The Importance of Early Recognition: a Case of DRESS Syndrome

Abstract

This case examines the presentation, diagnosis, and treatment of an otherwise healthy 22-year-old female who presented to urgent care with abdominal pain and fever 27 days after her first exposure to trimethoprim/sulfamethoxazole (TMP/SMX). However, this exposure was not recognized for an extended amount of time. She was initially diagnosed with gastroenteritis and sent home on metronidazole. She failed to improve and presented days later to her primary care physician’s office where she was treated with levofloxacin for a suspected urinary tract infection. Her clinical syndrome continued to progress and she developed a widespread rash and generalized edema. She was admitted to the hospital after outpatient laboratory analysis was suggestive of liver and kidney damage. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS syndrome) was suspected in the setting of her fever, rash, elevated liver enzymes, peripheral eosinophilia, and dermatopathological findings. DRESS syndrome is a diagnosis of exclusion and requires a high level of clinical suspicion. The diagnosis was confirmed after review of her history revealed she received two courses of TMP/SMX nearly four weeks prior.