A CHALLENGING CASE OF DRESS WITH MYOCARDITIS

Abstract

Introduction DRESS is a severe delayed drug hypersensitivity reaction with systemic involvement. Myocarditis is an under-recognized sequela of DRESS with high mortality if not treated quickly. Case Description A 55-year-old male with poorly-controlled DM II, HTN, and CKD III presented to the ED with a progressive pruritic rash and intermittent chest pain 4 weeks after starting daptomycin, clindamycin, and metronidazole for treatment of toe osteomyelitis. Examination revealed generalized erythematous papules coalescing into plaques without mucosal involvement. After cessation of antibiotics and receiving a dose of prednisone prior to admission, he had intermittent fevers but negative blood cultures. He underwent toe amputation and post-operatively had ventricular trigeminy and elevated troponin. Over the next few days, he developed facial edema, lymphadenopathy, AKI, transaminitis, eosinophilia (peak 2250 cells/mL), and worsening ventricular ectopy. He met definite criteria for DRESS by RegiSCAR. Cardiac MRI revealed findings suspicious for myocarditis. He had rapid clinical improvement with 5 days of methylprednisolone 1 mg/kg/day, but peripheral eosinophil counts remained variable (150-1370 cells/mL). It was debated if adjunctive agents should be started, but given other objective improvement he was weaned to 3-month oral prednisone taper and eosinophil counts ultimately normalized without symptom relapse. Discussion This case highlights the fact that DRESS can present after antibiotic discontinuation and that eosinophilia may not always be a reliable indicator of the clinical course. A multidisciplinary approach to DRESS myocarditis is imperative.