Trimethoprim-Sulfamethoxazole-Induced Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Complicated by Acute Liver Failure

Abstract

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a delayed adverse drug reaction that is characterized by fever, cutaneous manifestation, enlarged lymph nodes, hematologic abnormalities, and organ involvement. Multiple medications have been reported to cause DRESS with the presentation varying from drug to drug. Some cases are mild and can be managed by stopping the causative agent along with supportive measures; however, other cases can lead to multi-organ failure requiring systemic corticosteroids and organ transplant. Acute liver failure is a rare manifestation of DRESS. We report a patient who had recently completed a course of trimethoprim-sulfamethoxazole and presented with low-grade fever, diffuse skin rash, eosinophilia, elevated liver enzymes, acute kidney injury, and thrombocytopenia. DRESS was subsequently diagnosed based on history, physical examination, and relatively negative workup for an alternate diagnosis. The patient eventually showed improvement with steroid therapy without the need for a liver transplant. Due to its pharmacogenetic susceptibility, it is essential to recommend avoiding the causative medication for the patient's family members.

Guide to the management of acne in primary care

“…Patients should therefore be counselled to discontinue the drug should any rash develop and seek medical attention if it is severe or associated with mucositis. We recommend monitoring full blood count (FBC), renal function and liver function tests (LFTs) at baseline and after two to six weeks of therapy because trimethoprim can adversely affect renal and liver function 23 . Patients with reduced renal function, diabetes and those prescribed concomitant medications that can increase risk of hyperkalaemia should have ongoing monitoring 24 …”