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Furosemide/prednisone Various toxicities: case report

A 29-year-old woman developed DRESS syndrome, liver dysfunction and autoimmune haemolytic anaemia following treatment with furosemide for lower extremity swelling. Further, she exhibited lack of efficacy during treatment with prednisone [not all routes stated; dosages not stated]. The woman had a history of gastric bypass surgery and chronic pancreatitis. She presented with lower extremity swelling due to hypoalbuminaemia and protein-calorie malnutrition. A high calorie/protein diet was started. She was discharged on furosemide along with multivitamin tablets. After three weeks of the discharge, peri-oral rash extended to lower extremities, groin and trunk was noted. Upon presentation, she had erythema and crusting over body, small tense vesicles of legs with oedema of bilateral lower extremities. Blood analysis showed elevated levels of eosinophils, liver enzymes and International normalised ratio. Also, macrocytic anaemia and low level of vitamin D were noted. A left forearm skin biopsy showed spongiotic epidermis with paucicellular intraepidermal vesicle/bullae with scattered eosinophils and neutrophils. Within the epidermis, necrotic keratinocytes sites were observed. Naranjo scale score was found to be 5, suggestive of DRESS syndrome probably related to furosemide. The woman was started on treatment with oral prednisone. Consequently, her rash and liver function improved. However, she had sudden drop in haemoglobin level. No bleeding was noted. Blood workup showed elevated levels of LDH and reticulocyte, and positive C3 and poly antibody Coombs tests. A diagnosis of autoimmune haemolytic anaemia refractory to oral prednisone was thus made. Therefore, IV immune-globulin was administered. Her prednisone was continued. Her haemoglobin remained stable. She was discharged with prednisone taper over the next 12 weeks. Thereafter, no recurrence of autoimmune haemolytic anamia was noted. Kumar A, et al. Furosemide-Associated Drug Reaction With Eosinophilia and Systemic Symptoms. American Journal of Therapeutics : 5 Oct 2020. Available from: URL: 803514213 http://doi.org/10.1097/MJT.0000000000001234

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Editorial comment: Details of this case report have previously been published and processed for Adis PV [see Reactions 1778 p212; 803432451].

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Reactions 14 Nov 2020 No. 1830