Case Report

Equine Anti-Thymocyte Globulin (ATGAM) administration in patient with previous rabbit Anti-Thymocyte Globulin (Thymoglobulin) induced serum sickness: A case report

Joseph B Pryor*, Ali J Olyaei, Joseph B Lockridge and Douglas J Norman

Published: 23 March, 2018 | Volume 2 - Issue 1 | Pages: 015-019

Thymoglobulin is a rabbit-derived anti-thymocyte antibody directed at T-cells and commonly used for induction immunosuppression therapy in solid organ transplantation, especially in immunologically high risk kidney transplant recipients. Despite its frequent use and efficacy, the heterologous makeup of thymoglobulin can induce the immune system resulting in serum sickness which typically presents with rash, fever, fatigue, and poly-arthralgia in the weeks following drug exposure. ATGAM is another anti-thymocyte antibody, targeting the same epitopes, but differs from thymoglobulin by the animal in which the preparations are generated (equine vs. rabbit). Herein, we present a case of a patient with a known history of thymoglobulin-induced serum sickness, who presented with evidence of acute cellular and vascular rejection at their 12-month post-operative visit. Given their immunologically high risk status, they were successfully treated with ATGAM with improvement in their rejection and kidney function. To the author’s knowledge, this is the first case report of successful administration of ATGAM in a patient with a documented history of thymoglobulin induced serum sickness, demonstrating a possible treatment option for acute rejection in patients with reactions to thymoglobulin. 

Read Full Article HTML DOI: 10.29328/journal.jcn.1001013 Cite this Article Read Full Article PDF


Thymoglobulin; ATGAM; Serum sickness; Kidney transplantation


  1. Koyawala N, Silber JH, Rosenbaum PR, Wang W, Hill AS, et al. Comparing Outcomes between Antibody Induction Therapies in Kidney Transplantation. J Am Soc Nephrol. 2017; 28: 2188-2200. Ref.: https://goo.gl/WQYfYJ
  2. Halloran PF. Immunosuppressive Drugs for Kidney Transplantation. N Engl J Med. 2004; 351: 2715-2729. Ref.: https://goo.gl/uo57dt
  3. Tanriover B, Chuang P, Fishbach B, Helderman JH, Kizilisik T, et al. Polyclonal antibody-induced serum sickness in renal transplant recipients: treatment with therapeutic plasma exchange. Transplantation. 2005; 80: 279-281. Ref.: https://goo.gl/qL5FB4
  4. Hardinger KL, Rhee S, Buchanan P, Koch M, Miller B, et al. A prospective, randomized, double-blinded comparison of thymoglobulin versus atgam for induction immunosuppressive therapy: 10 year results. Transplantation. 2008; 86: 947-952. Ref.: https://goo.gl/43csFd
  5. James A, Mannon RB. The Cost of Transplant Immunosuppressant Therapy: Is This Sustainable? Current transplantation reports. 2015; 2: 113-121. Ref.: https://goo.gl/AjES7W
  6. Schnitzler MA, Woodward RS, Lowell JA, Amir L, Schroeder TJ, et al. Economics of the antithymocyte globulins Thymoglobulin and Atgam in the treatment of acute renal transplant rejection. PharmacoEconomics. 2000; 17: 287-293. Ref.: https://goo.gl/wHrd7K
  7. Szczech LA, Berlin JA, Feldman HI. The effect of antilymphocyte induction therapy on renal allograft survival. A meta-analysis of individual patient-level data. Anti-Lymphocyte Antibody Induction Therapy Study Group. Ann Intern Med. 1998; 128: 817-826. Ref.: https://goo.gl/nWUZ5f
  8. Vardhan H, Prasad N, Jaiswal A, Yadav B, Kumar S, et al. Outcomes of living donor renal transplant recipients with and without basiliximab induction: A long-term follow-up study. Indian Journal of Transplantation. 2014; 8: 44-50.
  9. Hardinger KL, Brennan DC, Klein CL. Selection of induction therapy in kidney transplantation. Transpl Int. 2013; 26: 662-672. Ref.: https://goo.gl/FiJq3U
  10. Cai J, Terasaki PI. Induction immunosuppression improves long-term graft and patient outcome in organ transplantation: an analysis of United Network for Organ Sharing registry data. Transplantation. 2010; 90: 1511-1515. Ref.: https://goo.gl/ZGWfd8
  11. Lawley TJ, Bielory L, Gascon P, Yancey KB, Young NS, et al. A prospective clinical and immunologic analysis of patients with serum sickness. N Engl J Med. 1984; 311: 1407-1413. Ref.: https://goo.gl/pfMx1z
  12. Pham PT, Pham PM, Miller JM, Pham PC. Polyclonal antibody-induced serum sickness presenting as rapidly progressive descending paralysis. Transplantation. 2007; 83: 1657. Ref.: https://goo.gl/gau9vh
  13. Lundquist AL, Chari RS, Wood JH, Miller GG, Schaefer HM, et al. Serum sickness following rabbit antithymocyte-globulin induction in a liver transplant recipient: case report and literature review. Liver Transpl. 2007; 13: 647-650. Ref.: https://goo.gl/jfrTKk
  14. Bielory L, Gascon P, Lawley TJ, Young NS, Frank MM. Human serum sickness: a prospective analysis of 35 patients treated with equine anti-thymocyte globulin for bone marrow failure. Medicine (Baltimore). 1988; 67: 40-57. Ref.: https://goo.gl/EbnaJH
  15. Regan JF, Campbell K, Van Smith L, Schroeder TJ, Womble D, et al. Sensitization following Thymoglobulin and Atgam rejection therapy as determined with a rapid enzyme-linked immunosorbent assay. Transplant Immunology. 1999; 7: 115-121. Ref.: https://goo.gl/eZPrvN

Similar Articles

Recently Viewed

Read More

Most Viewed

Read More

Help ?