63 yo M with a fever, rash, and joint pains

OBJECTIVES:

  • Evaluate fever and rash in a post-transplant patient

CASE:

63 yo M with a history of BOLT ~10 years ago who presents low grade fevers/chills, arthralgias and a rash. Four days ago, he developed a mild sore throat, dyspnea and nonproductive cough. He denies any rhinorrhea or congestion, chest pain, LE swelling. Yesterday, he developed diffuse “body aches” and onset of a whole body rash. He localizes his “aching” pain to his joints – mostly in his bilateral ankles, knees, elbows, wrists. He denies any joint stiffness, swelling, or redness. He describesrash as a nonpruritic and nonpainful that appeared concurrently on his chest and arms. It’s nonpruritic and nonpainful. He has rabbits in his yard but denies any other new exposures, sick contacts, or recent travel. Other ROS was negative.

His PMH (full medical history and medications) is notable for BOLT for COPD (CMV D+/R-) ~ 10 years ago that was complicated by cellular rejection 3 weeks ago. He received rabbit derived ATG and methylprednisone 1 g x 3 days.

His exam is notable for fever of 38.9C, HR 131, RR 22, SBP 100-140s/90s, SaO2 93% on 2LNC. He appears ill and in mild respiratory distress. He skin is notable for diffuse, blanching pink morbilliform rash on the trunk, upper arms and thighs. Face, palms and soles are spared. He has no joint effusions or tenderness and full ROM. His cardiopulmonary exam is normal with the exception of tachycardia and tachypnea.

His labs (full work-up) are notable for a Cr of 1.3, BUN of 23, WBC of 24 (95% PMNs), and unrevealing EKG and CXR.

What is your differential diagnosis for fever, rash and arthralgias in this patient? 


How would you initially manage this patient?

What additional work-up would you want?


CASE CONTINUED:

FINAL DIAGNOSIS:

What is it? (~5-7 min)

What are the risk factors? More specifically, does a history of rabbit exposure increase risk of this reaction? (~1 min)

How is it diagnosed? (~2-3 min)

How do you treat it? (~2-3 min)


TAKE HOME POINTS: 


REFERENCES:

  1. Snow, MH et al. 2009. Presumptive Serum Sickness as a Complication of Rabbit-derived Antithymocyte Globulin Immunosupression. Arthritis and Rheumatism. 61(9):1271-1274.
  2. Boothpur, R, et al. 2010. Serum Sickness After Treatment with Rabbit Antithymocyte Globulin in Kidney Transplant Recipients With Previous Rabbit Exposure. American Journal of Kidney Diseases. 55(1): 141-143
  3. Lundquist, AL, et al. 2007. Serum Sickness Following Rabbit Antithymocyte-Globulin Induction in a Liver Transplant Recipient: Case Reports and Literature Review. Liver Transplantation. 13: 640-650.
  4. Wener, MH. Serum sickness and serum sickness-like reactions. In: Uptodate, Adkison, NF (Ed), UpToDate, Waltham, MA. (Accessed on January 13, 2016.)
  5. Bierlory, L, et al. 1985. Cutaneous manifestations of serum sickness in patients receiving antithymocyte globulin. American Academy of Dermatology. 13:411-417.