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    Muhammad Tamlikha
    Drug Rash with Eosinophilia and Systemic Symptoms syndrome is rare. Clindamycin has not been shown to be associated with the syndrome in any literature. A 25-year-old medical student presented with 1 week of rash and 3 days of fever.

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    Piis0002934310002937 PDF

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    Muhammad Tamlikha
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    Drug Rash with Eosinophilia and Systemic Symptoms syndrome is rare. Clindamycin has not been shown to be associated with the syndrome in any literature. A 25-year-old medical student presented with 1 week of rash and 3 days of fever.

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    Drug Rash with Eosinophilia and Systemic Symptoms syndrome is rare. Clindamycin has not been shown to be associated with the syndrome in any literature. A 25-year-old medical student presented with 1 week of rash and 3 days of fever.

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    28 views2 pages

    Piis0002934310002937 PDF

    Uploaded by

    Muhammad Tamlikha
    Drug Rash with Eosinophilia and Systemic Symptoms syndrome is rare. Clindamycin has not been shown to be associated with the syndrome in any literature. A 25-year-old medical student presented with 1 week of rash and 3 days of fever.

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    of 2

    CLINICAL COMMUNICATION TO THE EDITOR

    Drug Rash with Eosinophilia and Systemic


    Symptoms Syndrome Associated with
    Clindamycin
    To the Editor:
    Drug Rash with Eosinophilia and Systemic Symptoms
    syndrome is a type of drug hypersensitivity syndrome (1/
    1,000-1/10,000 exposures) that typically develops 2 to 8
    weeks after initiation of the responsible drug and is associated with a 10% mortality rate.1 It is most commonly caused
    by aromatic anticonvulsants (phenobarbital, carbamazepine,
    and phenytoin), lamotrigine, and sulfonamides. Other less
    common documented causes include minocycline, allopurinol, gold salts, dapsone, and human immunodeficiency virus medications. To our knowledge, clindamycin has not
    been shown to be associated with Drug Rash with Eosinophilia and Systemic Symptoms syndrome in any literature.
    We describe the first case of Drug Rash with Eosinophilia
    and Systemic Symptoms syndrome caused by clindamycin
    administration.

    CASE SUMMARY
    A 25-year-old medical student presented with 1 week of
    rash and 3 days of persistent high spiking fevers (102F).
    The patient had been diagnosed with infectious mononucleosis 1 month previously, confirmed by Monospot test. Two
    weeks previously, he was diagnosed with strep throat with
    peritonsillar abscesses, for which he received a 10-day treatment of clindamycin and methylprednisolone. The patients
    sore throat resolved, but the day after the last dose of
    clindamycin and methylprednisolone, he developed a rash
    that began in the antecubital fossae and neck, as well as the
    abdomen, and subsequently spread bilaterally onto his
    thighs, legs, chest, and face, with persistent fever appearing
    on the fourth day. On admission, he exhibited a salmoncolored morbilliform rash diffusely spread throughout his
    body along with follicular accentuation present in the
    antecubital fossae, thighs, and neck. The naso-labial folds
    Funding: None.
    Conflict of Interest: The authors state that they have no conflict of
    interest regarding the content of the article.
    Authorship: All authors had access to the data and played a role in
    writing this manuscript.
    Requests for reprints should be addressed to David Tian, New York
    Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla,
    NY 10595.
    E-mail address: [email protected]

    0002-9343/$ -see front matter 2010 Elsevier Inc. All rights reserved.

    were not spared. Bilateral supraclavicular, anterior cervical, and posterior cervical lymph nodes were palpable.
    C4 and C3 levels were normal in value, whereas antinuclear antibody was negative. White blood count was
    7.0 10^3/L on admission with 5% eosinophils, which
    increased to 15% after 2 days. Atypical lymphocytes
    were 3%. Aspartate aminotransferase was 44 U/L, and
    alanine aminotransferase was 55 U/L. Infectious workups
    were all negative. Dermatology was consulted, and the
    diagnosis of Drug Rash with Eosinophilia and Systemic
    Symptoms syndrome was confirmed.

    DISCUSSION
    The most common presentation usually involves persistent
    fever and a skin rash that begins with a morbilliform eruption along with follicular accentuation, typically in the face,
    upper trunk, and extremities.1 As the rash progresses, there
    can be shedding of the skin and edema, with edema of the
    face being a hallmark of Drug Rash with Eosinophilia and
    Systemic Symptoms syndrome. Other symptoms include
    enlarged lymph nodes, arthritis, or arthralgias. The most
    dangerous aspect of Drug Rash with Eosinophilia and Systemic Symptoms syndrome is visceral involvement, with
    hepatitis being the most common result (50% of all cases).1
    Although fulminant hepatitis is the main cause of death,
    myocarditis, interstitial pneumonitis, interstitial nephritis,
    thyroiditis, and inflammation of the brain also can occur.
    Drug Rash with Eosinophilia and Systemic Symptoms syndrome also tends to have prominent eosinophilia along with
    atypical lymphocytes. Although the entire pathophysiology
    is unclear, it is thought that visceral involvement is due to
    eosinophil infiltration of the internal organs in association
    with interleukin-5.2
    Patients with Drug Rash with Eosinophilia and Systemic
    Symptoms syndrome should be evaluated for elevated liver
    enzyme levels along with immediate withdrawal of the
    suspected drug. If visceral involvement does occur, the
    involved organ system should be monitored for several
    months until normalization occurs. In general, if visceral
    involvement does not occur during the acute phase of the
    syndrome, it is unlikely to be a delayed event after the
    offending drug has been discontinued. The only exception
    to this is the thyroid. Thyroid dysfunction can be delayed;
    thus, it is important to check thyroid function for 3 to 6
    months after the acute event. Treatment usually involves 0.5
    to 1 mg/kg/d of prednisone for 2 to 3 weeks, followed by a
    slow taper over 4 to 6 weeks. However, depending on the
    extent of visceral involvement, prednisone can be adminis-

    e8

    The American Journal of Medicine, Vol 123, No 11, November 2010


    important not to confuse this with Drug Rash with Eosinophilia and Systemic Symptoms syndrome because of the
    fatal complications that can occur. Our patient did not develop any visceral involvement and was treated with prednisone. After 4 days of treatment, his fever and rash resolved, and he is currently doing well. It also is important to
    note that Drug Rash with Eosinophilia and Systemic Symptoms syndrome may have a genetic component, and firstdegree relatives should be warned as well.3 (Figure 1).
    David Tian, MD
    Ram Jhingan Mohan, MD
    Gary Stallings, MD
    New York Medical College
    Westchester Medical Center
    Westchester

    Figure 1 Presentation of DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) in a 25-year-old patient.

    doi:10.1016/j.amjmed.2010.04.004

    References
    tered and tapered for a few months. In general, long-term
    prednisone treatment is unnecessary.

    CONCLUSIONS
    Although clindamycin also can cause a mono rash similar
    to ampicillin in patients with infectious mononucleosis, it is

    1. Bocquet H, Bagot M, Roujeau JC. Drug-induced pseudolymphoma and


    drug hypersensitivity syndrome (Drug Rash with Eosinophilia and Systemic Symptoms: DRESS). Semin Cutan Med Surg. 1996;15:250-257.
    2. Lee JH, Park HK, Heo J, et al. Drug Rash with Eosinophilia and
    Systemic Symptoms (DRESS) syndrome induced by celecoxib and
    anti-tuberculosis drugs. J Korean Med Sci. 2008;23:521-525.
    3. Sullivan JR, Shear NH. The drug hypersensitivity syndrome: what is the
    pathogenesis? Arch Dermatol. 2001;137:357-364.

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