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DRESS syndrome and acute renal failure : case report An approximately 65-year-old woman developed DRESS syndrome and acute renal failure during treatment with esomeprazole, pantoprazole and omeprazole for gastrointestinal symptoms [not all routes, dosages and durations of treatment to reaction onset stated]. The woman was hospitalised on 1 July 2014, due to cough and gastrointestinal symptoms, such as nausea and vomiting. After 3 days, she developed fever, cough, abdominal pain, nausea and vomiting. She was treated initially with omeprazole infusion 40mg once daily and then with long term therapy (> 1 month) consisting of omeprazole, pantoprazole, and esomeprazole, in succession. Subsequently, she developed a fever without any rash. Blood tests showed an increase in the eosinophil count and eosinophil proportion. A routine urine test was positive for leukocytes. She was diagnosed with DRESS and acute renal failure secondary to proton pump inhibitor therapy. The woman was treated with continuous renal replacement therapy (CRRT) for oliguria and acute renal failure. Proton pump inhibitor therapy was discontinued. Thereafter, her serum creatinine level was restored. Subsequently, she was discharged but was not followed up. However, more than a year later, she was re-admitted on 28 August 2015 at the age of 66 years. Her chief complaints were fever, rash, chest tightness and anuria. A provisional diagnosis of renal failure was considered. Anamnesis revealed that two weeks prior to admission, she had initiated a course of oral omeprazole 20mg once daily due to symptoms of abdominal distension. One week prior to admission, she had gradually developed pruritus and a rash over her whole body including the limbs, with features that included desquamation, papules, macules, partially integrated blisters, and scabs. Upon admission, erythrocyte sedimentation rate was noted to be normal. Arterial blood gas analysis revealed severe metabolic acidosis and hyponatremia. Thereafter, an colour Doppler ultrasonography of the urinary system demonstrated that the sizes of the two kidneys were 102 x 48mm and 98 x 47mm, respectively. Also, the bilateral renal cortex was about 4mm in thickness. A subsequent urine analysis was positive for glucose, protein, and red blood cells. After that, the tests for the presence of anti-myeloperoxidase (MPO) antibody in peripheral blood produced weak positive results twice. Blood culture and echocardiography revealed no abnormalities. Subsequently, she received intermittent haemodialysis. A diagnosis of omeprazole induced DRESS and acute renal failure was considered. Based on the criteria suggested by the Registry of Severe Cutaneous Adverse Reaction (RegiSCAR), a score of 9 points was obtained, and hence DRESS was confirmed. A renal biopsy on day 18 of hospitalisation revealed the severe and chronic injury to the renal tubules and interstitium, accompanied by glomerular ischaemia and shrinkage. Immunohistochemical analysis showed that most renal interstitial lymphocytes were CD3+ /MPO+ neutrophils