describe the clinical course of children with cefaclor-related serum sickness-like reactions (cefaclor SSLR) and compare these with cases reported to the Adverse Drug Reactions Advisory Committee (ADRAC). METHODS: Twelve-month retrospective review of presentations to a tertiary paediatric ED (42,000 visits annually) via an ED computer database search and review of medical charts of children presenting with joint or skin reactions. Telephone interviews were conducted with the caregivers of children with cefaclor SSLR. RESULTS: Adverse skin or joint reactions occurred in 150 children; 70 after cefaclor alone, 10 after cefaclor in combination with other antibiotics and 70 after other antibiotic courses. SSLR occurred in 44 children; 32 after cefaclor alone, five after cefaclor in combination with other antibiotics and seven after other single antibiotics. In children with cefaclor SSLR, otitis media was the most common indication (59.4%), another 18.8% had viral illnesses. Prolonged sequelae occurred in four children, a situation not previously reported. Sixty reports of paediatric cefaclor SSLR were made to ADRAC during the study period, none originated from PMH ED. CONCLUSIONS: Cefaclor was associated with 53.3% of oral antibiotic related skin and joint adverse reactions and 84.1% of SSLR. The indications for its use in paediatric illness require careful reconsideration. ADRAC data under-represents the incidence of cefaclor SSLR.

Glomerular proliferative activity and T lymphocyte infiltration in acute serum sickness.

Because hypercellularity is an important feature in acute serum sickness (AcSS), we quantified glomerular proliferation with immunoperoxidase staining using anti-proliferating cell nuclear antigen (PCNA Mab) and studied its relationship with lymphocyte infiltration (M108 Mab). AcSS was induced in 31 New Zealand White rabbits; group A (n = 14), with proteinuria, sacrificed 6-8 days after immunization; group B (n = 10), without proteinuria, sacrificed 6-7 days after immunization; group C (n = 7), sacrificed prior to development of AcSS. Four normal rabbits were included as controls. Intraglomerular proliferation (PCNA-positive cells/glomerular cross section) was increased in group A (12.2 +/- SEM, 1.84) but not in groups B (0.93 +/- 0.17) and C (0.37 +/- 0.05), which were similar to controls (0.66 +/- 0.06). Lymphocyte infiltration (lymphs/glomerular cross section) increased with time and was more prominent in rabbits with proteinuria (1.9 +/- 0.21, P < 0.001 vs controls). Lymphocyte infiltration was correlated with proliferative activity (Spearman correlation, r = 0.67, P < 0.0001). There was correlation between the severity of glomerular deposition of IgG and C3 and glomerular proliferation and proteinuria. These studies demonstrate a chronological association between lymphocyte infiltration and proliferative activity in AcSS.

Dietary fish oil supplementation exacerbates serum sickness nephritis in mice.

The effects of fish oil (FO) on immune complex nephritis induced by bovine serum albumin (BSA) were studied in female B10.Br mice. The mice were fed an experimental fat-free diet composed of either 10% FO, safflower oil (SO), or beef tallow (BT) as a lipid source throughout the study. Proteinuria was observed in 84% of the FO group (n = 19), 53% of the SO group (n = 19) and in 48% of the BT group (n = 19; p = 0.0217 vs. FO). The FO group showed a tendency toward more severe renal histologic changes than the SO and BT groups. The levels of anti-BSA antibody and circulating BSA-anti-BSA immune complexes were significantly higher in the FO group than in the SO and in the BT groups. Avidity of the anti-BSA antibodies showed a lower tendendy in the FO group. Prostaglandin E2 and thromboxane B2 productions by the renal cortex were much lower in the FO than in the other two groups. The ratios thromboxane B2/prostaglandin E2 were higher in the FO than in the BT group. These results suggest that FO oil supplementation leads to the deterioration of BSA-induced immune complex nephritis in mice due to the altered immune responses in association with suppressed prostanoid production.

Inducible osteonecrosis in a rabbit serum sickness model: deposition of immune complexes in bone marrow.

We established inducible osteonecrosis in a rabbit serum sickness model. Osteonecrosis with marrow necrosis could be induced by the intravenous injection of horse serum in two doses separated in time by a period of three weeks. In this model, osteonecrosis could be successfully produced in rabbit femoral metaphysis. The incidence of marrow necrosis was 45% (9 of 20 rabbits) and trabecular necrosis occurred in 6 of 20 rabbits (30%) at 7 days after the second injection of the horse serum. In bone marrow of the femoral metaphysis, extravasation of erythrocytes and the formation of micro-thrombi in arterioles were often observed in an early stage of the present model and both findings correlate well each other (p = 0.0001). Immune complexes could be demonstrated using immunohistochemistry in bone marrow of the femoral metaphysis as well as in glomeruli of the kidney. Extravasation of erythrocytes in bone marrow of the femoral metaphysis was observed in 8 of 12 (67%) cases with immune complex deposition in the sinusoidal space of the femoral metaphysis and in 12 of 21 (57%) cases with immune complex deposition in glomeruli of the kidney. Immune complex deposition both in the sinusoidal space of femoral bone marrow (p = 0.0385) and in glomeruli of the kidney (p = 0.0209) closely related to extravasation of erythrocytes and microthrombi in arterioles in the early stage of this model. Early microcirculatory injury (extravasation of erythrocytes and microthrombi in arterioles) adjacent to osteonecrosis could be induced by immune complex deposition in femoral bone marrow and might be predictable characteristics for the inducible osteonecrosis in the present serum sickness model. The important findings in this study were that early microcirculatory injury was closely related to the deposition of immune complexes in femoral bone marrow, and that early microcirculatory injury associated with immune complex deposition was located close to osteonecrotic regions.

The importance of cellular adhesion for mesangial cell proliferation in serum sickness nephritis of the rat: a co-culture study of glomerular macrophages and mesangial cells.

The role of cell-cell contact on activating mesangial cell proliferation by nephritic macrophage was investigated. Nephritic glomerular macrophages were obtained from serum sickness nephritis (SSN) rat kidneys at 14 days after the cessation of sensitization, when proliferating cells were most increased in the glomeruli in the course of the SSN. The effect of the nephritic macrophages on mesangial cell proliferation was greater than that of control by co-culture allowing cellular contact. However, nephritic macrophages did not enhance mesangial cell proliferation by co-culture without direct contact even though the nephritic macrophages were activated with lipopolysaccharides. Conditioned medium from co-culture of the nephritic macrophages and mesangial cells did not enhance mesangial cell proliferation. Anti-intercellular adhesion molecules (ICAM)-1 antibody inhibited mesangial cell proliferation by direct co-culture dose-dependently. From these results, cellular contact was important for stimulation of mesangial cell proliferation by macrophages and ICAM-1 participated in these interactions.

Induction of type 2 salivary cystatin in immunological and chemical kidney injury.

We have previously reported that isoproterenol induces type 2 salivary cystatin in both submandibular glands and kidney tubule cells of rats but not in any other organs examined. In the present study, we investigated whether this salivary protein is induced in other conditions that show kidney tubule injury. Immunocytochemistry, using a monospecific antiserum to this cystatin, revealed specific staining within the proximal tubule epithelium of the cortex as well as in the inner and outer stripe of the medulla of immunologically and chemically injured rats. Cystatin could not be detected in kidneys from healthy rats by means of immunocytochemistry. Weak staining was found in 3/3 kidneys of rats treated with turpentine and in 5/5 animals treated with potassium dichromate. In rats treated with puromycin, cystatin could not be demonstrated in 5/5 animals having proteinuria of less than 100 mg/24 h; however, moderate staining was observed in 4/5 puromycin-treated rats having proteinuria greater than 100 mg/24 h. In Heymann nephritis, cystatin was present in 7/31 kidneys with proteinuria lasting 6 to 15 weeks and in none (0/7) with proteinuria of shorter duration. Strong staining was also observed in 10/10 kidneys from rats with moderate-to-severe chronic serum sickness. This study shows that elaboration of type 2 cystatin in rats is not limited to salivary glands and, with our previous study, suggests that induction of this cysteine inhibitor may represent a local response to generalized tissue injury in both submandibular and renal tissues. These findings further demonstrate that induction of cystatin in salivary glands is not unique to these glands and suggest that induction of this cysteine proteinase inhibitor may represent a local response to tissue injury caused by diverse mechanisms.

Influence of subepithelial deposits on permeability of the glomerular capillary wall in serum sickness nephritis in the rat.

Serum sickness nephritis was induced in male Fisher rats by immunization with egg albumin (EA). Correlations of subepithelial deposits (SD) with size and charge barriers of the glomerular filter were investigated using native (NF) and cationized (CF) ferritin as tracer probes. In proteinuric animals large numbers of NF molecules perfused from the abdominal aorta were observed to cross the glomerular basement membrane (GBM) and enter SD. The concentration of NF molecules was higher in GBM segments with SD than in GBM segments without SD, and the concentration of these molecules was higher within SD than in the intervening GBM. In contrast, CF clusters were fewer in number in the lamina rara externa (LRE) of GBM segments with SD than in the GBM segments without SD. CF particles could not be observed within SD, even in the areas of podocyte detachment. It is suggested that permeability in GBM segments with SD increases and that the development of proteinuria in this model can be attributed to alterations in both charge- and size-selective barriers to glomerular filtration.

The effects of hyperfiltration on serum sickness glomerulonephritis in rats.

The effects of hyperfiltration induced due to unilateral nephrectomy on immunologically induced glomerular injuries were studied. Glomerulonephritis was induced in rats by sensitizing them with egg albumin as an antigen. Unilateral nephrectomy did not affect the removal rate of the antigen from the glomeruli in the rats, but accelerated the rate of the glomerular injuries after cessation of the immunologically induced glomerular inflammation. The histopathological features were characterized by sclero-adhesive lesions with aneurysmal dilatation and hyalinosis of the glomerular capillaries. The parietal epithelial cells extended from the Bowman's capsule with matrices to cover the denuded basement membrane and formed adhesions. The neighboring capillaries collapsed, and the sclero-adhesive lesions progressed. These findings indicate that hyperfiltration at the capillary level did not accelerate the recovery from glomerulonephritis, but induced glomerular sclerosis with adhesions and deteriorated the trivial glomerular injuries to produce similar focal segmental lesions.

High-molecular-weight kininogen is cleaved in active erythema multiforme.

Erythema multiforme (EM) is an inflammatory disorder of the skin, which may include mucous membrane involvement, that features target (iris) lesions. Mediators specifically involved in EM are not well characterized; its pathogenesis remains enigmatic. In this study, evidence for participation of kinins in the pathophysiology of inflammation in EM was investigated by assessing cleavage of high-molecular-weight kininogen (HMWK) in plasma. These data were compared with analyses of plasmas from patients with serum sickness, chronic idiopathic urticaria/angioedema, and from normal control subjects. Patients with EM demonstrated significant levels of circulating cleaved HMWK in plasma during active disease (p less than 0.01), which declined during remission/recovery. Plasmas from patients with EM obtained during active disease also demonstrated significant levels of 94 kd C1 inhibitor (p less than 0.01) and C1 inhibitor-kallikrein complexes. Patients with serum sickness and chronic idiopathic urticaria/angioedema did not demonstrate these findings and did not differ from normal control subjects (p = not significant). Although the kininogenase responsible for HMWK cleavage in EM has not been conclusively demonstrated, these findings suggest that HMWK cleavage resulted from activation of the contact system and that some of the manifestations of EM in selected patients may in part be accounted for by inflammatory and proinflammatory actions of kinins. Based on these preliminary findings, it will be important to establish whether or not HMWK cleavage in EM is a general finding in patients with this disorder. Further investigation is needed to characterize more clearly kininogenase activity and elucidate the possible role of kinin generation in EM.

Changes in the molecular sieve of the glomerular basement membrane of rats with chronic serum sickness.

In order to explore the pathogenic mechanism of proteinuria in glomerulonephritis, ultrastructural changes of the glomerular basement membrane were investigated in rats with chronic serum sickness induced by repeated intravenous injections of bovine serum albumin (experimental rats). Rats injected with saline served as controls. The animals were sacrificed and examined 13 weeks after treatment, when the mean urinary protein of experimental animals reached 206 mg/24h/100g body weight. Enhanced transcapillary passage of anionic ferritin was observed in experimental rats. Purified glomerular basement membranes of control and experimental rats were examined by electron microscopy after negative staining. The glomerular basement membrane of experimental rats had enlarged pores. The results suggest that an increase in the radius of glomerular pores may be responsible for proteinuria in glomerulonephritis.

Inherited glomerular properties and their role in the expression of various forms of experimental glomerular injury.

1. Glomeruli possess properties which vary between Lewis and DA strains of rat. 2. These properties may account for differences in the expression of various forms of experimental glomerular injury. 3. The difference in susceptibility to Heymann nephritis in the Lewis strain was confirmed. 4. Chronic serum sickness induced by cationic human serum albumin led to capillary loop deposits in Lewis rats, whereas DA rats had mesangial deposits of rat immunoglobulin G even in control kidneys. 5. Lewis rats developed proteinuria after infusion of the polycation hexadimethrine whereas DA rats did not. 6. DA rats developed greater proteinuria after injection of puromycin aminonucleoside. 7. These results support the hypothesis that an individual's susceptibility to different forms of glomerulonephritis may result from their glomerular properties and not necessarily from their immune responses.