Allergy Asthma Respir Dis.  2017 Mar;5(2):111-116. 10.4168/aard.2017.5.2.111.

DRESS (drug reaction with eosinophilia and systemic symptom) syndrome caused by both first-line and second-line antitubercular medications: A case report with a brief literature review

• Hwang YH
• Jang DY
• Kang SY
• Sohn KH
• Kang DY
• Lee CH
• Kang HR

• KMID: 2392383
• DOI: http://doi.org/10.4168/aard.2017.5.2.111

Abstract

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but potentially fatal drug-induced systemic hypersensitivity response characterized by erythematous eruption, fever, leukocytosis with eosinophilia, and internal organ involvement. Antitubercular agents are potential causative agents for DRESS syndrome but difficult to verify as a culprit drug, since antitubercular agents are coadministered as a combination regimen. A 42-year-old female with endobronchial tuberculosis was diagnosed with DRESS syndrome after 4-week treatment of isoniazid, rifampicin, ethambutol, and pyrazinamide with prednisolone 50 mg. All the antitubercular agents were stopped and replaced with levofloxacin, cycloserine, p-aminosalicylic acid, and kanamycin. However, severe exacerbation of DRESS syndrome compelled the patient to discontinue the administration of the second-line antitubercular agents. Two months later, the patient underwent a patch test for all the antitubercular agents which had been used, and the results showed positivity to isoniazid and cycloserine. We report a rare case of DRESS syndrome that reacted to cycloserine as well as isoniazid. Development of coreactivity to other drugs should be differentiated with a flare-up reaction in the management of DRESS syndrome.

Keyword

Drug hypersensitivity syndrome; Antitubercular agents; Patch tests

MeSH Terms

Adult
Aminosalicylic Acid
Antitubercular Agents
Cycloserine
Drug Hypersensitivity Syndrome
Eosinophilia*
Ethambutol
Female
Fever
Humans
Hypersensitivity
Isoniazid
Kanamycin
Leukocytosis
Levofloxacin
Patch Tests
Prednisolone
Pyrazinamide
Rifampin
Tuberculosis
Aminosalicylic Acid
Antitubercular Agents
Cycloserine
Ethambutol
Isoniazid
Kanamycin
Prednisolone
Pyrazinamide
Rifampin

Figure

• 

  Fig. 1. Summary of clinical course. Clinical course of the patient from initial administration of first-line antitubercular medication (day 0). H, isoniazid; R, rifampin; Z, pyrazinamide; E, ethambutol; Lz, linezolid; SMX-TMP, sulfamethoxazole-trimethoprim; Lev, levofloxacin; CS, cycloserine; PAS, p-aminosalicylic acid; KM, kanamycin; DRESS, drug reaction with eosinophilia and systemic symptoms; ALT, alanine aminotransferase.

• 

  Fig. 2. Skin finding of patch test to antitubercular agents. Read at 48 hours (A), and 72 hours (B). Test drugs are isoniazid (INH), rifampin (R), pyridoxine (P), sul-famethoxazole-trimethoprim (sep), p-aminosalicylic acid (PAS), kanamycin (K), linezolid (zyv), cycloserine (CS), levofloxacin (LV), pyrazinamide (PZA), ethambutol (E), vaseline (V) in clockwise direction from the right top.

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