Case Report of Drug Rash with Eosinophilia and Systemic Symptoms Demonstrating Human Herpesvirus‐6 Reactivation

Abstract

Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe drug-induced hypersensitivity syndrome that presents with diffuse cutaneous eruptions, fever, and multiorgan involvement. Here we present a pediatric case of DRESS complicated by human herpesvirus (HHV)-6 reactivation. After 1 week of sulfasalazine, our patient developed a diffuse morbilliform eruption. Sulfasalazine was discontinued. The patient presented to the emergency department soon thereafter with worsening eruption, fever, rigors, facial edema, and lymphadenopathy. Methylprednisolone was initiated. Peripheral smear did not demonstrate eosinophilia but showed toxic granulation with atypical lymphocytes. Transaminase levels and white blood cell count quickly became elevated, with increased eosinophils, suggesting DRESS. During the methylprednisolone taper, our patient experienced symptom exacerbation, acute hepatitis, and HHV-6 seroconversion, indicating HHV-6 reactivation as the cause. As demonstrated by our patient, a decelerated methylprednisone taper is important because of potential symptom flaring during taper. Additionally, in the care of individuals with DRESS, HHV-6 is often tested for upon admission and not repeated. Delay in the rise of titers necessitates repeat testing.

Severe delayed skin reactions related to drugs in the paediatric age group: A review of the subject by way of three cases (Stevens–Johnson syndrome, toxic epidermal necrolysis and DRESS)

“…6 A type IVb 7 hypersensitivity reaction has been proposed, but viral infections, particularly herpesvirus 6, have been shown to play a role. 8 Reactivation of herpesvirus infection concurrent with drug hypersensitivity is considered specific of DRESS. 9,10 It is also well established that individuals with specific HLA haplotypes are predisposed to develop this syndrome when exposed to certain medications.…”

Immunopathogenic Insights on Preferential Human Herpesvirus-6 Reactivation in Drug Rash With Eosinophilia and Systemic Symptoms: A Scoping Review

“…Multi-organ system involvement have been reported with evidence of HHV-6 reactivation within specific organ parenchyma or in serum, sometimes leading to fatal sequelae related to the liver, 12 - 19 kidney, 7 , 12 , 20 - 23 gastrointestinal tract, 24 , 25 bone marrow, 12 , 26 - 28 lymph nodes, 12 , 29 , 30 peripheral and central nervous system, 7 , 31 - 34 heart, 13 , 35 and lung. 36 , 37 There have been many reports of new-onset autoimmune disease, as well.…”

Liver transplantation after DRESS syndrome: A case report and review of the literature

“…A few case reports recorded in the literature showed DRESS syndrome and significant hepatic injury (Table 1). In these studies, most of the patients were treated with corticosteroids 9‐30 . Among patients needing liver transplantation, there was approximately 50% perioperative mortality.…”