Page 35 - Delaware Medical Journal - May/June 2020
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ABSTRACTS
discharge. Though clinicians in the United States may not be familiar with the sequelae of cysticercosis, infection with Taenia solium is a common cause of new-onset seizure throughout the world, especially in endemic areas such as Mexico. As immigration continues to contribute to the American patient population, medical professionals should consider neurocysticercosis in their differential diagnoses. This vignette also helps to highlight IDSA guidelines, which recommend seizure prophylaxis rather than antiparasitic therapy in the setting of lesion
CONTRIBUTOR
■ FazadMohamedofMagnolia,Delawareisa first-year resident in the Internal Medicine Program at ChristianaCare. He received his medical degree from the Philadelphia College of Osteopathic Medicine.
2nd Prize, Poster
DRESSed to Kill; When a Red Rash Is a Harbinger for Severe Drug Reaction by Andrew Pajak, PGY1
Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare and debilitating hypersensitivity reaction. Pathogenesis
immune response but is also linked to viral reactivation from the Herpesviridae family.3 We present a patient with DRESS syndrome with profound HHV-6 viremia who developed fulminant liver failure.
Case Description: A previously healthy 21-year-old female recently started therapy with lamotrigine. Three weeks into treatment, she developed a sore throat
and fever. Despite negative testing for Streptococcus, she was placed on penicillin.
One week later, she presented again with persistent fever, and new-onset rash, facial edema, and vomiting. She was treated
for suspected DRESS syndrome, and
placed on prednisone, with the cessation
of penicillin and lamotrigine. Despite this, she presented again two days later, with worsening symptoms. She was febrile, severely tachycardic to 156bpm, tachypneic, and hypotensive. Initial lab work was 382u/L, ALT 536u/L), a WBC of 21,600/ mm3 with an absolute eosinophil count of 600mm3, and atypical lymphocytes at 950/ mm3. Physical exam showed a critically ill-appearing patient with lip desquamation without mucosal involvement and an erythematous, coalescing morbilliform
rash over her trunk, back, and extremities. She was given high-dose steroids, showed rapid improvement over the next 48 hours, and was discharged on prednisone. Four days later, she was readmitted and found to have severe transaminitis, peaking at AST 1609u/L and ALT 2020u/L. A CT scan showed hepatosplenomegaly and axillary lymphadenopathy. A liver biopsy revealed necrosis. Serum HHV-6 quantitative PCR returned with >2,000,000 copies/ml. The patient improved with supportive care and the continuation of prednisone.
Discussion: DRESS syndrome is a rare and potentially life-threatening condition. Symptoms typically start two to six weeks after initiation of a medication and usually include fevers, facial edema, and rash.3 Patients have a high likelihood of developing end-organ damage, most commonly manifested as liver failure, though severe pulmonary and renal damage have been reported, and mortality can reach 20%.1
A drug-induced hypersensitivity reaction, most often from anticonvulsant medications like lamotrigine, plays an integral role in the pathogenesis of DRESS syndrome. Interestingly, viral reactivation from the Herpesviridae family is also known to contribute to the pathogenesis and likely
Although not entirely understood, it is thought that the viremia has direct cytotoxic effects or causes an immune response that can result in tissue damage.2 Management of DRESS syndrome includes discontinuation of the offending drug and the addition of therapy is rarely used, in part due to the toxicity of the agents. Recovery involves a relapsing and remitting course which can often take weeks to months.
CONTRIBUTOR
■ Andrew Pajak is a first-year resident in the Internal Medicine Program at ChristianaCare. He received his medical degree from the Lake Erie College of Osteopathic Medicine.
References:
1. Gentile, I., Talamo, M., Borgia, G. Is the Drug-Induced Hypersensitivity Syndrome (DiHS) Due to Human Herpesvirus 6 Infection or to Allergy-Mediated Viral Reactivation? Report of a Case and Literature Review. BMC Infectious Diseases. March 6, 2010; 10:49
2. Roujeau, J.C. and Dupin, N. Virus Reactivation in Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Results from a Strong Drug- Specific Immune Response. The Journal of Allergy and Clinical Immunology: In Practice. May-June 2017. Volume 5 Issue 3, pages 811-812.
3. Shiohara, T.and Mizukawa, Y. Drug- Induced Hypersensitivity Syndrome (DiHS)/ Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): An Update in 2019. Allergology international. July 2019. Volume 68, Issue 3, Pages 301-308.
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