E06. DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS IN PATIENTS TREATED FOR RHEUMATOID ARTHRITIS

Abstract

Background: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a serious drug-induced condition characterized by an extensive rash, fever, lymphadenopathy, hematologic abnormalities and internal organ involvement, mainly liver. It typically occurs 2-6 weeks after exposure to the offending drug. Although it is a rare, mortality is high (10-20%), with most fatalities related to liver failure. Therefore, high index of suspicion is essential for its early diagnosis and management. Methods: We reported a 25 year old Qatari woman with DRESS Syndrome. Results: She was recently engaged, diagnosed with seropositive rheumatoid arthritis (RA) and started on Sulfasalazine (SSZ), Hydroxychloroquine (HCQ), Celebrex and Vitamin-D. Seventeen days later, she presented to A&E with a history of fever and widespread rash of one day duration. She also complained of yellowish discoloration in her sclera, sore throat, nausea and vomiting two days prior to her presentation. Examination revealed fever (38.2°C, hypotension (98/50), sinus tachycardia (118) with puffiness in her face and maculopapular painless and non-itchy rash involving cheeks, flexor aspect of forearms, extensor aspect of both legs, abdomen, sparing palms and soles with dry skin. She is jaundiced with no lymphadenopathy or organomegaly. Her throat was erythematous. Initial Laboratory results revealed leucocytosis (WBC 26.6∗103/ml), lymphocytosis (64%), neutrophils of (25%), eosinophils 2.1%, mild thrombocytopenia (136∗103/ml) with raised CRP (73 mg/dl), ESR 24 mm/hr, bilirubin 137 mg/dL (mainly direct), AST 165 U/L, ALT 138 U/L, ALP 737 U/L. Full intensive septic screen was negative and autoimmune causes has been ruled out. Over next few days her lab results reveled increased leucocytosis (48.5∗103/ml) with significant eosinophilia (13%) and lymphocytosis of 71%. We made provisional diagnosis of Drug reaction and suspected offending drugs including SSZ, Celecoxib and possibly HCQ which were all immediately discontinued. Our case fit the Japanese criteria for DRESS syndrome; she had 7 out of the 9 criteria (all apart from lymphadenopathy and Human herpesvirus 6 reactivation). She also fulfills all the Regi SCAR criteria apart from the lymphadenopathy. The patient was initially given oral Prednisolone 30mg once daily which later increase to 50mg daily. She made a complete recovery within a month with the discontinuation of offending medications and reducing dose of prednisolone. We managed to restart the patient on HCQ with no any problem. MTX later introduced after she confirmed that she has no plan for marriage or pregnancy at this stage. Conclusion: More than 50 drugs have been implicated to trigger DRESS syndrome and there is some evidence that possibly combinations of drugs could be the cause. High index of suspicion with early diagnosis and treatment could save lives in patient with DRESS. In our case the combination of SSZ and Celecoxib could be the cause.