Background:Vancomycin loaded with bone cement for joint replacement is a common treatment to prevent osteomyelitis. Red Man Syndrome (RMS) is the most common allergic reaction to Vancomycin and occurs mostly during rapid infusion of Vancomycin. Only few case reported as a result of local vancomycin(1). We hereby reported a case where RMS was developed after insertion of Vancomycin bone cement for total knee replacement (TKR).
Case Report:A 74-year-old woman was admitted for left TKR due to osteoarthritis. There were no abnormalities noticed after preoperative assessment. We performed spinal anesthesia for her. Total operation time was 80 minutes and tourniquet time was 55 minutes. The patient had received knee prosthesis with bone cement loaded with vancomycin 1000mg during implantation. There were no subjective complaints noticed and vital signs remained stable throughout the process. Tourniquet of the knee was then released. Erythematous rash on face, trunk and extremities (figure1,2) were noticed 45 minutes after released of tourniquet. She also complained of general discomfort and itchiness. She remained clear conscious and fine saturation around SpO2 97%. Unfortunately, hypotension to 47/34 mmHg preceded. Under the tentative diagnosis of Vancomycin induced RMS, we treated patient with 30 mg of Diphenhydramine, 100mg of Hydrocortisone associated with fluid challenge, and Ephedrine. Patient’s blood pressure was back to around 95/55 mmHg 15 minutes after and remained stable with 1-hour of close monitoring. She was transferred to general ward. Erythematous rash and itching condition had improved one hour later. She was discharged as scheduled.
Discussion:RMS is an anaphylactoid reaction due to histamine release from mast cells and basophils. It is the most common adverse reaction to vancomycin but rarely life-threatening. The adverse effect of RMS can be relieved by antihistamine(2). Another Vancomycin hypersensitivity is an anaphylactic reaction, which is IgE-mediated. It is rare but more lethal.
References:
1. Goh KLa. Allergic Reaction Following Insertion of Vancomycin Loaded in Bone Cement. The International Medical Journal Malaysia; Volume 13 Number 1, June 2014
2. Juyal A. Red m an Syndrome: an unusual complication of vancomycin beads. Bangladesh Journal of Medical Science Vol. 14 No. 03 July’15
Learning points:Vancomycin-induced RMS may occur despite administering through through the insertion of Vancomycin bone cement for TKR.

05 / Erythematous rash suspect red man syndrome following vancomycin loaded in bone cement: a case report