Red man syndrome (RMS) is an anaphlylactoid reaction caused by the rapid infusion of the glycopeptide antibiotic Vancomycin. RMS consists of a pruritic erythematous rash to the face, neck, and upper torso which may also involve the extremities to a lesser degree. Symptoms may include weakness, angioedema, and chest or back pain. RMS is caused by Vancomycin through the direct and non immune mediated release of histamine from mast cells and basophils. The amount of histamine release is generally related to the dose of Vancomycin infused and the rate of infusion. RMS is generally associated with more rapid infusion rates but can be seen following slower infusion rates and after several days of transfusion. Practitioners using vancomycin should be aware of this known drug reaction, its prevention and treatment.[1][2][3]

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Etiology
RMS most frequently occurs with IV vancomycin but may rarely occur from oral or intraperitoneal vancomycin.[4][5][6] It usually is related to a rapid infusion rate of vancomycin (1 gram in less than 1 hour). Current treatment recommendations are to administer vancomycin at a rate no faster than 1 gram/hour or 10 mg/min. RMS most often begins 4 to 10 minutes from the start of the first dose of IV vancomycin. It may occur later during the infusion or begin shortly after dose completion. RMS may occur from later doses as far out as 7 days.[1][2]

The increased incidence of methicillin/oxacillin-resistant Staphylococcus aureus, multiresistant Staphylococcus epidermidis, penicillin-resistant Streptococcus pneumoniae, and metronidazole-resistant Clostridium difficile has led to an increase in the use of vancomycin. Vancomycin is commonly used to treat bacterial endocarditis, abscesses with cellulitis, postoperative wound infections, infected surgically placed devices, and central line-associated bloodstream infections.[7][2]

There are case studies of RMS occurring from other antibiotics such as rifampin, cefepime, teicoplanin, ciprofloxacin, and amphotericin B.[3][8][9][1]

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Epidemiology
RMS is the most frequent adverse reaction to IV vancomycin. It occurs in 4% to 50% of infected patients treated with IV vancomycin. Patients under 40 years of age are at greatest risk of severe RMS reactions. Severe reactions include angioedema, hypotension, tachycardia, weakness, muscle spasms, and chest or back pain in addition to a rash of the face, neck, and upper torso. RMS usually is mild and easily managed. There are rare cases of life-threatening RMS reactions.[1]

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Pathophysiology
Vancomycin was discovered in 1952 in soil obtained from the jungles of Borneo. Initial preparations of the antibiotic lacked purification and were brown. Therefore, many referred to vancomycin as "Mississippi mud." Clinicians initially thought RMS, otic, and renal toxicity were secondary to impurities in vancomycin. However, even after vancomycin was purified RMS continued to be observed. Animal and several human studies indicate vancomycin activates the degranulation of mast cells and basophils increasing histamine release.
Red man syndrome is the most common adverse reaction to the drug vancomycin (Vancocin). It’s sometimes referred to as red neck syndrome. The name comes from the red rash that develops on the face, neck, and torso of affected people.
Vancomycin is an antibiotic. It’s often used to treat serious bacterial infections, including those caused by methicillin-resistant staphylococci, commonly referred to as MRSA. The drug prevents bacteria from forming cell walls, which causes the bacteria to die. This inhibits further growth and stops the spread of the infection.
Vancomycin can also be given in situations when a person has allergies to other types of antibiotics, such as penicillin.

Symptoms

The main symptom of red man syndrome is an intense red rash on the face, neck, and upper body. It usually occurs during or after an intravenous (IV) infusion of vancomycin. In many cases, the faster the medicine is given, the more likely the rash is to appear.
The rash usually appears within 10 to 30 minutes of vancomycin treatment beginning. Delayed reactions have also been seen in people who’ve been receiving vancomycin infusions for several days.
In many cases, a reaction following vancomycin infusion is so mild that it may go unnoticed. Discomfort and sensations of burning and itching are also frequently observed. Other less common but more serious symptoms include:

hypotension (low blood pressure)

shortness of breath

dizziness

headache

chills

fever

chest pain

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