Jonathan Pickos, DO
Detroit Medical Center/Wayne State University
Detroit
Disclosure information not submitted.
Aryan Shiari, MD
Pulmonary & Critical Care / Clinical Educator Fellow, PGY-V
Wayne State University/Detroit Medical Center, United States
Disclosure information not submitted.
Sara Lee, MD, MPH
Assistant Professor of Critical Care Medicine
Wayne State University, United States
Disclosure information not submitted.
Title: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) causing Shock with Liver Failure
Case Report Body
Introduction: DRESS is a rare life-threatening hypersensitivity reaction inducible by multiple medications, occurring 2-6 weeks after exposure. Due to the non-specificity of key characteristics of skin manifestations, hematologic abnormalities and multi-organ involvement, DRESS is difficult to recognize and diagnosed by exclusion. In the intensive care unit (ICU), treatment regimens are often extensive and identifying the causative drug for DRESS is often challenging.
Description: A 43-year-old woman initially hospitalized nine-days ago for alcoholic hepatitis was transferred to the ICU with hypotension, tachycardia, abdominal pain, and acute encephalopathy. Empirical treatment of sepsis was started with cefepime, vancomycin, and metronidazole. Laboratory results showed rising leukocytosis and eosinophilia at 1.7 cells per cubic millimeter (K/CUMM). Patient developed worsening mentation, shock requiring vasopressors, mechanical ventilation, and renal failure. Antibiotics were substituted to meropenem, micafungin, and vancomycin. On day three, a new rash developed covering the thorax, abdomen, and lower extremities with dusky-colored palpable purpura and peripheral erythema coalescing into plaques. Skin biopsy revealed vacuolar interface dermatitis with superficial perivascular mixed infiltrate and eosinophils consistent with DRESS. Causative agents were identified as either vancomycin or cefepime due to patient exposure two weeks prior. As cultures remained negative for growth, all antimicrobials were discontinued. Intravenous immunoglobulin (IVIG) at 1 mg/kg were given for two-days and methylprednisolone 1 mg/kg daily for four-days with subsequent resolution of rash, eosinophilia, and shock.
Discussion: Herein we present a case of severe DRESS with associated shock, diffuse purpuric rash, eosinophilia, and acute on chronic liver failure. The suspected agents, vancomycin and cefepime, have been reported to cause DRESS. As early identification and cessation of inducing agents is key to reversing end-organ damage, early recognition of DRESS remains crucial. IVIG can be considered as it may be beneficial in refractory cases while harmful in others. Based on expert consensus, severe cases may warrant systemic corticosteroids. In this case, IVIG with high dose systemic corticosteroids resulted in resolution of shock.