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Drug rash with eosinophilia and systemic symptoms: case report A 16-year-old girl with Bourneville tuberous sclerosis developed drug rash with eosinophilia and systemic symptoms (DRESS), initially during treatment with carbamazepine and later with valproate.* The girl started treatment with carbamazepine 400 mg/day following diagnosis of tuberous sclerosis. Five weeks later, she was hospitalised with a skin eruption and fever (40°C). On examination, she had cervical lymphadenopathy, and widespread erythematous macules and papules. Laboratory analyses identified hypereosinophilia (0.8 × 109/L) and elevated levels of AST (338 UI/L), ALT (792 UI/L) and γglutamyl transpeptidase (GGT; 236 UI/L). DRESS was suspected and carbamazepine was discontinued. The girl’s symptoms had resolved 3 weeks later and valproate 1 g/day was started. Three weeks after valproate initiation, she developed fever and a generalised rash and stopped taking valproate. However, her symptoms persisted and she was hospitalised 8 days later. On examination, she had cervical adenopathy, generalised skin desquamation, facial oedema and fever (40.2°C). Laboratory analyses showed cytolysis (AST 284 UI/L and ALT 394 UI/L), cholestasis (GGT 262 UI/L and alkaline phosphatase 543 UI/L) and leucocytosis (26.9 × 109/L) with 34% eosinophilia (9.1 × 109/L). Analysis of a skin biopsy showed findings that were compatible with a drug reaction. Corticosteroids were administered; her symptoms resolved within 4 weeks and did not recur over 6 months’ follow-up. Author comment: "According to objective causality assessment using the Naranjo probability scale, valproateinduced DRESS was probable." * It was unclear which salt was administered. Ben Salem S, et al. A recurrent drug rash with eosinophilia and systemic symptoms. Pediatric Dermatology 24: 666-668, No. 6, Nov-Dec 2007 Tunisia

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Reactions 26 Jan 2008 No. 1186