DRESS syndrome: carbamazepine induced anaphylactic shock

Abstract

A 51-year-old female of Southeast Asian ethnicity was referred to our Neurosurgery service for a newly diagnosed intracranial meningioma. She underwent surgical excision of the tumor and was discharged home on Carbamazepine. Four weeks later, she presented back to our Emergency Department (ED) with fever, generalized rash, and altered mental status. The rash appeared a week prior to the patient’s presentation to the ED, and she complained of spikes of fever for two days. On arrival, her temperature was 41 °C. She was tachypneic at 24 breaths/min, and hypotensive at 95/55 mm Hg, with a heart rate of 120 beats per minute (BPM). Soon after triage, she was moved to the resuscitation room for further assessment and management.

On examination, the patient appeared to be in moderate distress, anxious, and slightly confused with a Glasgow Coma Scale (GCS) of 14/15. She had a generalized, macular, pruritic, urticarial rash with irregular confluent margins that was consistent with an allergic reaction. Apart from the above-detailed findings, her examination was unremarkable. There was no mucosal surfaces involvement. Her chest was clear on auscultation. Her abdomen was soft, non-tender, with no organomegaly. No focal neurological deficits were detected.

Her investigations included a full septic panel. Laboratory workup revealed elevated Liver Function Tests {Alkaline Phosphatase (ALP) of 120 IU/L (Normal range 35 – 104), Aspartate Transaminase (AST) of 65 IU/L (Normal Range > 32), Alanine Aminotransferase (ALT) of 82 IU/L (Normal Range > 33)}, Lactate Dehydrogenase (LDH) of 367 IU/L (Normal Range 135 – 214), Procalcitonin of 1.01 ng/mL (Normal Range < 0.5), and C-Reactive Protein (CRP) of 150.2 mg/L (Normal Range < 0.5). Of note, she had no Leukocytosis nor eosinophilia.

The patient’s empirical treatment plan in the ED included the administration of Intravenous (IV) Fluids, antihistamines, and Ceftriaxone. Upon admission, she was commenced on IV Dexamethasone 4 mg twice a day. Additionally, Carbamazepine was stopped immediately.

The day following her admission, the patient’s lab work was repeated, and it showed an improvement in CRP, but most notably, her differential complete blood count revealed eosinophilia of 0.73x10^9/L (Normal Range > 0.7), which further went up to 1.33x10^9/L two days later. She was also reviewed by the dermatologist who agreed with the diagnosis of DRESS. A skin biopsy was proposed. However, the patient did not consent to the procedure.

On day 3 of her admission, the patient clinically improved on treatment and remained afebrile and vitally stable. She was therefore discharged home with a follow-up clinic appointment.

Written patient consent for publishing the case with no identifiable personal information was obtained.