PARANOID ABOUT RASHES: OLANZAPINE INDUCED DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS

Abstract

<h3>Introduction</h3> Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a severe adverse reaction caused by more than 50 prescription drugs. Although antiepileptics and antibiotics account for most cases, the variety of potential drug classes can make identifying the causative agent challenging. <h3>Case Description</h3> Thirty-year-old male was initially admitted to the medical ICU for treatment of alcoholic hepatitis. Hospital course was complicated by an upper GI bleed, hepatic encephalopathy, respiratory failure, and multiple infections requiring repeated courses of antibiotics. Two months into the hospital stay, he developed a diffuse pruritic maculopapular rash that progressed to cover his trunk, neck and extremities. Workup revealed elevated aminotransferases along with worsening creatinine, leukocytosis, and eosinophilia concerning for DRESS. Medication review revealed the patient received several days of vancomycin in addition to a month-long course of olanzapine for paranoia suffered while inpatient. Patient first received olanzapine 8 weeks prior to symptom onset. HLA-A*32:01 was obtained and negative. Topical steroids were applied, and potential offending medications held. Rash resolved over the next few weeks followed by clinical improvement. Olanzapine was added to the allergy list to avoid future episodes. <h3>Discussion</h3> The diagnosis of DRESS can be challenging as it often occurs in the inpatient setting with patients exposed to varying amounts of multiple drugs, including less common agents such as olanzapine. When multiple culprit drugs have been administered, evaluating factors such as timeline of exposure and genetic predisposition may be helpful in identifying the cause. This can lead to prompt removal of the offending drug minimizing morbidity and mortality.