DRESS syndrome induced by sodium meglumine ioxitalamate

We report the first case of DRESS (drug rush with eosinophilia and systemic symptoms) syndrome induced by sodium meglumine ioxitalamate. Immediate reactions are the more frequent adverse reactions to iodinated contrast media (ICM) (1–6). Occurrence of delayed hypersensitivity reactions caused by these products had been more rarely reported (1–6). We report a case of DRESS syndrome induced by sodium meglumine ioxitalamate (Telebrix 35 ; Guerbet, Paris, France). A 71-year-old woman was hospitalized for thoracic pain and dyspnea. Coronary angiography was performed with sodium meglumine ioxitalamate (Telebrix 35 ). The conclusion was thrombosis of the anterior interventricular artery leading to the diagnosis of an antero-septal myocardial infarction. Treatment with isosorbide dinitrate (Risordan ; SanofiAventis, Paris, France), chlorhydrate of propranolol (Avlocardyl ; Bristol-Myers Squibb, Paris, France), acetylsalicylic acid (Aspirine ; Siphat, Tunis, Tunisia), and clopidogrel hydrogen sulfate (Plavix ; Astra Zeneca, Paris, France) was started. The days following the coronary angiography were without incidents. Seven months after, the patient underwent a transluminal angioplasty with a stent installation. which included the injection of the same ICM (Telebrix 35 ). Two days later, the patient had developed a pruritic maculo-papular rash, fever (38.5 ), and oliguria (diuresis within 100 cc/24 heures). Laboratory investigations revealed a creatinine rise (266 lmol/l) and eosinophilia (1600 elements/mm). Hepatic enzymes were within normal limits. Blood cultures were negative and the C-reactive protein level was within normal limits. A skin biopsy showed perivascular infiltration of lymphocytes accompanied with dermal infiltrates of eosinophils. Given the association of fever, rash, eosinophilia and the renal attack, the diagnosis of DRESS syndrome was established and sodium meglumine ioxitalamate was suspected to be the trigger agent. As they were started 7 months ago, the other treatments received by the patient were continued. Four days after, the rash intensified, renal insufficiency aggravated (creatinine = 411 lmol/l) and eosinophilia increased to 1800 elements/mm. Fever and rash were completely resolved within 17 days with normalization of creatinine level and eosinophilia count. Six weeks after complete resolution, the patient was patch tested with European standard series, and sodium meglumine ioxitalamate (30% in water and undiluted). Reactions were evaluated at D2 and D3 according to ICDRG guidelines. Positive reactions (++) were seen at D2 and D3 to sodium meglumine ioxitalamate (30% in water and undiluted). The same patch tests gave negative results in nine healthy control subjects. Thus, the diagnosis of DRESS syndrome induced by sodium meglumine ioxitalamate was confirmed. Late adverse reactions with ICM occurred from 1 h to 2 days after administration but have been reported to occur up to 7 days after administration (2, 3). They include rash, urticaria or eczema, more rarely, Stevens-Johnson or Lyell syndromes, even fixed drug eruption or vasculitis (1–6). Most of these skin eruptions appear to be T-cell mediated allergic reactions as shown by the frequently reported positive patch tests and delayed intradermal tests to the ICM (4–6). DRESS syndrome is a severe, acute drug reaction, defined by the presence of fever, skin eruption and systemic findings including enlarged lymph nodes, abnormal liver function, renal impairment, pulmonary or cardiac infiltrates along with hematological abnormalities, mainly hypereosinophilia and lymphocytosis (7, 8). In our patient, the diagnosis of DRESS syndrome was definite according to the new RegiSCAR group criteria (9). Iodinated contrast mediainduced DRESS syndromes are rarely reported (10–12). Kanny et al. (11) reported in 2005, four ICM-induced DRESS syndromes that were triggered by Iohexol, Iobitridol and Ioxaglate. In these four cases of DRESS, patch tests with ICM were positive only two times out of four. To the best of our knowledge, apart from these cases, only another case had been reported in the literature (12). Our case is considered the first case reported of DRESS syndrome induced by sodium meglumine ioxitalamate.