EC Clinical and Medical Case Reports

Introduction: DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome is a severe toxidermia that combines skin manifestations with systemic involvement. Cardiac involvement has been rarely reported. Nevertheless, its occurrence is often a poor prognostic factor.

Case Description: This was a 44-year-old man with a history of bipolar disorder who was recently diagnosed, and put on carbamazepine. He was admitted to the medical ward with fever, extensive maculo-papular skin lesions with acute renal failure with preserved diuresis that had been evolving for 7 days. The diagnosis of a severe toxidermia type DRESS syndrome was evoked at this stage (probable according to the RegiSCAR score).

Carbamazepine was stopped and the patient received corticosteroids and antihistamines. Two days later, he developed acute respiratory failure and was transferred to the ICU. Examination showed a conscious, febrile patient in respiratory distress, hemodynamically stable, a generalized maculopapular and desquamative rash, facial oedema, aphthous ulceration on the inside of the cheeks and on the palate, and bilateral axillary and cervical lymphadenopathies. Electrocardiogram showed a sinus tachycardia with negative T waves.

Laboratory investigations revealed: eosinophil count at 253 el/mm³, creatinine level at 110 µmol/l, C-reactive protein (CRP) was found as 125 mg/l, troponin-hs level of 570 ng/ml and N-terminal pro-hormone of basic natriuretic peptide (NT-proBNP) at 4594 pg/l. An echocardiogram showed a moderately impaired left ventricular ejection fraction at 43% with homogeneous kinetics and elevated left ventricular filling pressures. A chest CT scan showed perihilar flaky alveolar opacities and bilateral pleural effusion. Viral serologies: EBV, CMV, Herpes virus 6 showed previous immunity. Hepatitis serology was negative as well as the immunological assessment. The skin biopsy showed typical lesions of toxidermia. A DRESS syndrome complicated by myocarditis and acute lung oedema was considered. The patient was treated with non-invasive ventilation, diuretics and corticosteroids with improvement after 48 hours.

Conclusion: Dress syndrome can become complicated even after withdrawal of the presumed culprit treatment. Close monitoring is necessary to ensure early diagnosis.

Keywords: Drug Reaction with Eosinophilia and Systemic Symptoms; Myocarditis; Carbamazepine

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