Diphenylhydantoin Induced DRESS Syndrome: A Case Report

Abstract

Case Report 46Drug Rash with Eosinophilia and Systemic Symptoms" (DRESS) syndrome is a severe adverse drug reaction. The drugs most often implicated are anti-convulsants, bupropion, sulfonamides, sulfasalazine, allopurinol, minocycline, abacavir and neviparine. There are also immune and infectious causes that can lead to DRESS syndrome. A 70-year-old female patient had undergone endovascular coil embolization for intracranial aneurysm and experienced a generalised seizure postoperatively. She had been given diphenylhidantoin (DPH). Six days after DPH therapy, the patient had complained of widespread skin rash. Although DPH was replaced with levetiracetam afterwards, the skin rash deteriorated, causing facial oedema and swelling of the tongue. She had severe facial oedema with swelling of the tongue, causing disturbance of breathing. On the second day in the critical care unit, the patient's breathing deteriorated, leading successively to intubation and mechanical ventilation. The patient's rash was still persistent and the results of a punch biopsy taken from the lesions revealed superficial perivascular dermatitis involving spongiotic eosinophils compatible with spongiotic drug eruption. As a result, it is important to realise that medications we use can be the cause of a range of reactions ranging from simple rash to life threatening syndromes.Key Words: Drug reactions, dress syndrome, diphenylhidantoin AbstractOn physical examination at presentation, the patient had fever (38.8°C), diffuse erythema involving trunk and extremities, sparing palms of hands and feet, facial oedema and angioedema of the lips and tongue (Figures 1, 2). The laboratory findings on critical care arrival were as follows: WBC 17,000, PLT 335,000, Hb 10.5 gr dL -1 , Htc 33%, eosinophils 22.7%, total bilirubin 0.6 mmol, BUN 82 gr, creatinine 1.47 mg dL -1 and GFR 38 mL kg -1. The CBC revealed anisopoichilocytosis and eosinophilia. On the chest x-ray there was thickening of the middle and lower peribronchial zones of the lung parenchyma. Abdominal ultrasound showed minimal enlargement of the spleen and liver from the midclavicular line. Ursodeoxycholic acid therapy was started due to the potential for toxic hepatitis. In consensus with the dermatology department, the patient was given 80 mg day -1 prednisolone.On the second day of hospitalization in the critical care unit, the patient's breathing deteriorated, leading successively to intubation and mechanical ventilation. The patient's rash was still persistent and the results of the punch biopsy taken from the lesions revealed superficial perivascular dermatitis involving spongiotic eosinophils compatible with spongiotic drug eruption. Continuation of the prednisolone therapy until regression of the rash and cessation by reducing to a dosage of 10 mg week -1 was planned.On the third day of hospitalization, E. coli was detected in the urine culture and Ceftriaxone 2x1 gr was given accordingly.On the fifth day of hospitalization, the patient's skin lesions started to fade and, as her respir...

Phenytoin Induced Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome: A Clinical Case Report

“…2,4 Applying the Naranjo adverse drug reaction probability scale, there was a presumable relationship (score of 7) between the development of the DRESS syndrome and treatment with phenytoin as shown in Table 1.The patient profile in this case was similar to other reported cases in terms of the presentation and onset of clinical manifestations. 2,3,18 The most important step in the treatment of patients suffering from DRESS syndrome is the immediate withdrawal of the inciting drug. By far, systemic corticosteroids administered IV alone or followed by oral corticosteroids is the mainstay treatment which can produce rapid improvements in symptoms.…”

“…2,4 Applying the Naranjo adverse drug reaction probability scale, there was a presumable relationship (score of 7) between the development of the DRESS syndrome and treatment with phenytoin as shown in Table 1.The patient profile in this case was similar to other reported cases in terms of the presentation and onset of clinical manifestations. 2,3,18…”

“…Adjustments should be made according to the severity of the disease and any underlying co-morbidities. 9,11,18 Supportive therapy consists of antipyretics, antihistamines, topical steroids and moisturizers. 4 Though the use of intravenous immunoglobulin (IVIG),immunosupressants and anti-viral treatment such as ganciclovir has been proposed, such management is not validated by well-designed controlled studies.…”

Non-Aromatic Anticonvulsant (Divalproex sodium) Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome

“…Due to its manifestation of a wide spectrum of clinical features, DRESS is often confused with druginduced hypersensitivity reactions. The classic triad for DRESS is fever, eosinophilia, and visceral organ involvement [11]. Although Bocquet et al first presented the diagnostic criteria for DRESS, a widely used scoring criterion by the Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) group is used to diagnose DRESS syndrome (Table 3) [4,12].…”