Replace Red Man Syndrome With Vancomycin Flushing Reaction

Imagine this scenario: a 14-year-old Native American boy is being treated with vancomycin for osteomyelitis caused by methicillin-resistant Staphylococcus aureus. During the first infusion, he develops diffuse flushing, which resolves with a slower infusion rate and administration of diphenhydramine. During bedside rounds the next morning, the medical student managing the patient reports that overnight the patient developed red man syndrome. An uncomfortable pause follows as the medical team recognizes the awkwardness of the phrase and as the patient and his family try to understand what message is being conveyed by “red man syndrome”: a term that would seem, erroneously, to invoke race as a key component to its pathophysiology.

Providing some historical context is important. In 1959, an article entitled “An anaphylactoid reaction to vancomycin” was published in the Journal of the American Medical Association.¹ The pathophysiology of this reaction was hypothesized to involve vancomycin-induced release of histamine from mast cells. Because of this and other untoward effects (eg, oto- and renal toxicity), vancomycin (a name derived from the word vanquish), was not extensively used until the proliferation of methicillin-resistant S aureus occurred in the 1970s and 80s.² Sometime during this period, the anaphylactoid reaction was rebranded as “red man” or, rarely, “red neck syndrome,” a reflection of the diffuse erythematous flushing in affected patients. It is unclear where this eponym originated or why the original term, anaphylactoid reaction, fell out of favor. Nonetheless, the first mention of red man syndrome occurred in the New England Journal of Medicine in 1985,³ and the term has been propagated ever since. The fact that the term “red man” is a racial slur that arose in the 17th century to describe Native Americans has seemingly not deterred its use. Other authors have also recognized the anachronistic nature of the term and called for its replacement, although evidently without success.^4,5 The lack of awareness and sensitivity toward Native American peoples and cultures and their historical trauma is unfortunately consistent with a larger systemic problem, namely, the invisibility of Native Americans in modern society.

In their large study entitled Reclaiming Native Truth, Native American researchers found that perceptions by the general US population regarding Native Americans were both inaccurate and full of misconceptions.⁶ For example, despite the fact that Native Americans make up 2% of the general population, 40% of respondents believe Native Americans do not exist. Only 13% of K–12 schools taught any history of Native Americans post-1900. In modern society, contemporary Native Americans lack visibility, and when they are portrayed in media or arts, they are typically shown by using pre-1900 stereotypes or caricatures. The invisibility of Native Americans can lead to bias and institutional racism. For Native Americans, especially youth, the lack of visibility and recognition can be devastating to establishing and maintaining a cultural identity.⁷ Native American tribes, traditions, and ceremonial regalia have a long history of exploitation and appropriation by mainstream society. Changing this narrative begins with the recognition that Native Americans are foundational members of our society and the elimination of culturally insensitive accounts and descriptors.

Retaining a disease name, such as red man syndrome, that is potentially offensive and perceived as a racial slur to Native Americans may further exacerbate distrust and needlessly impede progress in improving care for this population. Indeed, Native Americans experience higher rates of depression, suicidal ideation, substance abuse, and mood and anxiety disorders when compared with the general population.⁸ Native Americans 10 to 39 years of age have the highest suicide rate compared with other racial and ethnic groups in the United States. Mortality rates are 5.5 years fewer than the general population, and Native Americans die at a higher rate from preventable diseases than any other group. These health disparities are multifactorial but include a lack of culturally appropriate care, inadequate resource allocation, discrimination, and both distrust of and limited access to the health care systems. Although modest gains in the health status of Native Americans have occurred recently, especially in programs that include strong cultural components, significant challenges remain.

Medicine has a long history of using offensive eponyms and terms, such as hysteria, invalid, or mongoloid, to describe diseases and their processes, particularly those not fully understood or considered foreign. Recent efforts to replace diseases named for Nazi experimenters with pathophysiologically descriptive terms have occurred, such as exchanging Hallervorden–Spatz syndrome with pantothenate kinase–associated neurodegeneration.⁹ Concurrently, some college and professional sports entities have changed culturally insensitive team names and mascots toward achieving a more respectful, equitable, and culturally aware society that promotes health for all. It is time for medicine to follow suit by eliminating offensive terms from its nomenclature. Indeed, in the naming of the novel coronavirus, severe acute respiratory syndrome coronavirus 2, and its associated clinical disease, coronavirus disease 2019, World Health Organization guidelines¹⁰ were employed to ensure that stigmatization associated with the virus and its origins were minimized. These guidelines should be applied retroactively as well in renaming terms deemed offensive, stigmatizing, or inaccurate.

We think a directive is needed to modify the original version of the term proposed by Rothenberg in 1959 to “vancomycin flushing reaction” as a replacement for “red man syndrome” in the medical lexicon, both in practice and in writing. This modified term is respectful, descriptive, and linguistically simpler than the original term, “anaphylactoid reaction.” By doing so, the field of medicine will move closer to becoming the respectful, equitable field that it strives to be and that its patients of all races and ethnicities deserve.

• Copyright © 2020 by the American Academy of Pediatrics