Correspondence

Pseudo-Red-Man Syndrome

N Engl J Med 1993; 328:584-585February 25, 1993

Article

To the Editor:

Red-man syndrome is a well-known erythematous reaction involving the upper trunk in patients who have received vancomycin1. The flushing may be associated with pruritus and hypotension. It appears to be caused by histamine, other mediators, or vancomycin itself. Teicoplanin is a newer glycopeptide antibiotic with an antimicrobial spectrum similar to that of vancomycin, but with a very long half-life. It is not known to be associated with red-man syndrome2. Red-man syndrome appeared to develop in the following patient after he received teicoplanin.

The patient was a 65-year-old man who had undergone quadruple coronary-artery bypass surgery. He was enrolled in a double-blind trial comparing teicoplanin and cefazolin as prophylaxis against postoperative infection. The intraoperative and postoperative course was uncomplicated. On the fifth postoperative day the patient was noted to have diffuse erythema involving both arms. The erythema started about 10 cm below the shoulders and extended to the wrists. There was no blanching or warmth. There was complete sparing of the area under his wristwatch. The only other medications that he had been receiving were aspirin and an antihistamine for rhinitis.

I initially considered the possibility that he had red-man syndrome, but he had not received vancomycin, so I was quite puzzled. Then his bathrobe caught my eye. The bright red terry-cloth robe was brand-new. The patient had not been compliant with the manufacturer's instructions, and no one had ever washed it in cold water to remove the sizing3. The red dye from the robe had colored the patient's arms, which were still wet from a shower. The spared areas were those covered by the traditional hospital gown and the wristwatch. In fact, what appeared to be rubor was merely “robe-or.” Teicoplanin was exonerated. I warn other clinicians that unwashed terry-cloth robes of the appropriate colors may also lead to pseudocyanosis, pseudojaundice, and pseudochlorosis. The most cost-effective form of prophylaxis under these circumstances is machine washing.

Irving E. Salit, M.D., C.M., F.R.C.P.(C).
Toronto Hospital, Toronto, ON M5G 2C4, Canada

3 References

1
Wallace MR, Mascola JR, Oldfield EC III. Red man syndrome: incidence, etiology, and prophylaxis. J Infect Dis 1991;164:1180-1185
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