Case Presentation: A 44-year-old female with a history of hypertension and depression, presented to the emergency department with 3 days of diffuse worsening rash, fever, and leukocytosis. Four weeks prior to symptom onset, the patient was prescribed a two-week course of Augmentin for a sinus infection. Prior to arrival, she was seen at an outside hospital and was found to have diffuse erythroderma with pustules, leukocytosis, and eosinophilia. At this time, she was started on 40 mg prednisone daily and dermatology performed a punch biopsy. Histologic findings were consistent with drug eruption and the patient’s steroid regimen was increased to 60 mg daily. On initial evaluation in the emergency department, the patient was febrile, tachypneic and tachycardic, with imaging showing increased bibasilar opacities. Her registry of severe cutaneous adverse reaction (RegiSCAR) score was 4, categorizing the patient as probable drug rash with eosinophilia systemic symptoms (DRESS) syndrome. Her initial troponin was 0.52 ng/mL (normal < 0.060) and EKG revealed lateral ST-segment elevation in leads I and aVL. Cardiology was consulted and the patient was consented for coronary angiography. Computed tomography angiogram of the chest was negative for pulmonary embolism and showed bilateral multifocal ground glass opacities. Prior to the coronary angiogram, the patient deteriorated and was transferred to the medical intensive care unit (MICU) for increased work of breathing, elevated lactate, and repeat troponin of 15.24 ng/mL. That evening the patient experienced a pulseless electrical activity (PEA) arrest. A return of spontaneous circulation (ROSC) was briefly obtained, however she experienced a second arrest and repeat attempts at resuscitation were unsuccessful.

Discussion: DRESS Syndrome is a severe drug reaction involving a widespread rash, fever, internal organ involvement, and eosinophilia (1). Presentation is typically 2 to 8 weeks after exposure to the inciting drug and the most commonly affected organs include the liver, kidney, lung and heart. Myocarditis is a rare consequence of DRESS syndrome and has a mortality of up to 55% of cases (6). These cardiac reactions may take two forms: hypersensitivity myocarditis, which has an indolent course, and acute necrotizing eosinophilic myocarditis (ANEM) (3). ANEM is commonly associated with new onset ST-segment elevation, peripheral blood eosinophilia, elevated cardiac biomarkers, a rash consistent with DRESS syndrome, and sudden cardiac arrest (4) , all of which were seen in this patient. ANEM is associated with a mortality rate of 50-70% and a median survival of 3 to 4 days (5). The gold standard for the treatment of ANEM includes the removal of the offending agent, steroid therapy, and supportive care (2). Several medication classes have been associated with DRESS syndrome such as anticonvulsants, antibiotics, and non-steroidal anti-inflammatory drugs. Amoxicillin has been associated with myocarditis and DRESS, but no reports exist identifying augmentin as an offending agent (1).

Conclusions: This report is unique in that it is the first case that specifically identifies Augmentin as a trigger for DRESS syndrome with resulting myocarditis. Given its high mortality, it is important for providers to be aware of myocarditis as a potentially fatal complication of dress syndrome, and the medications with which it is associated.