Myocarditis and Drug Rash With Eosinophilia and Systemic Symptoms Syndrome: A Deadly Combination

DRESS syndrome (Drug Rash with Eosinophilia and Systemic Symptoms) is a severe delayed type IV hypersensitivity drug reaction by T helper cell 2 (Th2) and Interleukin 5 (IL-5) resulting in activation of eosinophils. It is mostly reported with antiepileptic drugs (AEDs), antibiotics, and allopurinol. Here, we present the second case of myocarditis secondary to DRESS syndrome caused by amoxicillin. Most of the case reports present with cross-reactivity among the anticonvulsants and beta-lactams, which is also rarely been reported. Amoxicillin could reactivate human herpesvirus 6 (HHV 6) and Epstein-Barr virus (EBV) with a presentation similar to DRESS syndrome, but our patient was neither taking the anticonvulsants nor have any viral infection in the recent past. His RegiSCAR score was 6, consistent with definite DRESS syndrome. Management includes identification and prompt withdrawal of the offending drug and supportive care for patients without severe organ involvement and systemic corticosteroids for patients with severe organ involvement.

[1]  A. Meyer,et al.  Drug-induced hypersensitivity syndrome with myocardial involvement treated with tofacitinib , 2019, JAAD case reports.

[2]  T. Anzai,et al.  Refractory cardiac myocarditis associated with drug rash with eosinophilia and systemic symptoms syndrome due to anti-bipolar disorder drugs: a case report , 2018, European heart journal. Case reports.

[3]  R. Haque,et al.  DRESS Syndrome due to benzylpenicillin with cross-reactivity to amoxicillin. , 2018, The journal of allergy and clinical immunology. In practice.

[4]  S. Esposito,et al.  Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome in two young children: the importance of an early diagnosis , 2018, Italian Journal of Pediatrics.

[5]  A. Yazar,et al.  Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome associated with cefotaxime and clindamycin use in a 6 year-old boy: a case report , 2017, The Pan African medical journal.

[6]  A. Pannu,et al.  Diagnostic criteria for drug rash and eosinophilia with systemic symptoms , 2017, Journal of family medicine and primary care.

[7]  W. Pichler,et al.  Cardiac involvement in DRESS syndrome. , 2016, Asian Pacific journal of allergy and immunology.

[8]  S. Silva,et al.  Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome). , 2016, Revista da Associacao Medica Brasileira.

[9]  K. Aouam,et al.  The rest of the story of the patient described in the letter to the editors: ‘Hypersensitivity to amoxicillin after… (DRESS) to carbamazepine…: a possible co‐sensitization’ , 2016, British journal of clinical pharmacology.

[10]  L. Naldi,et al.  Drug reaction with eosinophilia and systemic symptoms (DRESS): an original multisystem adverse drug reaction. Results from the prospective RegiSCAR study , 2013, The British journal of dermatology.

[11]  J. Roujeau,et al.  The DRESS syndrome: a literature review. , 2011, The American journal of medicine.

[12]  K. Aouam,et al.  Amoxicillin-Induced Hypersensitivity After DRESS To Carbamazepine , 2010, The World Allergy Organization journal.

[13]  Mei-Ching Yu,et al.  Association of DRESS syndrome with chylous ascites. , 2006, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[14]  T. Shiohara,et al.  Virus reactivation and intravenous immunoglobulin (IVIG) therapy of drug-induced hypersensitivity syndrome. , 2005, Toxicology.

[15]  Yuan-Tsong Chen,et al.  HLA-B*5801 allele as a genetic marker for severe cutaneous adverse reactions caused by allopurinol. , 2005, Proceedings of the National Academy of Sciences of the United States of America.

[16]  Yuan-Tsong Chen,et al.  A marker for Stevens–Johnson syndrome , 2004 .

[17]  J. Roujeau,et al.  Increased levels of interleukin 5 are associated with the generation of eosinophilia in drug‐induced hypersensitivity syndrome , 1998, The British journal of dermatology.

[18]  B. Crickx,et al.  Amoxicillin-induced flare in patients with DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms): report of seven cases and demonstration of a direct effect of amoxicillin on Human Herpesvirus 6 replication in vitro. , 2010, European journal of dermatology : EJD.

[19]  G. Bahat,et al.  Drug rash with eosinophilia and systemic symptoms syndrome induced by sulfasalazine. , 2010, Joint, bone, spine : revue du rhumatisme.

[20]  D. Wendling,et al.  DRESS syndrome in a patient on sulfasalazine for rheumatoid arthritis. , 2005, Joint, bone, spine : revue du rhumatisme.