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DRESS syndrome: case report A 69-year-old man developed DRESS syndrome while receiving vancomycin and rifampicin [Rifadine]. The man, was admitted with a methicillin-resistant Staphylococcus lugdunensis infection with possible endocarditis, and he received vancomycin, rifampicin [dosage and route not stated] and gentamicin. His fever and back pain resolved, while his inflammatory syndrome improved; however, he developed acute renal failure, and gentamicin was discontinued. On day 23, his general condition deteriorated with the development of a biological inflammatory syndrome, maculopapular skin rash and reappearance of fever. Tests revealed hypereosinophilia, while blood smear revealed a few activated lymphocytes. DRESS syndrome was suspected. Rifampicin and vancomycin were discontinued on day 24 and 28, respectively. His clinical condition deteriorated, and he was transferred to an ICU in shock. He developed facial oedema and generalised erythroderma. Examination suggested septic shock with multiple organ failure, with hypothermia, renal failure, encephalopathy, hepatocellular failure with elevated transaminase levels, decreased prothrombin ratio and factor V levels, decompensated metabolic acidosis, thrombocytopenia and disseminated intravascular coagulation. Negative bacteriology samples and the worsening clinical picture confirmed DRESS syndrome, and he received corticosteroids and ventilation. A high ferritin level suggested a haemophagocytosis syndrome. A diabetes condition requiring insulin therapy was also diagnosed from his DRESS syndrome. His erythroderma, confusion syndrome, haemodynamic failure, renal and liver failure and hypereosinophilia rapidly normalised. On day 55, while receiving prednisone, renal failure, encephalopathy and an extensive maculopapular rash reappeared. Blood count revealed a moderate progressive rise in eosinophilia. An acute exacerbation of DRESS syndrome associated with a decrease in corticosteroids was hypothesised. PCR tests for cytomegalovirus, Epstein-Barr virus and human herpes virus-6 were positive. His corticosteroid dosage was increased, and his renal function and exanthema improved; however, hepatocellular failure persisted. His liver parameters then progressively normalised. At follow-up, there was a favourable trend with no recurrence of sepsis. Author comment: Because of the long delay in the onset of symptoms after the introduction of the drug, it is sometimes difficult to establish the drug responsible for the DRESS syndrome. In our case, for example, both vancomycin and rifampicin could have been implicated. Cariou ME, et al. [Vancomycin-induced DRESS syndrome: a case report]. Annales de Biologie Clinique 71: 190-5, No. 2, Mar 2013. Available from: URL: http:// dx.doi.org/10.1684/abc.2013.0807 [French; summarised from a translation] 803095826 France

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Reactions 23 Nov 2013 No. 1479