Thread by @DrStevenTChen

#hospmed19 is here, and I'm excited to join up with all my @SHMlive colleagues soon! In honor of the momentous occasion, I put together one last inpatient #tweetorial before the conference!

Let's chat about RED MAN SYNDROME (RMS)!

#MedEd #FOAMed #medthread #dermatology
1/

What is RMS? It's a hypersensitivity reaction, most commonly reported to vancomycin. However, it's been reported with other anti-infectives too (including cipro, rifampin, amphotericin, etc). What is the usual distribution seen clinically with RMS?
2/

RMS usually occurs around the head and neck and upper torso. That's why it's other name is "Red Neck Syndrome." The clinical exam is described as flushing & erythema. Patients complain of pruritus, & can also get pain, spasms, and even hypotension!

pc: aac.asm.org/content/56/12/…
3/

Most know the mantra that if you give the infusion slowly, you can prevent RMS. Different suggested rates have been published, with some articles (eg:ncbi.nlm.nih.gov/pmc/articles/P…) arguing nothing shorter than 1 hour, and some saying no faster than 10mg/min (academic.oup.com/jid/article-ab…)
4/

Given the constellation of signs and symptoms seen with RMS, as well as the relation to rate of infusion, what do you think is the mechanism of this hypersensitivity reaction?
5/

RMS has been shown to be mediated via histamine release. This is complicated by patients who may have high histamine levels for other reasons (other drugs, infections itself), predisposing some to getting RMS. This explains why it resolves so quickly after stopping the drug.
6/

As you might suspect, aside from slowing down the infusion, RMS can be treated (and prevented) with antihistamines. Studies have shown that diphenhydramine and hydroxyzine can be helpful.

In patients that absolutely need the drug, there are desensitization protocols too.
7/

One quick note that vancomycin (and other antibiotics) can also cause anaphylaxis, so it's always important to closely monitor our patients to make sure what we're dealing with is just RMS (which shouldn't be life threatening), versus scarier things.
8/

I remember being taught in residency that RMS wasn't a thing anymore, because of improved ways that vancomycin was being purified. This led me to find an interesting article on the History of Vancomycin. cc:@AdamRodmanMD

academic.oup.com/cid/article/42…
9/

Did you know vancomycin used to be called "Mississippi Mud," because of the brown color? Bottom line: even after purification was improved, RMS is still a thing.

Quick aside to mention that oral vanco (eg: for C-diff) shouldn't cause RMS, but there are still case reports!
10/

To recap:
- RMS is from histamine release related to infusion rate of vancomycin (and other drugs).
- Prevention and treatment is with antihistamines.
- Monitor patients closely to ensure you're not dealing with anaphylaxis.
- PO vanco shouldn't cause it (but it's reported).
11/

Finally, if you want to hear more from me, but in person (!!), I'll be giving my talk on #Derm Emergencies at #hospmed19, Monday, 3/25, from 2-2:40 pm! Hope to see you there!

#dermtwitter #medtwitter #dermatologia

Thanks again to @tony_breu for the suggested topic!
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