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

Young-Hoon Hwang; Dong Yeon Jang; Sung Yoon Kang; Kyung-Hee Sohn; Dong Yoon Kang; Chang Hoon Lee; Hye-Ryun Kang

doi:10.4168/aard.2017.5.2.111

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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

Case Report

Allergy Asthma Respir Dis 2017;5(2):111-116.

Published online: 5 March 2017

DOI: https://doi.org/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

Young-Hoon Hwang¹, Dong Yeon Jang¹, Sung Yoon Kang^2,³, Kyung-Hee Sohn^2,³, Dong Yoon Kang⁴, Chang Hoon Lee², Hye-Ryun Kang^2,^3,⁴

¹School of Medicine, Seoul National University, Seoul, Korea

²Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea

³Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea

⁴Regional Pharmacovigilance Center, Seoul National University Hospital, Seoul, Korea

Correspondence to: Hye-Ryun Kang http://orcid.org/0000-0002-2317-4201 Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-0820, Fax: +82-2-742-3291, E-mail: helenmed@snu.ac.kr

• This research was supported by a grant from Ministry of Food and Drug Safety to operation of the regional pharmacovigilance center in 2016.

Received 3 August 201618 October 2016 Accepted 25 October 2016

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/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Drug hypersensitivity syndrome, Antitubercular agents, Patch tests

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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.

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.

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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