Difficult clinical management of antituberculosis DRESS syndrome complicated by MRSA infection

Abstract

Rationale:Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug-induced hypersensitivity reaction characterized by skin rash, fever, blood abnormalities, and multiple organ involvement. The diagnosis of DRESS syndrome is often delayed because of its variable presentation. Prompt withdrawal of the culprit drug is the definitive treatment. DRESS syndrome induced by antituberculosis drugs has rarely been reported.Patient Concerns:A 50-year-old man admitted to our hospital with recurrent episodes of progressive rash, fever, eosinophilia, lymphadenopathy, hepatic, and pulmonary involvement were experienced after repeat trials of the same antituberculosis drugs.Diagnoses:We diagnosed it as DRESS caused by antituberculosis drugs.Interventions:The case responded well to treatment with systemic corticosteroids and intravenous immunoglobulins. However, repeated bouts of infection with methicillin-resistant Staphylococcus aureus occurred during treatment (clavicular osteomyelitis and knee septic arthritis). He was cured after treatment with linezolid.Outcomes:The patient was discharged on day 112. At 8-month follow-up, there was no relapse of drug eruption and joint swelling.Lessons:Early diagnosis and prompt withdrawal of all suspected drugs is a key tenet of the treatment of DRESS. Our case report highlights the risks inherent in delayed diagnosis of DRESS and the challenges in the clinical management of this condition. Pulmonary manifestations with radiological changes on chest X-ray and CT can be seen in DRESS. These changes need to be differentiated from those caused by pulmonary infections. Clavicular osteomyelitis infected with MRSA may be caused by iatrogenic injury during subclavian vein catheterization. This type of MRSA infections should be treated for 4 to 6 weeks. Blood eosinophilia could be a useful marker of disease progression and treatment response in patients with DRESS. However, more experience and clinical evidence is needed to confirm this.

An unusual case of ATT induced DRESS syndrome

“…Other severe cutaneous drug eruptions (Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), Acute generalized exanthematous pustulosis (AGEP), Hyper eosinophilic syndrome), viral or bacterial infections, hypereosinophilic syndrome, Angio immunoblastic T cell lymphoma, lymphoma, Sézary syndrome, Acute cutaneous lupus erythematosus and autoimmune connective tissue disease may present with skin eruption, fever, and systemic symptoms and mimic DRESS [11,12] . Identification and prompt withdrawal of the offending drug is the mainstay of treatment for patients with drug reaction with eosinophilia and systemic symptoms.…”

Eosinophil Polymorphonuclear Leukocytes in TB: What We Know so Far

“…The drug reaction with eosinophilia and systemic symptom (DRESS) is a drug-induced life-threatening syndrome including severe eruption, fever, hypereosinophilia, and internal organ involvement (35). DRESS caused by anti-TB drugs is rarely reported and is mostly due to rifampicin (36). A 39-year-old Cambodian woman with TB presented with DRESS syndrome with hypereosinophilia at 1,400 cells/mm 3 , which was diagnosed to be induced by ethambutol (37).…”

A 27 years old Woman with Drug Reaction with Eosinophilic and Systemic Syndrome (DRESS) induced by 2nd Line treatment of Multi Drug Resistance Tuberculosis: A Case Report

“…The clinical manifestations of DRESS include drug-induced general skin rash, fever, lymphadenopathy, abnormal hematological findings, liver damage, as well as damage to other internal organs such as kidney, lung, heart, and pancreas. The condition is potentially life-threatening (3) . The most common drugs associated with DRESS include anticonvulsants (mostly aromatase derivatives), antimicrobial agents, particularly penicillin and sulfonamide-based agents, and antipyretic/ antiinflammatory analgesics (4) .…”