Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome

Abstract

A 78-year-old woman presented to the emergency department in June 2022 with progressively worsening rash for 4 days.The patient recently completed a 4-week course of vancomycin for right-hand abscess and Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.On physical examination, the patient was afebrile with a temperature of 99.5 degrees Fahrenheit, a heart rate of 81 beats per minute, blood pressure of 79/39 mmHg, a respiratory rate of 17, and oxygen saturation of 91 % on room air.The patient was alert and oriented to person, place, and time, but she was in mild distress and ill-appearing with dry mucous membranes but without oral ulcers, facial edema, or lymphadenopathy.Her cardiac, pulmonary, and abdominal examinations were unremarkable.Examination of her extremities showed a right dorsal hand wound that was clean, dry, and intact with mild erythema, yet without purulent drainage or surrounding erythema.Examination of the integument system showed diffuse, maculopapular blanchable rash on the chest, abdomen, arms, and legs involving greater than 80 % of her body surface area (BSA) as seen on Figure 1.There were no vesicular or bullous lesions, peeling, drainage, or tenderness to palpation on examination.The initial laboratory tests showed kidney injury with serum creatinine (SCr) of 1.98 mg/dL (baseline, 0.9 mg/dL), alanine aminotransferase (ALT) of 19 U/L (normal, 0-34 U/L), aspartate aminotransferase (AST) of 18 U/L (normal, 15-46 U/L), alkaline phosphatase of 72 U/L (normal, 38-126 U/L), and elevated C-reactive protein (CRP) of 51.6 mg/L (normal, 0.0-9.9mg/L).Repeat laboratory tests 3 days later showed new leukocytosis of 13.3 × 10 3 /uL (normal, 3.6-10.7 × 10 3 /uL) and absolute eosinophilia of 2.0 × 10 3 /uL (normal, 0.0-0.5 × 10 3 /uL) with

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