View Article PDF

An 82-year-old woman presented to the emergency department after developing a generalised rash. She had a background of diffuse large B-cell lymphoma, which was successfully treated with a reduced-dose bendamustine-rituximab combination therapy (the last dose of which was six weeks prior to presentation). She had been on her regular medications for at least four months prior to presentation, and denied starting any new medications (including over-the-counter) in the intervening period.

On presentation, she was febrile (temperature 39.1oC) and had an erythematous blanching morbiliform eruption that covered >90% of her body-surface area (Figure 1A and 1B). Her blood tests revealed an acute kidney injury (creatinine 218μmol/L). Her liver functions tests were normal.

Figure 1A: Erythroderma covering the patient’s torso (a), and limbs (b).

Figure 1B: Erythroderma covering the patient’s torso (a), and limbs (b).

A punch biopsy of the skin revealed severe epidermal spongiosis and microvesiculation, with infiltrate of lymphocytic and eosinophilic infiltrates (Figure 2). Peripheral eosinophilia developed on the third day of admission. The peak eosinophil count was 2.9x109 (on the sixth day of admission).

Figure 2: Histological examination of punch biopsy revealed a vesicular spongiotic reaction, with light eosinophilic and lymphocytic infiltrates.

Upon reviewing her history, it was noted that she had undergone a re-staging CT scan four days prior to admission, in which she received iohexol contrast. This was her second exposure to iodinated contrast material (the first of which was at the time of the diagnostic CT scan five months preceding the current presentation). Drug reaction with eosinophilia and systemic symptoms (DRESS) was diagnosed.1 The patient required a short stay in the intensive care unit for blood pressure support. She made a full recovery, and was discharged after 10 days with a home-based rehabilitation programme. Her rash had completely resolved at follow-up four weeks after her discharge, and she was advised to avoid contrast agents in the future.

DRESS is a rare, but recognised, side-effect of iodinated contrast media exposure.2 Our patient fulfilled the RegiSCAR diagnostic criteria for DRESS.3 Due to the vigorous systemic inflammatory response, multi-organ dysfunction may ensue. Reported mortality rates can reach as high as 10%.4 The cornerstones of treatment is cessation of the implicated causative agent, and supportive care.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Yassar Alamri, Department of Medicine, Canterbury District Health Board, Christchurch; Blake Hsu, Haematology, Canterbury District Health Board, Christchurch.

Acknowledgements

Correspondence

Dr Yassar Alamri, Department of Medicine Canterbury District Health Board, Christchurch.

Correspondence Email

yassar.alamri@nzbri.org

Competing Interests

Nil.

1. Peyrière H, Dereure O, Breton H, et al. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol. 2006 Aug; 155(2):422–8.

2. Macías EM1, Muñoz-Bellido FJ, Velasco A, Moreno E, Dávila I. DRESS syndrome involving 2 unrelated substances: imipenem and iodinated contrast media. J Investig Allergol Clin Immunol. 2013; 23(1):56–7.

3. Kardaun SH, Sidoroff A, Valeyrie-Allanore L, et al. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol. 2007 Mar; 156(3):609–11.

4. Walsh SA, Creamer D. Drug reaction with eosinophilia and systemic symptoms (DRESS): a clinical update and review of current thinking. Clin Exp Dermatol. 2011 Jan; 36(1):6–11. doi: 10.1111/j.1365-2230.2010.03967.x.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

An 82-year-old woman presented to the emergency department after developing a generalised rash. She had a background of diffuse large B-cell lymphoma, which was successfully treated with a reduced-dose bendamustine-rituximab combination therapy (the last dose of which was six weeks prior to presentation). She had been on her regular medications for at least four months prior to presentation, and denied starting any new medications (including over-the-counter) in the intervening period.

On presentation, she was febrile (temperature 39.1oC) and had an erythematous blanching morbiliform eruption that covered >90% of her body-surface area (Figure 1A and 1B). Her blood tests revealed an acute kidney injury (creatinine 218μmol/L). Her liver functions tests were normal.

Figure 1A: Erythroderma covering the patient’s torso (a), and limbs (b).

Figure 1B: Erythroderma covering the patient’s torso (a), and limbs (b).

A punch biopsy of the skin revealed severe epidermal spongiosis and microvesiculation, with infiltrate of lymphocytic and eosinophilic infiltrates (Figure 2). Peripheral eosinophilia developed on the third day of admission. The peak eosinophil count was 2.9x109 (on the sixth day of admission).

Figure 2: Histological examination of punch biopsy revealed a vesicular spongiotic reaction, with light eosinophilic and lymphocytic infiltrates.

Upon reviewing her history, it was noted that she had undergone a re-staging CT scan four days prior to admission, in which she received iohexol contrast. This was her second exposure to iodinated contrast material (the first of which was at the time of the diagnostic CT scan five months preceding the current presentation). Drug reaction with eosinophilia and systemic symptoms (DRESS) was diagnosed.1 The patient required a short stay in the intensive care unit for blood pressure support. She made a full recovery, and was discharged after 10 days with a home-based rehabilitation programme. Her rash had completely resolved at follow-up four weeks after her discharge, and she was advised to avoid contrast agents in the future.

DRESS is a rare, but recognised, side-effect of iodinated contrast media exposure.2 Our patient fulfilled the RegiSCAR diagnostic criteria for DRESS.3 Due to the vigorous systemic inflammatory response, multi-organ dysfunction may ensue. Reported mortality rates can reach as high as 10%.4 The cornerstones of treatment is cessation of the implicated causative agent, and supportive care.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Yassar Alamri, Department of Medicine, Canterbury District Health Board, Christchurch; Blake Hsu, Haematology, Canterbury District Health Board, Christchurch.

Acknowledgements

Correspondence

Dr Yassar Alamri, Department of Medicine Canterbury District Health Board, Christchurch.

Correspondence Email

yassar.alamri@nzbri.org

Competing Interests

Nil.

1. Peyrière H, Dereure O, Breton H, et al. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol. 2006 Aug; 155(2):422–8.

2. Macías EM1, Muñoz-Bellido FJ, Velasco A, Moreno E, Dávila I. DRESS syndrome involving 2 unrelated substances: imipenem and iodinated contrast media. J Investig Allergol Clin Immunol. 2013; 23(1):56–7.

3. Kardaun SH, Sidoroff A, Valeyrie-Allanore L, et al. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol. 2007 Mar; 156(3):609–11.

4. Walsh SA, Creamer D. Drug reaction with eosinophilia and systemic symptoms (DRESS): a clinical update and review of current thinking. Clin Exp Dermatol. 2011 Jan; 36(1):6–11. doi: 10.1111/j.1365-2230.2010.03967.x.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

An 82-year-old woman presented to the emergency department after developing a generalised rash. She had a background of diffuse large B-cell lymphoma, which was successfully treated with a reduced-dose bendamustine-rituximab combination therapy (the last dose of which was six weeks prior to presentation). She had been on her regular medications for at least four months prior to presentation, and denied starting any new medications (including over-the-counter) in the intervening period.

On presentation, she was febrile (temperature 39.1oC) and had an erythematous blanching morbiliform eruption that covered >90% of her body-surface area (Figure 1A and 1B). Her blood tests revealed an acute kidney injury (creatinine 218μmol/L). Her liver functions tests were normal.

Figure 1A: Erythroderma covering the patient’s torso (a), and limbs (b).

Figure 1B: Erythroderma covering the patient’s torso (a), and limbs (b).

A punch biopsy of the skin revealed severe epidermal spongiosis and microvesiculation, with infiltrate of lymphocytic and eosinophilic infiltrates (Figure 2). Peripheral eosinophilia developed on the third day of admission. The peak eosinophil count was 2.9x109 (on the sixth day of admission).

Figure 2: Histological examination of punch biopsy revealed a vesicular spongiotic reaction, with light eosinophilic and lymphocytic infiltrates.

Upon reviewing her history, it was noted that she had undergone a re-staging CT scan four days prior to admission, in which she received iohexol contrast. This was her second exposure to iodinated contrast material (the first of which was at the time of the diagnostic CT scan five months preceding the current presentation). Drug reaction with eosinophilia and systemic symptoms (DRESS) was diagnosed.1 The patient required a short stay in the intensive care unit for blood pressure support. She made a full recovery, and was discharged after 10 days with a home-based rehabilitation programme. Her rash had completely resolved at follow-up four weeks after her discharge, and she was advised to avoid contrast agents in the future.

DRESS is a rare, but recognised, side-effect of iodinated contrast media exposure.2 Our patient fulfilled the RegiSCAR diagnostic criteria for DRESS.3 Due to the vigorous systemic inflammatory response, multi-organ dysfunction may ensue. Reported mortality rates can reach as high as 10%.4 The cornerstones of treatment is cessation of the implicated causative agent, and supportive care.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Yassar Alamri, Department of Medicine, Canterbury District Health Board, Christchurch; Blake Hsu, Haematology, Canterbury District Health Board, Christchurch.

Acknowledgements

Correspondence

Dr Yassar Alamri, Department of Medicine Canterbury District Health Board, Christchurch.

Correspondence Email

yassar.alamri@nzbri.org

Competing Interests

Nil.

1. Peyrière H, Dereure O, Breton H, et al. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol. 2006 Aug; 155(2):422–8.

2. Macías EM1, Muñoz-Bellido FJ, Velasco A, Moreno E, Dávila I. DRESS syndrome involving 2 unrelated substances: imipenem and iodinated contrast media. J Investig Allergol Clin Immunol. 2013; 23(1):56–7.

3. Kardaun SH, Sidoroff A, Valeyrie-Allanore L, et al. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol. 2007 Mar; 156(3):609–11.

4. Walsh SA, Creamer D. Drug reaction with eosinophilia and systemic symptoms (DRESS): a clinical update and review of current thinking. Clin Exp Dermatol. 2011 Jan; 36(1):6–11. doi: 10.1111/j.1365-2230.2010.03967.x.

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.
Login, subscribe or email nzmj@nzma.org.nz to purchase this article.

LOGINSUBSCRIBE