red man syndrome

(RMS)

The most common allergic reaction to vancomycin. Vancomycin is a bactericidal antibiotic with activity against most gram-positive cocci, including methicillin-resistant Staphylococcus aureus.
It is an infusion-related reaction, occurring during rapid infusion of vancomycin. It may also occur when infused in a slow rate.

Patients commonly complain of diffuse burning and itching and of generalized discomfort. They can rapidly become dizzy and agitated, and can develop headache, chills, fever, and paresthesia around the mouth.

(Symptoms)
• pruritus (itching)
• erythematous rash that involves the face, neck, and upper torso
Less frequently:
• hypotension
• angioedema

(Causes)
• rapid infusion of the first dose of vancomycin

(Risk factors)
• Caucasian ethnicity
• age ≥ 2 years
• previous RMS history
• vancomycin dose ≥ 10 mg/kg
• vancomycin concentration ≥ 5 mg/mL
• antecedent antihistamine use

(Hypersensitivity reactions that vancomycin can cause)
• red man syndrome
• anaphylaxis

(Examples of other antibiotics that stimulate histamine release and can cause RMS)
• ciprofloxacin
• amphotericin B
• rifampicin
• teicoplanin

(Treatment)
• discontinuation of the vancomycin infusion: Once the rash and itching dissipate, the infusion can be resumed at a slower rate and/or at a lesser dosage.
• diphenhydramine hydrochloride intravenously or orally: Diphenhydramine is a first-generation H1-antihistamine, suppressing the itching, sneezing, and inflammatory responses as well as inducing sedative effects.

(Prevention)
• slow intravenous administration: Minimizes the risk of infusion-related adverse effects. Vancomycin is much better tolerated when it is given in smaller and more frequent doses. E.g. administration of each intravenous dose of vancomycin at least a 60 min interval, longer infusion times (for patients receiving doses considerably larger than 1 g vancomycin).
• pretreatment with antihistamines combined with an H2 receptor blocker: Offers protection against infusion-related reaction with vancomycin. E.g. famotidine, cimetidine, nizatidine.

(Comparison)
• red man syndrome: Erythematous rash that involves the face, neck, and upper torso. Caused by allergic reaction to vancomycin.
• blue man syndrome: Bluish skin discolouration, predominantly in sun-exposed areas. Caused by deposition of lysosomal membrane-bound dense bodies, similar to lipofuscin, in the dermis of patients on chronic amiodarone therapy.
• argyria (argyrosis): The skin turns blue or blue-gray. It is caused by excessive exposure to chemical compounds of the element silver, or to silver dust.
• gray baby syndrome: Characterized by abdominal distention, hemodynamic collapse, and ashen-gray skin discoloration in neonates. An adverse reaction to chloramphenicol.
• jaundice: The skin, whites of the eyes, and mucous membranes turn yellow because of a high level of bilirubin. Many causes, including hepatitis, gallstones, and tumors.
• hyperpigmentation: Some areas of the skin darker than others. They can appear brown, black, gray, red, or pink spots or patches. Caused by adrenal disorders (e.g. Addison's disease), hemochromatosis, thyroid dysfunctions (e.g. Grave's disease, thyrotoxicosis), etc. Melanin can clump, causing damaged or unhealthy skin cells to appear darker.
• melasma: Brown to gray-brown patches on the face. Caused by pregnancy and oral contraceptives and hormones. Caused by phenytoin and carbamazepine.

Cf. red skin syndrome