A Fatal Case of Vancomycin Associated Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome in a Septuagenarian

Abstract

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially life-threatening multi-system disorder with a mortality rate of up to 10%, due to severe hypersensitivity drug reaction involving the skin and multiple internal organ systems. We emphasize the increasing prevalence of DRESS syndrome secondary to vancomycin use. A 79-year-old woman presented to the hospital with complaints of right upper quadrant pain, intense pruritis, and jaundice of one-week duration. She was on vancomycin and cefepime for six weeks after a wound infection, and both the medicines were withheld a week ago due to the increasing creatinine. She was afebrile with a pulse-94/min, blood pressure-92/46 mm of Hg, and respiratory rate-14/min. She had scleral icterus, diffuse maculopapular rash, generalized edema, right upper quadrant tenderness, and a positive Murphy’s sign. Investigations revealed hemoglobin-10.5 gm/dl, white blood cell count-16.0 K/uL, peripheral eosinophil count-1730 K/uL, alkaline phosphatase-2742 U/L, aspartate transaminase-612 U/L, alanine transaminase-674 U/L, total bilirubin-14.2 mg/dl with a direct component of 9.5mg/dl, blood urea nitrogen-64 mg/dl, creatinine-5.01 mg/dl, glomerular filtration rate-8 ml/min and vancomycin trough level-10.8 mcg/ml. Imaging studies were unremarkable. The renal function improved after high dose steroids, N-acetylcysteine and withdrawal of vancomycin, but the progression of liver failure continued. Eventually, she passed away due to multiorgan failure. Vancomycin is a rare drug to cause DRESS syndrome with 31 cases reported to date. Early recognition of this condition can hasten proper treatment and recovery. Further research on the association of vancomycin trough levels and DRESS syndrome needs to be conducted.

Antibacterial antibiotic-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: a literature review

“…One case of vancomycin-induced ATN as a complication of DRESS is reported by Kim et al [ 53 ]. Vancomycin trough levels > 15 mg/L are an independent predictor of nephrotoxicity, but any relationship with DRESS has not been examined [ 54 ]. Based on our review, just in 3 cases out of 13 patients who trough level of vancomycin was reported for them, the level was higher than recommended range (23.08%).…”

Vancomycin-induced drug rash with eosinophilia and systemic symptoms (DRESS)

“…Vancomycin-induced DRESS tends to present with greater incidence of renal impairment compared with other drugs 2. Hepatic compromise from vancomycin-induced DRESS can be variable, with some patients presenting with significant transaminitis 3–5. Other patients may present with only a mild elevation in liver function tests; these patients tend to be younger and healthier, like the one presented in this report 6 7.…”

“…Other patients may present with only a mild elevation in liver function tests; these patients tend to be younger and healthier, like the one presented in this report 6 7. Previously published cases of vancomycin-induced DRESS report onset of symptoms after at least 3 weeks of antibiotic therapy 3–7. This suggests that patients who require greater duration of vancomycin therapy, such as those with endocarditis or osteomyelitis, are at greater risk of developing DRESS.…”

The effect of ifosfamide and mesna in the treatment of children with various types of cancer

“…Ifosfamide is a synthetic analog of cyclophosphamide and is used for treating various solid cancers (1). On the other hand, it is an antineoplastic and cytotoxic medicine used to treat and manage diverse cancers, including sarcoma, lymphoma, lung cancer (2), soft tissue, and bone sarcomas (3). It is considered a bifunctional alkylating agent and metabolized by the P450 cytochrome (CYP450) system to active components.…”

“…It is considered a bifunctional alkylating agent and metabolized by the P450 cytochrome (CYP450) system to active components. These active metabolites, including acrolein and ifosfamide mustard (3), inhibit DNA synthesis (2). There are two mechanisms for the action of these metabolites.…”