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Al-Anii FM, Sadat-Ali M, Al-Tabash KW, AlMulhim AI, AlMousa SA, AlHawas AM. Vancomycin flushing syndrome in orthopaedic practice: A case report. World J Orthop 2023; 14:771-775. [PMID: 37970623 PMCID: PMC10642402 DOI: 10.5312/wjo.v14.i10.771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/16/2023] [Accepted: 09/07/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Vancomycin flushing syndrome (VFS), also known as red man syndrome, is an allergic reaction to vancomycin. It typically presents as a rash on the face, neck, and upper torso after intravenous administration of vancomycin. VFS is blamed on rapid intravenous infusion of vancomycin during management and rarely happens after local use. A review of the literature showed that in the last 23 years, 4 such cases have been reported. Here, we add another case of VFS developed after slow local absorption of vancomycin in cement beads. CASE SUMMARY A 44-year-old male with a known case of hypertension, no history of allergies to medications, and a history of chronic osteomyelitis of the right tibia with discharging sinus over the anterolateral aspect of the leg. The pus culture grew Staphylococcus aureus, which was sensitive to clindamycin and vancomycin. The patient underwent irrigation and debridement with the placement of vancomycin cement beads made from 4 g of vancomycin powder and 40 g of polymethyl methacrylate. Three hours postoperatively, the patient developed a pruritic, erythematous, macular rash predominantly on his face, neck, chest, and lower extremities and to a lesser extent his upper extremities. A diagnosis of VFS was made and was successfully treated with cetirizine (10 mg, oral) and methylprednisolone sodium succinate (125 mg, intravenous). The patient continued to have itching with a facial rash for 12 h with gradual improvement. A decision was made to not remove the beads as the patient continued to improve. Gradually, the rash disappeared after 96 h with no further sequela. CONCLUSION VFS can occur not only after rapid intravenous injection of vancomycin but also with local release, as in our case. As orthopaedic surgeons routinely use vancomycin with polymethyl methacrylate in chronic osteomyelitis and revision arthroplasty, they should be aware of such a complication occurring.
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Affiliation(s)
- Fawaz M Al-Anii
- Orthopaedic Surgery, Imam AbdulRahman Bin Faisal University and King Fahd Hospital of the University, AlKhobar 31952, Saudi Arabia
| | - Mir Sadat-Ali
- Orthopaedic Surgery, Imam AbdulRahman Bin Faisal University and King Fahd Hospital of the University, AlKhobar 31952, Saudi Arabia
| | - Khalid Waleed Al-Tabash
- Orthopaedic Surgery, Imam AbdulRahman Bin Faisal University and King Fahd Hospital of the University, AlKhobar 31952, Saudi Arabia
| | - Ahmad I AlMulhim
- Orthopaedic Surgery, Imam AbdulRahman Bin Faisal University and King Fahd Hospital of the University, AlKhobar 31952, Saudi Arabia
| | - Sulaiman A AlMousa
- Orthopaedic Surgery, Imam AbdulRahman Bin Faisal University and King Fahd Hospital of the University, AlKhobar 31952, Saudi Arabia
| | - Abdulaziz M AlHawas
- Orthopaedic Surgery, Imam AbdulRahman Bin Faisal University and King Fahd Hospital of the University, AlKhobar 31952, Saudi Arabia
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Obal M, Gacoń E, Piechocki K, Symonides B. [ Red man syndrome as a complication of vancomycin therapy]. Pol Merkur Lekarski 2022; 50:240-242. [PMID: 36086983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
UNLABELLED Red man syndrome (RMS) is a side effect of vancomycin therapy and manifests itself mainly by a red blotchy rash with itching and sometimes muscle pain and a decrease of arterial blood pressure. A CASE REPORT 24-year-old patient admitted to hospital with a history of chest pain radiating to the back. EKG has shown the depression of PQ, in the ECHO mark of liquid in the pericardial cavity and the increase of CRP and troponin concentrations. The patient was diagnosed with acute pericarditis and treated with ibuprofen and colchicine. Due to the increasing parameters of inflammation, a bacterial etiology was suspected and vancomycin was administered. During antibiotic therapy, there were symptoms of a mild adverse reaction in the form of a maculopapular rash and periodic decreases in blood pressure. RMS was diagnosed and symptoms resolved after treatment with cetirizine. CONCLUSIONS RMS should be distinguished from anaphylaxis and treated according to the diagnosis.
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Affiliation(s)
- Mateusz Obal
- Medical University of Warsaw, Poland: Student Scientific Group "Pressor", Department of Internal Medicine, Hypertension and Vascular Diseases
| | - Ewa Gacoń
- Medical University of Warsaw, Poland: Student Scientific Group "Pressor", Department of Internal Medicine, Hypertension and Vascular Diseases
| | - Kacper Piechocki
- Medical University of Warsaw, Poland: Department of Internal Medicine, Hypertension and Vascular Diseases
| | - Bartosz Symonides
- Medical University of Warsaw, Poland: Department of Internal Medicine, Hypertension and Vascular Diseases
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Alvarez-Arango S, Yerneni S, Tang O, Zhou L, Mancini CM, Blackley SV, Keet CA, Blumenthal KG. Vancomycin Hypersensitivity Reactions Documented in Electronic Health Records. J Allergy Clin Immunol Pract 2020; 9:906-912. [PMID: 33011300 DOI: 10.1016/j.jaip.2020.09.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/26/2020] [Accepted: 09/15/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Vancomycin, the most common antimicrobial used in US hospitals, can cause diverse adverse reactions, including hypersensitivity reactions (HSRs). Yet, little is known about vancomycin reactions documented in electronic health records. OBJECTIVE To describe vancomycin HSR epidemiology from electronic health record allergy data. METHODS This was a cross-sectional study of patients with 1 or more encounter from 2017 to 2019 and an electronic health record vancomycin drug allergy label (DAL) in 2 US health care systems. We determined prevalence and trends of vancomycin DALs and assessed active DALs by HSR phenotype determined from structured (coded) and unstructured (free-text) data using natural language processing. We investigated demographic associations with documentation of vancomycin red man syndrome (RMS). RESULTS Among 4,490,618 patients, 14,426 (0.3%) had a vancomycin DAL with 18,761 documented reactions (2,248 [12.0%] free-text). Quarterly mean vancomycin DALs added were 253 ± 12 and deleted were 12 ± 2. Of 18,761 vancomycin HSRs, 7,903 (42.1%) were immediate phenotypes and 3,881 (20.7%) were delayed phenotypes. Common HSRs were rash (32% of HSRs) and RMS (16% of HSRs). Anaphylaxis was coded in 6% cases of HSRs. Drug reaction eosinophilia and systemic symptoms syndrome was the most common coded vancomycin severe cutaneous adverse reaction. RMS documentation was more likely for males (odds ratio, 1.30; 95% CI, 1.17-1.44) and less likely for blacks (odds ratio, 0.59; 95% CI, 0.47-0.75). CONCLUSIONS Vancomycin causes diverse adverse reactions, including common (eg, RMS) and severe (eg, drug reaction eosinophilia and systemic symptoms syndrome) reactions entered as DAL free-text. Anaphylaxis comprised 6% of documented vancomycin HSRs, although true vancomycin IgE-mediated reactions are exceedingly rare. Improving vancomycin DAL documentation requires more coded entry options, including a coded entry for RMS.
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Affiliation(s)
- Santiago Alvarez-Arango
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University, Baltimore, Md; Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University, Baltimore, Md
| | - Sharmitha Yerneni
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass
| | - Olive Tang
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Christian M Mancini
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | | | - Corinne Allison Keet
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore, Md
| | - Kimberly G Blumenthal
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass.
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Valentin B, Dartus J, Trouillez T, Gaboriau L, Loiez C, Dezèque H, Odou P, Décaudin B, Migaud H, Genay S, Senneville E. [Reaction during dalbavancin infusion: About one case]. Therapie 2020; 76:488-490. [PMID: 32723578 DOI: 10.1016/j.therap.2020.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/11/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Benjamin Valentin
- CHU Lille, institut de pharmacie, rue Philippe Marache, 59000 Lille, France.
| | - Julien Dartus
- Département d'orthopédie, CHU Lille, 59000 Lille, France
| | | | - Louise Gaboriau
- CHU Lille, centre régional de pharmacovigilance, 59000 Lille, France
| | - Caroline Loiez
- CHU Lille, institut de microbiologie, 59000 Lille, France
| | - Hervé Dezèque
- Département d'orthopédie, CHU Lille, 59000 Lille, France
| | - Pascal Odou
- CHU Lille, institut de pharmacie, rue Philippe Marache, 59000 Lille, France; Université Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, 59000 Lille, France
| | - Bertrand Décaudin
- CHU Lille, institut de pharmacie, rue Philippe Marache, 59000 Lille, France; Université Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, 59000 Lille, France
| | - Henri Migaud
- Département d'orthopédie, CHU Lille, 59000 Lille, France; Université Lille, EA 4490 - PMOI - Physiopathologie des Maladies Osseuses Inflammatoires, 59000 Lille, France
| | - Stéphanie Genay
- CHU Lille, institut de pharmacie, rue Philippe Marache, 59000 Lille, France; Université Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, 59000 Lille, France
| | - Eric Senneville
- Département de maladies infectieuses, CH Gustave Dron, 59200 Tourcoing, France; Université Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, 59000 Lille, France
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Abstract
Red man syndrome (RMS) is a well-known hypersensitivity reaction caused by intravenous administration of vancomycin, with symptoms ranging from flushing, erythematous rash, pruritus, mild to profound hypotension, and even cardiac arrest. RMS has not previously been described from local application of vancomycin powder in a surgical wound, a technique increasingly utilized for infection prophylaxis in many surgical disciplines including neurosurgery. We describe the first reported case of RMS as a result of local intra-wound application of vancomycin powder for infection prophylaxis. A 73-year-old male with a history of Parkinson's disease underwent 2-stage deep brain stimulation implantation surgeries. Vancomycin powder was applied locally in the surgical wounds for infection prophylaxis during both of the surgeries. The patient developed a well-demarcated, geometric erythematous pruritic rash following the second surgery that was clinically diagnosed as RMS and resolved without sequelae.
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Affiliation(s)
- Yasunori Nagahama
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Marta J VanBeek
- Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jeremy D W Greenlee
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Lin SK, Mulieri KM, Ishmael FT. Characterization of Vancomycin Reactions and Linezolid Utilization in the Pediatric Population. J Allergy Clin Immunol Pract 2017; 5:750-756. [PMID: 28189630 DOI: 10.1016/j.jaip.2016.12.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 11/29/2016] [Accepted: 12/28/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Red man syndrome (RMS) occurs because of non-IgE-mediated histamine release. Unlike vancomycin allergy, which necessitates the use of an alternative drug (often linezolid), RMS does not typically preclude further vancomycin use. Care should be taken to differentiate these reaction types from one another to prevent unnecessary vancomycin avoidance. OBJECTIVE To characterize vancomycin reaction types in our population, and to determine whether having a reaction consistent with RMS is associated with otherwise unexplained vancomycin avoidance and linezolid use. METHODS We retrospectively reviewed charts for children with documented vancomycin reactions. We classified the in-hospital reactions via an objective analysis and estimated the prevalence of different reaction types. We then identified children who received linezolid over 3 years, and investigated reasons for linezolid use instead of vancomycin. RESULTS Of the 78 in-hospital reactions we characterized, 72 (92%) were objectively consistent with RMS, 5 we could not objectively classify (2 most likely RMS, 3 more suspicious for possible IgE-mediated allergy), and 1 was a non-RMS/non-IgE reaction. Of 60 children who received linezolid, 19 had previous reactions consistent with RMS, which should not preclude further vancomycin. Nevertheless, only 7 of 19 (37%) had a clear explanation for receiving linezolid instead of vancomycin compared with 32 of 39 (82%) children without previous vancomycin reactions (P < .001). CONCLUSIONS The vast majority of patients had vancomycin reactions consistent with RMS. These patients are at risk for unnecessary vancomycin avoidance and linezolid utilization. We propose that this may be related to how reactions appear in the electronic medical record.
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Affiliation(s)
- Samantha K Lin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Penn State Hershey Medical Center, Hershey, Pa
| | - Kevin M Mulieri
- Department of Pharmacology, Penn State College of Medicine, Hershey, Pa; Department of Pharmacy, Penn State Hershey Medical Center, Hershey, Pa
| | - Faoud T Ishmael
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Penn State Hershey Medical Center, Hershey, Pa.
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