DRESS vs. DRSS: The Heterogenous Presentation of Drug Reaction with Eosinophilia and Systemic Symptoms

Abstract

Background: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is typically characterized by extensive skin rash with associated visceral organ involvement, fever, lymphadenopathy, and eosinophilia. The condition typically has a two-to-eight-week latency period in symptom development following initiation of offending drug. Additionally, hepatic injury is the most common visceral organ involved with separate long-term sequelae of DRESS including autoimmune conditions such as autoimmune thyroid disease, vitiligo, and lupus erythematosus. Case Presentation: An 18-year-old, college-attending male, with a two-month history of Bactrim use for acne treatment, presented with an eight-day history of diffuse rash without mucosal involvement. Patient initially developed a pruritic rash that responded to Zyrtec and the discontinuation of Bactrim. Patient later became febrile and the rash returned. The rash was described to start as a pink, maculopapular rash that coalesced to become more diffuse, violaceous plaques. The patient presented to campus health services where he was received a dose of epinephrine and methylprednisolone due to anaphylaxis concerns along with ceftriaxone for meningitis concerns, and referred to the hospital for further evaluation. His hospital workup was significant for leukocytosis without eosinophilia with accompanying transaminitis, hyperbilirubinemia, elevated lactate, and abnormal coagulation studies. Rickettsia labs and blood cultures were negative, ruling out rocky mountain spotted fever and meningococcemia. Patient also had a normal EKG and low TSH with a normal free T4. Given these findings and patient’s recent Bactrim use, the patient was diagnosed with DRESS and started on prednisone. Over the next few days, the transaminitis and hyperbilirubinemia improved. Given the improvement in symptoms and no new presentation of organ involvement, patient was discharged with dermatology follow-up for a steroid taper and endocrinology assessment for thyroid abnormalities secondary to or independent from DRESS. Discussion: Despite its name, DRESS can present without eosinophilia. Early recognition despite the condition’s heterogenous presentation is imperative for triaging severity of disease and treatment initiation with glucocorticoids, discontinuation of offending drug, and appropriate supportive care. Additionally, the use of Bactrim for the acne treatment should be used with caution given its association with this severe drug reaction.