Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)

A Fatal Case of Vancomycin Associated Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome in a Septuagenarian

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially life-threatening multi-system disorder with a mortality rate of up to 10%, due to severe hypersensitivity drug reaction involving the skin and multiple internal organ systems. We emphasize the increasing prevalence of DRESS syndrome secondary to vancomycin use. A 79-year-old woman presented to the hospital with complaints of right upper quadrant pain, intense pruritis, and jaundice of one-week duration. She was on vancomycin and cefepime for six weeks after a wound infection, and both the medicines were withheld a week ago due to the increasing creatinine. She was afebrile with a pulse-94/min, blood pressure-92/46 mm of Hg, and respiratory rate-14/min. She had scleral icterus, diffuse maculopapular rash, generalized edema, right upper quadrant tenderness, and a positive Murphy’s sign. Investigations revealed hemoglobin-10.5 gm/dl, white blood cell count-16.0 K/uL, peripheral eosinophil count-1730 K/uL, alkaline phosphatase-2742 U/L, aspartate transaminase-612 U/L, alanine transaminase-674 U/L, total bilirubin-14.2 mg/dl with a direct component of 9.5mg/dl, blood urea nitrogen-64 mg/dl, creatinine-5.01 mg/dl, glomerular filtration rate-8 ml/min and vancomycin trough level-10.8 mcg/ml. Imaging studies were unremarkable. The renal function improved after high dose steroids, N-acetylcysteine and withdrawal of vancomycin, but the progression of liver failure continued. Eventually, she passed away due to multiorgan failure. Vancomycin is a rare drug to cause DRESS syndrome with 31 cases reported to date. Early recognition of this condition can hasten proper treatment and recovery. Further research on the association of vancomycin trough levels and DRESS syndrome needs to be conducted.

DRESS syndrome due to vemurafenib treatment: switching BRAF inhibitor to solve a big problem

We present a case report of an early-onset drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) induced by vemurafenib (BRAF inhibitor) in a middle-age man affected by a metastatic, BRAF mutant melanoma who was started on first-line metastatic treatment with vemurafenib and cobimetinib.After initiating the treatment, the patient presented an extensive cutaneous rash with eosinophilia and renal impairment. Due the constellation of signs and symptoms, a diagnosis of DRESS syndrome was made which strongly contraindicated the reintroduction of vemurafenib due to its hypersensibility reaction. Thus, vemurafenib was stopped immediately, and we started corticoid treatment with clinical improvement.Due to the contraindication to start vemurafenib again, after multidisciplinary view of the case and having balanced the risks and benefits, we successfully performed a switch to another BRAF inhibitor in a progressively ascending pattern, without any skin toxicity and with a good response of the metastatic melanoma.

Drug-induced hypersensitivity syndrome caused by valproic acid as a monotherapy for epilepsy: First case report in Asian population

Valproic acid (VPA) is a broad-spectrum antiseizure drug used for a variety of clinical conditions, such as epilepsy and mood disorders. Drug-induced hypersensitivity syndrome (DRESS) accompanied by hyponatremia, thrombocytopenia, hypoalbuminemia and elevated aminotransferase has never been reported as an adverse effect of VPA monotherapy during titration for epilepsy in Asian population. Hereby, we present the case of a 73-year-old Chinese male who suffered from DRESS and other complications two weeks after initiating VPA treatment for epilepsy. Understanding the risk associated with VPA-induced DRESS, and taking effective measures to avoid the severe side effects are necessary.