Case Presentation:

59-year-old Male who presented to the Emergency Department (ED) with generalized rash and fevers. The patient stated that the rash started as a blister in his groin and then spread to the rest of his body. The patient’s past medical history was significant for seizures controlled with phenytoin, cirrhosis secondary to alcohol abuse, esophageal varices, depression, COPD and SCC of the tongue. The patient reported regular use of  over the counter ibuprofen when troubled by headaches, but on the days prior to initiation of the rash the patient had a severe headache that prompted him to take multiple doses of ibuprofen.  The patient stated that he had been taking “a few” extra tablets of ibuprofen every day due to a severe migraine attack. Further inquiry revealed that the patient had consumed 30 tablets of ibuprofen within 36 hours.

On examination the patient was afebrile, upper trunk was clear, but a blanching erythema was noted on greater than 50% of body surface including bilateral axilla, lower trunk, antecubital fossa, inguinal folds and buttocks with thin erosions; no evidence of conjunctivitis, oral, urethral or anal involvement. Notably the rash also spared the palmar and plantar surfaces. His skin showed superimposed blisters on the inguinal area, distributed in a non-follicular pattern. There was no evidence of sloughing of the skin or mucosa. Nikolsky sign and Asboe-Halsen were negative. The Dermatology service performed a bedside skin biopsy in the ED from two sites.

On Hospital day two the previous areas of erythema evolved into a desquamating lesions. Routine hematological investigations showed a normal white blood cell count with neutrophilia and slight eosinophilia. Biochemical investigations revealed an elevated creatinine. Bacterial swab and cultures from the lesions were negative.  Blood cultures revealed no growth. Histological analysis revealed a presence of neutrophils and eosinophils in both epidermis and dermis, and necrotic keratinocytes consistent with Pustular Drug Eruption. The patient’s rash improved after stopping the ibuprofen. Two days after cessation of ibuprofen the patient’s creatinine normalized. The patient was discharged to home with visiting nurse services for local wound care.

Discussion:

Drug reaction with eosinophilia and systemic symptoms (DRESS). Infectious and noninfectious causes  must be given consideration depending on clinical history.This patient met 6 out of 6 RegiSCAR for DRESS. The liver is the most common organ involved in DRESS and the kidneys the second most common. This case underscores the importance of a history taking in identifying triggers for an acute rash. This patient developed DRESS from a previously well tolerated drug after increasing the frequency of intake. If caught early DRESS is self limited and only requires hydration, local wound care and cessation of the offending agent.

Conclusions:

DRESS can present in patients who increase the frequency or dose of medications commonly associated with adverse drug reactions.