Drug reaction with eosinophilia and systemic symptoms syndrome (DRESS) syndrome associated with azithromycin presenting like septic shock: a case report

Journal of Medical Case Reports

Timothy E Albertson²  Mark C Henderson¹  Lam-Phuong Nguyen²  Narin Sriratanaviriyakul² 

[1] Department of Internal Medicine, University of California, Davis, 4150 V Street, Sacramento, CA 95817, USA;VA Northern California Health Care System, 10535 Hospital Way, Mather, CA 95655, USA

关键词: Azithromycin hypersensitivity;    Erythroderma;    Eosinophilia;    Drug-induced hypersensitivity syndrome;    Drug allergy;    DRESS syndrome;   

Others  :  1181020
DOI  :  10.1186/1752-1947-8-332

 received in 2014-04-10, accepted in 2014-08-13,  发布年份 2014

【 摘 要 】

Introduction

Drug reaction with eosinophilia and systemic symptoms syndrome is a potentially life-threatening cutaneous hypersensitivity reaction characterized by extensive mucocutaneous eruption, fever, hematologic abnormalities including eosinophilia and/or atypical lymphocytosis, and extensive organ involvement. The drugs most often responsible for causing drug reaction with eosinophilia and systemic symptoms syndrome are anticonvulsants, antimicrobial agents and antipyretic or anti-inflammatory analgesics. Although azithromycin is widely prescribed in clinical practice, serious cutaneous reactions from this agent have been rarely described. We report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin.

Case presentation

A 44-year-old previously healthy Caucasian man with history of tobacco use presented to his primary care physician with fever and productive cough. He was prescribed azithromycin, promethazine hydrochloride and dextromethorphan hydrobromide syrup. One week later, he developed a blistering erythematous rash over both hands, which over the next two weeks spread to involve nearly his entire body surface, sparing only his face. He was admitted to an outside hospital with signs of systemic inflammatory response syndrome and severe sepsis, presumably from a skin infection. Despite aggressive therapy he deteriorated, with worsening diffuse erythema, and was transferred to our institution. He developed multiple organ failure requiring ventilatory and hemodynamic support. Pertinent laboratory studies included a leukocytosis with a white blood cell count of 17.6×10⁹/L and 47% eosinophils. A skin biopsy showed evidence of spongiotic lichenoid dermatitis with eosinophils and neutrophils, compatible with a systemic drug-induced hypersensitivity reaction. Our patient was started on high-dose steroids and showed dramatic improvement within 48 hours.

Conclusions

We report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin exposure. Clinicians should be aware of this potentially devastating complication from this commonly prescribed medication.

【 授权许可】

   
2014 Sriratanaviriyakul et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

【 参考文献 】

• [1]Bigby M, Jick S, Jick H, Arndt K: Drug-induced cutaneous reactions. A report from the Boston Collaborative Drug Surveillance Program on 15,438 consecutive inpatients, 1975 to 1982. JAMA 1986, 256:3358-3363.
• [2]Alanko K, Stubb S, Kauppinen K: Cutaneous drug reactions: clinical types and causative agents. A five-year survey of in-patients (1981-1985). Acta Derm Venereol 1989, 69:223-226.
• [3]Walsh SA, Creamer D: Drug reaction with eosinophilia and systemic symptoms (DRESS): a clinical update and review of current thinking. Clin Exp Dermatol 2011, 36:6-11.
• [4]Wang F, Li Y, Mo Y, Shen C, Yang L, Zhang X: Cutaneous adverse drug reactions: an 8-year retrospective study on hospitalized patients in Southern China. Indian J Dermatol Venereol Leprol 2012, 78:488-490.
• [5]Bocquet H, Bagot M, Roujeau JC: Drug-induced pseudolymphoma and drug hypersensitivity syndrome (Drug Rash with Eosinophilia and Systemic Symptoms: DRESS). Semin Cutan Med Surg 1996, 15:250-257.
• [6]Harris JA, Kolokathis A, Campbell M, Cassell GH, Hammerschlag MR: Safety and efficacy of azithromycin in the treatment of community-acquired pneumonia in children. Pediatr Infect Dis J 1998, 17:865-871.
• [7]Kardaun SH, Sidoroff A, Valeyrie-Allanore L, Halevy S, Davidovici BB, Mockenhaupt M, Roujeau JC: Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol 2007, 156:609-611.
• [8]Husain Z, Reddy BY, Schwartz RA: DRESS syndrome: part II. Management and therapeutics. J Am Acad Dermatol 2013, 68:709. e1-9; quiz 718-720
• [9]Cacoub P, Musette P, Descamps V, Meyer O, Speirs C, Finzi L, Roujeau JC: The DRESS syndrome: a literature review. Am J Med 2011, 124:588-597.
• [10]Bauer KA, Brimhall AK, Chang TT: Drug reaction with eosinophilia and systemic symptoms (DRESS) associated with azithromycin in acute Epstein-Barr virus infection. Pediatr Dermatol 2011, 28:741-743.
• [11]Schmutz JL, Trechot P: [DRESS associated with azithromycin in a child]. Ann Dermatol Venereol 2013, 140:75.
• [12]Pursnani A, Yee H, Slater W, Sarswat N: Hypersensitivity myocarditis associated with azithromycin exposure. Ann Intern Med 2009, 150:225-226.
• [13]Ichiche M, Kiesch N, DeBels D: DRESS syndrome associated with HHV-6 reactivation. Eur J Intern Med 2003, 14:498-500.
• [14]Picard D, Janela B, Descamps V, D’Incan M, Courville P, Jacquot S, Rogez S, Mardivirin L, Moins-Teisserenc H, Toubert A, Benichou J, Joly P, Musette P: Drug reaction with eosinophilia and systemic symptoms (DRESS): a multiorgan antiviral T cell response. Sci Transl Med 2010, 2:46ra62.