A Rare Presentation of Clozapine-Induced DRESS Syndrome

Abstract

Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) is an uncommon side effect of certain medications. It causes a skin reaction, with eosinophilia and other organ involvement. This case describes a presentation of a 32-year-old female with a past medical history significant for schizophrenia and bipolar disorder who presented for a rash. She had been started on clozapine 10 days prior to admission. After extensive workup she was found to have DRESS syndrome secondary to clozapine use. This is the second reported case in the literature of clozapine-induced DRESS syndrome. This case is unique because it is the first case to present with the common manifestations of DRESS syndrome including eosinophilia, rash, lymphadenopathy, and organ involvement after clozapine use.

Unravelling cases of clozapine-related Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) in patients reported otherwise: A systematic review

“…Elevated c-reactive protein (CRP) levels were reported in six patients (22.2%) (Dimitri Valente et al, 2018;Manfredi and Sabbatani, 2007;Parekh et al, 2014;Pathak et al, 2019;Sanader et al, 2019) (Supplemental Table S6). Interferon gamma and human herpesvirus (HHV) 6 and 7 were evaluated only in two patients (4.8%) (Ben-Ari et al, 2008;Moazez et al, 2018) (Supplemental Table S6). In both cases, findings were negative for clozapine.…”

“…In 12 (44.4%) cases, clozapine was the only medication reported by the authors (Chatterjee and Safferman, 1997;Druss and Mazure, 1993;Fineschi et al, 2004;Fong et al, 2005;Luo et al, 2007;Nguyen et al, 2017;Pathak et al, 2019;Rami et al, 2006;Sanader et al, 2019;Schonfeldt-Lecuona and Connemann, 2002;Simonson and Kluger, 2018;Thatcher et al, 1995), whereas 15 patients received at least one co-medication other than clozapine (Supplemental Tables S3 and S5). Valproate was co-prescribed in six patients (22.2%) (Au et al, 2004;Chan et al, 2015;Dimitri Valente et al, 2018;Hassine et al, 2017;Parekh et al, 2014;Siddiqui et al, 2008) and lithium in six (22.2%) (Cohen et al, 2015;Hassine et al, 2017;Manfredi and Sabbatani, 2007;Moazez et al, 2018;Siddiqui et al, 2008;Suvarna et al, 2020), with two of them receiving both (Hassine et al, 2017;Siddiqui et al, 2008).…”

Clozapine-Related Diarrhea and Colitis

“…31 Several cases of DRESS have been reported in clozapine-treated patients. [32][33][34] The pathogenesis of DRESS has been hypothesized to be a complex interaction of accumulation of drug metabolites caused by a genetic deficiency of metabolizing enzymes, drug hypersensitivity associated with specific human leukocyte antigen genotypes, and possible virus-drug interactions. 31 It can be speculated whether DRESS and benign and transient clozapine-induced eosinophilia share some similarities.…”

Permanent renal sequelae secondary to drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome induced by quetiapine

“…Before that, in 2014, the FDA issued the same alert with ziprasidone, a second-generation antipsychotic medication, because the FAERS had received six reports of ziprasidone-associated DRESS 11. There are several published case reports of patients experiencing DRESS syndrome with other atypical antipsychotics like clozapine 12 13. There have not been any alert reports from the FDA with quetiapine, although information from the data submitted by the WHO global adverse drug reaction database (Vigibase) indicates that 46 cases of DRESS syndrome linked to quetiapine have been reported 14.…”

“…The clinical pharmacist searched and identified in the literature some cases that related DRESS syndrome with atypical antipsychotics,8–14 so quetiapine treatment was withdrawn and the corticosteroid dose was increased up to 1 mg/kg/day (methylprednisolone 90 mg IV). After these changes the skin lesions resolved completely and the eosinophil count started to decrease for the first time.…”