Case Presentation: Introduction:DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) is a rare but severe and delayed hypersensitivity reaction to a medication, characterized by rash, eosinophilia, fever, and systemic organ involvement. We describe a case in a 54-year-old patient treated with carbamazepine for trigeminal neuralgia.A 54-year-old woman with a history of hypertension and hyperlipidemia was diagnosed one month prior to admission with new onset trigeminal neuralgia and started on Carbamazepine 100 mg twice daily for a week, then increased to 200 mg twice daily. She presented to the ED with a five-day history of a worsening pruritic, maculopapular rash involving the abdomen, extremities, and neck, and subjective fevers. On examination, she was hypotensive, tachycardic, and afebrile, with the aforementioned rash and nontender anterior cervical lymphadenopathy.Labs were notable for leukocytosis (WBC 22,000/μL) with marked eosinophilia (16.7%), hyponatremia, acute kidney injury, transaminitis, and elevated lactate. Further infectious workup was negative, and chest X-ray was normal. The patient required ICU admission and early pressor support with norepinephrine. DRESS syndrome was suspected due to the constellation of symptoms and temporal association with initiating carbamazepine. The patient was treated with systemic corticosteroids, with improvement in renal and hepatic function. She was subsequently discharged home on the 4th hospital day with a six-week tapered course of oral prednisone and discontinuation of carbamazepine. The patient was followed closely as an outpatient with eventual resolution of her rash.
Discussion: DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) is a rare and potentially severe hypersensitivity reaction to various medications, including psychotropic drugs, nonsteroidal anti-inflammatory agents (NSAIDs), and certain antimicrobials including vancomycin and beta-lactams (1). Our patient developed a rash 30 days after initiating carbamazepine therapy. This rash could potentially be confused with other severe drug-related skin reactions, such as Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN), which are typically characterized by a shorter latency period of 5–28 days. In our case, the patient improved by discontinuing carbamazepine and treatment with systemic corticosteroids. Intensive treatments, such as high-dose methylprednisolone (30 mg/kg/day), intravenous immunoglobulin, and plasmapheresis, have been suggested as potential therapies for DRESS syndrome as well. (2). The prognosis of DRESS syndrome varies, with a mortality rate estimated between 1.7% and 10%, primarily due to fulminant hepatitis or liver necrosis (3,4,5). Poor prognostic indicators include eosinophil counts above 6000 × 10^3/μL, thrombocytopenia, pancytopenia, leukocytosis, and coagulopathy.
Conclusions: This case highlights the importance of clinicians being vigilant in recognizing early signs and symptoms of DRESS syndrome, especially when prescribing carbamazepine, and underscores the need for close monitoring of side effects and long-term sequelae.