Delayed Onset Acute Liver Failure in Vancomycin-Induced DRESS Syndrome After Prednisone Taper

Abstract

A 26-year-old male with bilateral hip MRSA osteomyelitis being treated with Vancomycin was admitted to the hospital for fever and chest pain. He was found to have a troponin I level of 1.0 ng/mL, serum creatinine of 5.9 mg/dL and a random Vancomycin level of 117 mcg/mL. The patient's liver function tests were also elevated with total bilirubin 1.7μmol/L, AST 113 U/L, ALT 142 U/L and alkaline phosphatase 262 U/L. WBC count was 15 K/UL with 11% eosinophils. Urgent hemodialysis for Vancomycin induced acute renal failure was initiated and alternative antibiotics for osteomyelitis were initiated. Transthoracic echocardiogram revealed an ejection fraction of 55%. On day two of hospitalization the patient developed a diffuse maculopapular rash. A 10-day course of oral prednisone for drug-induced rash was initiated with full resolution of symptoms. Liver and renal function tests improved to reference range. Two days following completion of systemic steroid therapy the patient developed acute onset liver failure with studies revealing an AST 3,498 U/L, ALT 1171 U/L and INR 3.6. There was no hemodynamic compromise and abdominal ultrasound was unrevealing. The patient was emergently transferred to a liver transplant center for further management of acute liver failure. Repeat echocardiogram following transfer revealed an ejection fraction of 20%. The patient met clinical criteria for Drug Reaction with Eosinophila and Systemic Symptoms (DRESS) syndrome on the basis of extensive rash, recent peripheral eosinophilia and hepatitis with involvement of the kidneys and heart. Given the time course, prednisone was masking the underlying processes that eventually lead to development of acute liver failure. The patient survived with normalization of liver function tests following continued avoidance of Vancomycin and steroids. In review of literature, DRESS syndrome carries a mortality rate of 10-20%, with most fatalities caused by liver failure. Vancomycin is a frequently utilized antimicrobial that has emerged as increasingly associated with the development of DRESS syndrome and acute liver failure. This case demonstrates a rare presentation where acute liver failure was of delayed onset from recent steroid therapy. In the right clinical setting, a high index of suspicion is necessary for the recognition of this clinical entity as avoidance of inciting medication and steroid therapy can be life saving.