Drug Rash with Eosinophilia and Systemic Symptoms Syndrome Presenting After the Initiation of Staphylococcus hominis Infectious Endocarditis Treatment: A Case Report and Updated Review of Management Considerations

Abstract

We present the case of a 62-year-old Caucasian man who was being treated for mitral valve endocarditis via a six-week course of vancomycin. On Day 32 of the treatment, he developed an erythematous, pruritic, desquamating, and painful rash covering 80% of the total body surface area and intermittent fevers. Laboratory findings included leukocytosis with peripheral blood eosinophilia and elevated erythrocyte sedimentation rate, C-reactive protein, and serum creatinine.Although the patient only completed five weeks of antibiotics, the decision was made to not complete the six-week antibiotic course due to suspicion of vancomycin-induced drug rash with eosinophilia and systemic symptoms (DRESS). The patient was then given 80 mg of intramuscular triamcinolone (Kenalog) and advised to apply topical 0.1% triamcinolone twice per day. At the three-month follow-up, the rash, leukocytosis, eosinophilia, and renal dysfunction had resolved. Clinicians must maintain a high index of suspicion for vancomycin-induced DRESS in patients with rash and eosinophilia for early recognition and treatment.DRESS syndrome treatment typically involves discontinuing the causative drug and promptly administering steroids. However, there is a therapeutic dilemma in administering steroids during the course of an active infection. Therefore, this article serves two purposes. First, this case report highlights our approach towards managing a patient with DRESS and concurrent infectious endocarditis. Second, we include a review of the management considerations when prescribing pulsed steroids so that clinicians have a single source as a practical guide towards reducing the potentially severe systemic sequelae in DRESS syndrome and its associated treatment.

A rare case of infant eosinophilia induced by oral vancomycin: a case report and literature review

“…Table 3 and Table 4 present a summary and analysis of 44 cases of eosinophilia caused by vancomycin. 2–8,35–65 Of these 44 cases, drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome, was found in 35 cases. 2–8,35–57 In other cases, some patients had increased eosinophil counts an...…”

“…2–8,35–65 Of these 44 cases, drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome, was found in 35 cases. 2–8,35–57 In other cases, some patients had increased eosinophil counts and involvement of other organs such as kidney, lung and heart function due to intravenous use of vancomycin. 58,…”

“…58,62,63 Although the reported cases were been clearly diagnosed as DRESS, they were considered to have this syndrome based on the case data. A comprehensive review all of the 44 published cases with eosinophilia caused by vancomycin demonstrated the following (Table 4): 2–8,35–65 male patients were more often affected (27 of 44 patients; 61.4%); the median age was 46.8 years (range, 2 months to 59 years); the median time to vancomycin-related symptoms was 23.5 days (range, 3–49 days); and the median eosinophil count was 5.22 × 10 9 /l (range, 0.85–37.5 × 10 9 /l). Fever (32 of 44 patients; 72.7%) and/or rash (36 of 44 patients; 81.8%) were the first symptoms of eosinophilia in patients with vancomycin treatment; and another two cases had hypotension or were asymptomatic after intraperitoneal injection of vancomycin.…”