Drug rash with eosinophilia and systemic symptoms caused by the dietary supplement diindolylmethane

Abstract

Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe adverse drug reaction that is potentially life threatening with a mortality rate up to 10%. It is characterized by a variable combination of severe skin eruption, fever, lymphocyte activation (enlarged lymph nodes and atypical lymphocytes), eosinophilia, and internal organ involvement of which the liver is the most common affected organ. Compared with other cutaneous drug reactions, DRESS is characterized by a late onset, usually 2-8 weeks after the initiation of the drug (mainly antiepileptic drugs, allopurinol, and antibiotics) therapy, and a longer duration of symptoms despite discontinuation of the culprit drug. For the first time, we report a case of DRESS that is caused by a dietary supplement. Our patient reacted to diindolylmethane (DIM), which is derived from cruciferous vegetables such as broccoli, cauliflower, cabbage, kale, and Brussels sprouts. It is also an investigational drug being used in treating conditions related to human papilloma virus infection, such as cervical intraepithelial neoplasia and recurrent respiratory papillomatosis, and it is considered a potential chemopreventive agent. The current frequency of DIM consumption is unknown. Previous studies on the safety of DIM showed no severe adverse reactions.