(1) TMP-SMZ-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but recognised complication, occurring in 0.01%-0.1% of patients, (2) and can cause fulminant hepatic failure. We describe a case of TMP-SMZinduced DRESS syndrome associated with fulminant hepatic failure in an adolescent who was successfully managed with extracorporeal liver dialysis.
CASE REPORTA 17-year-old Chinese male adolescent presented to our emergency department with fever, myalgia and a nonpruritic maculopapular rash over his trunk and neck. He had developed nonpruritic, confluent, erythematous macules and papules after taking TMP-SMZ (80 mg TMP, 400 mg SMZ) for 28 days. The macules and papules first appeared over the neck and chest, and progressively spread to his limbs and the rest of his trunk within the next few days. He had been prescribed TMP-SMZ and isotretinoin by a general practitioner for nodular cystic acne vulgaris. Despite symptomatic treatment by the general practitioner, the patient's rash and fever did not subside, thus prompting a visit to our emergency department.The patient had no significant medical history and no glucose-6-phosphate dehydrogenase deficiency. Other than TMP-SMZ and isotretinoin, he occasionally took paracetamol for fever. He was not on any recreational medication or herbal supplement, and denied any alcohol intake. He had recently travelled to Batam (an island in the Riau Archipelago) two months ago and engaged in water sports. However, he did not recall having any insect bite and denied any sexual intercourse.Clinical examination upon admission revealed him to be alert but jaundiced, with a fever of 38.4°C and a confluent, erythematous, maculopapular rash over his trunk, face, arms and legs (Fig. 1) ABSTRACT Trimethoprim-sulfamethoxazole (TMP-SMZ) is a commonly used antibiotic that has been associated with drug rash with eosinophilia and systemic symptoms (DRESS) syndrome. DRESS syndrome is characterised by fever, rash, lymphadenopathy, eosinophilia and one or more major organ involvement. Although rare, TMP-SMZ is a recognised cause of fulminant hepatic failure. We report a 17-year-old Chinese male adolescent who presented with fever, myalgia, generalised maculopapular rash and lymphadenopathy after taking TMP-SMZ for acne vulgaris. He subsequently developed hepatic encephalopathy and was worked up for urgent liver transplantation. He responded well to extracorporeal liver dialysis (originally intended as a bridging therapy) and subsequently recovered without the need for liver transplantation. This case report highlights the importance of early recognition of TMP-SMZ-induced DRESS syndrome and the need for early discontinuation of the drug in the affected patient. Extracorporeal liver dialysis and transplantation should be considered in the management of TMP-SMZ-induced fulminant hepatic failure.
Keywords: drug rash with eosinophilia and systemic symptoms (DRESS), fulminant hepatic failure, molecular adsorbents recirculation system liver dialysis, trimethoprim-sulfame...
