Red Man Syndrome

 

Background

This week while on rounds at work, one of the differential diagnoses that was mentioned for a patient on our list, was Red Man Syndrome. The patient had Stevens-Johnson syndrome, which I had learned about in respiratory school, but I had never heard of Red Man syndrome before. Being curious, here’s what I learned when I inquired further about red man syndrome.

Introduction

Vancomycin is an antibiotic that is commonly used to fight various infections. However, like all

medications, vancomycin administration is not without risk. Vancomycin can cause two types of hypersensitivity reactions:

• red man syndrome
• anaphalyxis reaction

Signs

Some of the signs associated with red man syndrome include the following:

• puritis
• erythematosus  rash on the face and neck
• some less frequently seen signs are

o   hypotension

o   angioedema

Symptoms

• patient c/o diffuse burning and itching
•  discomfort
• dizzy
• agitated
• headache
• chills and fever
• parasthesia around the mouth
• in severe reactions:

o   chest pain

o   difficulty breathing

Timing of Signs and Symptoms
signs and symptoms typically present 4-10 minutes after infusion of Vancomycin or soon after completion of the medication infusion typically associated with rapid I.V. infusion (< 1 hour) after first infusion of Vancomycin. To help avoid such potentially harmful reactions associated with Vancomycin, most hospitals has as their protocol, to infuse at 60 min. as a minimum. Any rate of infusion faster than that, places patients at risk for reaction

Links

Red man syndrome has also been linked to administration of Vancomycin when given via intra-peritoneal route or orally. In years past, red man syndrome was thought to be caused by the impurities seen in Vancomycin preparations and earned its name, “Mississippi Mud”.

Reaction mechanism

• mast cell degranulation
•  IgE and complement involvement

Summary

• Vancomycin should be given over at least one hour interval.  Longer infusion times should be used if giving larger doses  (Vancomycin > 1 gram)
• Vancomycin better tolerated when given in smaller, frequent doses
• If unable to give over prolonged infusion times, pretreatment with antihistamines combined with H₂ antagonist can be protective

Reference:

1. Sivagnanam, S., Deleu, D. Red man syndrome. Crit Care 2003, 7: 119-120.

Procalcitonin: What is its value clinically?

Introduction

This week at work we had a patient that presented to the ICU from an outside hospital. The patient had an anaphylactic reaction that caused the upper airway to be compromised. The team at the outside hospital tried to intubate the patient, but was unsuccessful. The patient required an emergency tracheotomy, and was subsequently transferred to a tertiary facility. During my rounds, I noticed that the Procalcitonin (PCT) level on admission was 7.1. Not being familiar with PCT, I decided to investigate what Procalcitonin was, how useful the biomarker is clinically, and how it is used to help guide care for the patient. In other words, I wanted to answer the question; what is the utility of Procalcitonin, clinically? Here’s what I found out.

Procalcitonin is a prohormone precursor of calcitonin that is expressed mainly in C cells of the thyroid gland. The conversion of Procalcitonin is inhibited by different cytokines and bacterial endotoxins. The main utility of Procalcitonin is to establish the presence of bacterial infections, because serum Procalcitonin levels rise and fall sharply in bacterial infections. In a healthy person, PCT levels are typically very low.

When is PCT of any value?

Procalcitonin has some limitations and its utility is variable, depending on the setting and age population. However, Procalcitonin can be reliable used to guide antibiotic therapy and has been shown to reduce morbidity and mortality Procalcitonin levels can be useful in the following:

-       adult ICU patient’s to help guide discontinuance of antibiotics

-       once PCT levels have dropped to 0.5-1 ng/mL, it is generally accepted to stop antibiotic coverage

-       PCT levels are also helpful in determining when to give antibiotics. For example, PCT levels are particularly helpful in patients with respiratory tract infections such as: COPD, community acquired pneumonia, bronchitis, URI/LRI infections ----> start antibiotics if PCT > 0.25-0.5 ng/mL

When is PCT of no value?

-       Viral infections

-       The use of PCT levels should not be used for intensification of antibiotics in adult ICU patients, because this was associated with an increase in mortality

-       Currently there is insufficient evidence to support the use of Procalcitonin-guided antibiotic therapy in neonates with sepsis, children with unknown source of fever, or in the post-operative, at risk for infection population.

Therefore, Procalcitonin is just another tool in a clinician’s kit that can be used to help in making a diagnosis and guiding treatment, but like so many other indices and biomarkers, it is not the Holy Grail.

Reference:
1. Soni, NJ., Samson, DJ., Galaydick, JL., Vats, V., Huang, ES., Aronson, N., Pitrak, DL. Procalcitonin-Guided Antibiotic Therapy: A Systematic Review and Meta-analysis. J. of Hosp Med; Vol. 8, No. 9, 2013; 530-540.
2. Prkno, A., Wacker, C., Brunkhorst, FM., Schlattmann, P. Procalcitonoin-guided therapy in intensive care unit patients with severe sepsis and septic shock - a systematic review and mata-nalysis. Crit. Care 2013, 17R291
3. Morris, C., Paul, K. Procalcitonin-Guided Antibiotic Therapy for Acute Respiratory Infections. American Family Physician, Vol 94, No. 1, July 1, 2016; 57-58.