Vancomycin and Red Man Syndrome Vancomycin can cause two types of hypersensitivity reaction – the red man syndrome and anaphylaxis. 'Red man Syndrome' is thought to be an infusion-related reaction consisting of pruritus, an erythematous rash involving the face, neck and upper torso. Patients commonly complain of the sensations of burning and itching. Agitation, dizziness, headaches, chills, fever and perioral paresthesia are also described. The incidence of red man syndrome varies between 3.7% and 47% in infected patients []. The 'Red Man Syndrome' seen in association with intravenous vancomycin administration is not a true allergic reaction.

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It appears to be due to vancomycin-induced histamine release without involvement of preformed antibodies []. In animal models, vancomycin provokes histamine release from rat peritoneal mast cells []. There is evidence of reduced side effects associated with vancomycin when antihistamines are given with therapy. In a prospective, randomized, double-blind, placebo-controlled study in 30 patients who required vancomycin chemoprophylaxis before elective arthroplasty, oral pre-treatment with either a histamine H1 receptor antagonist (diphenhydramine 1 mg/kg) or a histamine H2 receptor antagonist (cimetidine 4 mg/kg) significantly reduced the histamine-related adverse effects of rapid vancomycin infusion []. Hypothesized mechanism of reaction It is generally understood that systemic bioavailability of orally administered vancomycin is negligible []. In one study, after 7 doses of oral vancomycin 250 mg every 8 hours in healthy volunteers, no vancomycin concentrations were detected in serum (sensitivity limit 0.64 micrograms/ml) or urine [].

However, the presence of an inflammatory bowel process can result in increased absorption of oral vancomycin []. In patients with pseudomembranous colitis and severe renal failure, several studies have revealed that orally administered vancomycin may occasionally reach therapeutic concentrations in serum and even pose a risk of systemic toxicity [,]. In one of these case reports an anephric girl with C. Difficile pseudomembranous colitis received oral vancomycin 250 mg every 6 hours. She developed unexplained fever and encephalopathy.

Sustained serum vancomycin concentrations of 34 micrograms/ml were recorded, with Cerebrospinal fluid (CSF) concentrations of 4.3 microgram/ml. Discontinuation of the drug, along with haemodialysis caused the serum concentration to fall to 24 microgram/ml with resolution of the symptoms []. Case presentation The patient, an 82 year old Caucasian woman, was admitted to hospital with confusion. She had a number of active medical problems, including atrial fibrillation, ischaemic heart disease, chronic kidney disease, hypertension and osteoarthritis.