Reactions 1479, p16 - 23 Nov 2013 S Ethambutol DRESS in an elderly patient: case report A 68-year-old woman developed drug reaction with eosinophilia and systemic symptoms (DRESS) with early features resembling Stevens-Johnson Syndrome (SJS) during treatment with ethambutol for tuberculous pericarditis. The woman had been receiving ethambutol [dosage and route not stated], isoniazid, rifampicin and levofloxacin for 7 weeks when she was admitted to the emergency department. On admission she had maculopapular rashes on her extremities and trunk in addition to painful erosions on her oral mucosa. Prominent targetoid lesions, blisters and a positive Nikolsky sign were seen on physical examination. She also had acute conjunctivitis and a high fever. Her laboratory results showed the following: CRP 12.9 mg/dL and leukocytes 3 810 /mm 3 . Stevens-Johnson Syndrome (SJS) was suspected and her anti-tuberculous medications were withdrawn. She was treated with methylprednisolone and gradually her oral mucosal lesions and skin rash improved. Her CRP had dropped to 3.5 mg/dL and her fever had resolved by day 9 so her dose of methylprednisolone was tapered down. She began to deteriorate on day 11. She had maculopapular eruptions and painful cervical lymphadenopathy. The new cutaneous lesions were different from the previous ones which had suggested SJS. Her laboratory tests showed the following: leukocytosis with hypereosinophilia, atypical lymphocytosis, elevated ALT and acute renal dysfunction. The woman had a RegiSCAR score of 9 which suggested definite DRESS. A renal biopsy showed diffuse eosinophilic infiltrations in her renal interstitium. She was treated with haemodialysis and high dose systemic corticosteroids. She began to recover and was discharged after being hospitalised for a month. Corticosteroid treatment was continued for another month. Drug patch tests and lymphocyte transformation tests were conducted 4 months later and both these tests confirmed ethambutol as the causative agent in this case. Author comment: "[I]t remains difficult to determine whether the present case is a SJS-DRESS overlap or DRESS from the beginning that developed a delayed flare-up...In conclusion, we report here a case of ethambutol-induced DRESS initially presenting with features of SJS, in which the culprit drug was confirmed by patch test and [lymphocyte transformation tests]." Kim J-Y, et al. A case of drug reaction with eosinophilia and systemic symptoms induced by ethambutol with early features resembling Stevens-Johnson syndrome. Acta Dermato-Venereologica 93: 753-754, No. 6, Oct 2013. Available from: URL: http://dx.doi.org/10.2340/00015555-1600 - South Korea 803096002 1 Reactions 23 Nov 2013 No. 1479 0114-9954/13/1479-0001/$14.95 Adis © 2013 Springer International Publishing AG. All rights reserved

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Reactions 1479, p16 - 23 Nov 2013

SEthambutol

DRESS in an elderly patient: case reportA 68-year-old woman developed drug reaction with

eosinophilia and systemic symptoms (DRESS) with earlyfeatures resembling Stevens-Johnson Syndrome (SJS) duringtreatment with ethambutol for tuberculous pericarditis.

The woman had been receiving ethambutol [dosage androute not stated], isoniazid, rifampicin and levofloxacin for7 weeks when she was admitted to the emergencydepartment. On admission she had maculopapular rashes onher extremities and trunk in addition to painful erosions on heroral mucosa. Prominent targetoid lesions, blisters and apositive Nikolsky sign were seen on physical examination. Shealso had acute conjunctivitis and a high fever. Her laboratoryresults showed the following: CRP 12.9 mg/dL and leukocytes3 810 /mm3. Stevens-Johnson Syndrome (SJS) was suspectedand her anti-tuberculous medications were withdrawn. Shewas treated with methylprednisolone and gradually her oralmucosal lesions and skin rash improved. Her CRP haddropped to 3.5 mg/dL and her fever had resolved by day 9 soher dose of methylprednisolone was tapered down. She beganto deteriorate on day 11. She had maculopapular eruptionsand painful cervical lymphadenopathy. The new cutaneouslesions were different from the previous ones which hadsuggested SJS. Her laboratory tests showed the following:leukocytosis with hypereosinophilia, atypical lymphocytosis,elevated ALT and acute renal dysfunction.

The woman had a RegiSCAR score of 9 which suggesteddefinite DRESS. A renal biopsy showed diffuse eosinophilicinfiltrations in her renal interstitium. She was treated withhaemodialysis and high dose systemic corticosteroids. Shebegan to recover and was discharged after being hospitalisedfor a month. Corticosteroid treatment was continued foranother month. Drug patch tests and lymphocytetransformation tests were conducted 4 months later and boththese tests confirmed ethambutol as the causative agent in thiscase.

Author comment: "[I]t remains difficult to determinewhether the present case is a SJS-DRESS overlap or DRESSfrom the beginning that developed a delayed flare-up...Inconclusion, we report here a case of ethambutol-inducedDRESS initially presenting with features of SJS, in which theculprit drug was confirmed by patch test and [lymphocytetransformation tests]."Kim J-Y, et al. A case of drug reaction with eosinophilia and systemic symptomsinduced by ethambutol with early features resembling Stevens-Johnson syndrome.Acta Dermato-Venereologica 93: 753-754, No. 6, Oct 2013. Available from: URL:http://dx.doi.org/10.2340/00015555-1600 - South Korea 803096002