Allergy Asthma Respir Dis AARD Allergy, Asthma & Respiratory Disease 2288-0402 2288-0410 The Korean Academy of Pediatric Allergy and Respiratory Disease; The Korean Academy of Asthma, Allergy and Clinical Immunology 10.4168/aard.2020.8.1.40 Case Report A case of toxic epidermal necrolysis induced by cytomegalovirus infection followed by DRESS (drug reaction with eosinophilia and systemic symptoms) Sim Da Woon Son Seyeong Yu Jieun https://orcid.org/0000-0002-5100-9473 Koh Young-Il Division of Allergy, Asthma, and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea. Correspondence to: Young-Il. Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea. Tel: +82-62-220-6580, Fax: +82-62-225-8578, yikoh@chonnam.ac.kr 01 2020 31 01 2020 8 1 40 44 11 02 2019 08 04 2019 08 04 2019 © 2020 The Korean Academy of Pediatric Allergy and Respiratory Disease; The Korean Academy of Asthma, Allergy and Clinical Immunology 2020 The Korean Academy of Pediatric Allergy and Respiratory Disease; The Korean Academy of Asthma, Allergy and Clinical Immunology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/).

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions. Although viral reactivation is associated with DRESS syndrome, its role in TEN remains unclear. An 80-year-old woman visited our hospital because of fever and skin eruption. DRESS syndrome was diagnosed and was thought to caused by the use of the drug allopurinol. She was treated by discontinuation of the drug and administration of systemic steroids. She recovered from DRESS syndrome and was discharged from the hospital with tapering doses of steroids prescribed. One week after discharge, she visited our hospital again as the skin rash recurred and oral pain as well as oral and ocular mucosal lesions developed. In addition to the skin rash, blisters and Nikolsky's sign that were different from the skin lesions present in the previous DRESS syndrome were observed. Unlike those in DRESS syndrome, the viral serological test results were positive for anti-cytomegalovirus (CMV) IgM and CMV polymerase chain reaction. Therefore, it was thought that TEN was due to reactivation of CMV and she was treated this with ganciclovir and intravenous immunoglobulin. Here, we report a case of TEN caused by viral reactivation after DRESS syndrome developed after use of allopurinol which recovered after steroid treatment.

 Cytomegalovirus Drug hypersensitivity syndrome Toxic epidermal necrolysis Chonnam National University https://doi.org/10.13039/501100002456 CRI18006-1

This study was supported by a grant from the Chonnam National University Hospital Biomedical Research Institute (CRI18006-1).

 Cacoub P Musette P Descamps V Meyer O Speirs C Finzi L The DRESS syndrome: a literature review Am J Med 2011 124 588 597 Kardaun SH Sekula P Valeyrie-Allanore L Liss Y Chu CY Creamer D Drug reaction with eosinophilia and systemic symptoms (DRESS): an original multisystem adverse drug reaction. Results from the prospective RegiSCAR study Br J Dermatol 2013 169 1071 1080 Mustafa SS Ostrov D Yerly D Severe cutaneous adverse drug reactions: presentation, risk factors, and management Curr Allergy Asthma Rep 2018 18 26 Gerull R Nelle M Schaible T Toxic epidermal necrolysis and Stevens-Johnson syndrome: a review Crit Care Med 2011 39 1521 1532 Khalaf D Toema B Dabbour N Jehani F Toxic epidermal necrolysis associated with severe cytomegalovirus infection in a patient on regular hemodialysis Mediterr J Hematol Infect Dis 2011 3 e2011004 Aihara M Sugita Y Takahashi S Nagatani T Arata S Takeuchi K Anticonvulsant hypersensitivity syndrome associated with reactivation of cytomegalovirus Br J Dermatol 2001 144 1231 1234 Bocquet H Bagot M Roujeau JC Drug-induced pseudolymphoma and drug hypersensitivity syndrome (Drug Rash with Eosinophilia and Systemic Symptoms: DRESS) Semin Cutan Med Surg 1996 15 250 257 Kardaun SH Sidoroff A Valeyrie-Allanore L Halevy S Davidovici BB Mockenhaupt M Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol 2007 156 609 611 Pichler WJ Adam J Daubner B Gentinetta T Keller M Yerly D Drug hypersensitivity reactions: pathomechanism and clinical symptoms Med Clin North Am 2010 94 645 664 xv Mockenhaupt M Stevens-Johnson syndrome and toxic epidermal necrolysis: clinical patterns, diagnostic considerations, etiology, and therapeutic management Semin Cutan Med Surg 2014 33 10 16 Schwartz RA McDonough PH Lee BW Toxic epidermal necrolysis: Part II. Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment J Am Acad Dermatol 2013 69 187.e1 187.e16 quiz 203–4 Ishida T Kano Y Mizukawa Y Shiohara T The dynamics of herpesvirus reactivations during and after severe drug eruptions: their relation to the clinical phenotype and therapeutic outcome Allergy 2014 69 798 805 Letko E Papaliodis DN Papaliodis GN Daoud YJ Ahmed AR Foster CS Stevens-Johnson syndrome and toxic epidermal necrolysis: a review of the literature Ann Allergy Asthma Immunol 2005 94 419 436 quiz 436–8, 456 Hodson EM Craig JC Strippoli GF Webster AC Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients Cochrane Database Syst Rev 2013 2 CD003774 Soriano A Smerieri N Bonilauri S De Marco L Cavazza A Salvarani C Colonic perforation due to severe cytomegalovirus disease in granulomatosis with polyangiitis after immunosuppression Clin Rheumatol 2018 37 1427 1432 Truhan AP Ahmed AR Corticosteroids: a review with emphasis on complications of prolonged systemic therapy Ann Allergy 1989 62 375 391 Meyers JD Flournoy N Thomas ED Risk factors for cytomegalovirus infection after human marrow transplantation J Infect Dis 1986 153 478 488 Choi HJ Oh SH Chang SE Lee MW Choi JH Moon KC A case of cutaneous cytomegalovirus infection in a renal transplant patient Korean J Dermatol 2005 43 999 1002 Jaber S Chanques G Borry J Souche B Verdier R Perrigault PF Cytomegalovirus infection in critically ill patients: associated factors and consequences Chest 2005 127 233 241 Alexander BT Hladnik LM Augustin KM Casabar E McKinnon PS Reichley RM Use of cytomegalovirus intravenous immune globulin for the adjunctive treatment of cytomegalovirus in hematopoietic stem cell transplant recipients Pharmacotherapy 2010 30 554 561 Skin manifestation at first visit with fever and skin rash. (A) Maculopapular rash on trunk. (B, C) Undamaged lip and oral mucosa. Skin findings at revisit after discharge. (A) Skin rash and blister lesion of trunk. (B) Lip mucosal involvement. (C) Eye mucosal involvement. (D) Nikolsky's sign on trunk.