Journal List > Allergy Asthma Respir Dis > v.5(2) > 1059241

Hwang, Jang, Kang, Sohn, Kang, Lee, and Kang: 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

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 anti-tubercular 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.

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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.
aard-5-111f1.tif
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.
aard-5-111f2.tif
Table 1.
Clinical features and implicated drugs of 38 cases with of antitubercular medication-related DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome
Study Age/sex Types of tuberculosis Time to onset Implicated drugs
Ye et al., 20163 61/M N/A 30 Days HREZ
  56/F N/A 30 Days HR
  35/F N/A 12 Days H
  43/F N/A 60 Days HREZ
Choi et al., 20164 22/F Lung 2 Months E
Arruti et al., 20165 21/M Lung 1 Months H
Shin et al., 20166 17/F Pleura 1 Months HREZ
Zhang et al., 20157 43/M Meninx 2 Months H
Toujani et al., 20158 45/F Lymph node 34 Days HREZ
Moon et al., 20159 53/M Lung (MDR) 20 Days PTH, PAS, S
Lee et al., 201510 71/M Meninx 2 Months H
Thong et al., 201411 74/M Lung 12 Days HRZ
  34/M Lung 5 Days HRES
  50/M Lung N/A HREZ
  30/M Lymph node 11 Days HREZ
  47/M Lung 72 Days HRE
  62/M Lung 80 Days HRE
Shebe et al., 201412 34/M N/A 4 Weeks R
Palmero et al., 201313 27/F Lung, peritoneum 30 Days HREZ
  31/F Pleura 21 Days R
  32/F Lung 30 Days R
  23/M Lung 40 Days H
  30/F Lung, ganglion 35 Days HE
  35/M Lung, pleura 30 Days HREZ
  31/M Lung (not cavitated) 12 Days HRE
  41/M Lung, larynx 60 Days HRZ
  38/M Lung (miliary) 21 Days R
  18/F Lung (MDR) 30 Days Z, Mfx
  34/F Lung (MDR) 60 Days CS, Eth, Mfx, Lev, PAS
Kim et al., 201314 68/F Pericardium 7 Weeks E
Kim et al., 201315 33/M Lung (MDR) 3 Weeks PTH, PAS
Draz et al., 201316 41/F Lymph node 21 Days HREZ
Cheng et al., 201317 12/M Lung 4 Weeks HEZ
Rodriguez et al., 201218 19/M Lymph node 2 Weeks HREZ
Jung et al., 201219 26/F Lung 4 Weeks RE
Lee et al., 201020 72/F Urethra 4 Weeks HRE
Yoon et al., 200721 32/M Lung 2 Weeks HREZ
  25/F Lung 4 Weeks HREZ

N/A, not available; MDR, multidrug resistant tuberculosis; H, isoniazid; R, rifampicin; Z, pyrazinamide; E, ethambutol; PTH, prothionamide; PAS, p-aminosalicylic acid; S, strepto-mycin; Lev, levofloxacin; CS, cycloserine; Eth, ethionamide; Mfx, moxifloxacin.

Deceased.

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