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DRESS syndrome: case report A 22-year-old man with cholestatic hepatitis A virus developed DRESS syndrome following exposure to oseltamivir, metronidazole and cefotaxime [routes and dosages not stated]. In January 2010, the man was diagnosed with acute hepatitis A and was initially treated conservatively in hospital. He subsequently developed a sudden fever and increased liver enzymes. Oseltamivir was administered empirically for possible pandemic swine influenza. One day later, an intensely pruritic skin rash developed over his whole body. His fever persisted and gall bladder wall thickening was evident on an adbomino-pelvic CT scan. Cefotaxime and metronidazole were started for suspected acute cholecystitis. The following day (9 Feruary 2010), he was transferred to another hospital with cholestatic hepatitis A, fever and skin rash. Laboratory findings included a WBC count of 15 900/mm3 with 8% eosinophils. Cefotaxime was continued for 4–5 days for persistent fever and jaundice. On hospital day 4, his fever and skin rash worsened. A subsequent skin biopsy was consistent with a drug eruption. On hospital day 8, a liver biopsy revealed eosinophilic microabscess, and peripheral blood eosinophils had increased to 32.4%. A diagnosis of DRESS syndrome and prolonged cholestatic hepatitis A with renal azotemia was made. Cefotaxime was immediately withdrawn and the man commenced hydrocortisone and immune globulin therapy. His symptoms improved within 1 week. After 20 days of treatment, he developed a recurrent fever and subsequent testing for cytomegalovirus was positive. Maintenance prednisolone therapy was stopped and he started ganciclovir. Ten days later, his liver enzyme levels increased and another fever developed with a decrease in his prothrombin level. Recurrent DRESS syndrome was suspected, for which pulsed methylprednisolone was started, followed by prednisone. His condition improved and prednisone was gradually tapered. Author comment: "[H]epatitis A virus infection appeared to have triggered DRESS syndrome development by reducing the hepatic clearance of drugs, leading to an accumulation of drugs and their metabolites. . . Our future plan is to perform patch tests using oseltamivir, cefotaxime and metronidazole to identify the causative drug once prednisone treatment is ceased." An J, et al. Drug rash with eosinophilia and systemic symptoms syndrome following cholestatic hepatitis A: a case report. Korean Journal of Hepatology 18: 803078242 84-8, No. 1, Mar 2012 - South Korea

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Reactions 6 Oct 2012 No. 1422