Syndrome DRESS (Drug Rash with Eosinophilia and Systemic Symptoms)

Case Report: Adult Still's Disease in an Alemtuzumab-Treated Multiple Sclerosis Patient

Background

Autoimmune adverse events are the most relevant risks of alemtuzumab therapy. We present a patient with relapsing-remitting multiple sclerosis, who developed adult-onset Still's disease (AOSD) following alemtuzumab treatment.

Case Presentation

The patient suffered from sore throat, swallowing difficulties, high spiking quotidian fever, generalized skin rash, arthritis, and myalgia 2 months after the second course of alemtuzumab. Laboratory tests revealed elevated acute-phase reactants, anemia, neutrophilic leukocytosis, and thrombocytosis. Serum calprotectin, interleukin-2, and interleukin-6 levels were strongly increased. Autoimmune, rheumatic, neoplastic, infectious, and granulomatous disorders were excluded. The NLRP1 and NLRP3 gene test, which was performed under the presumption of a cryopyrin-associated autoinflammatory syndrome, was negative. Based on the Yamaguchi and Fautrel criteria, and supported by the histological findings from a skin biopsy of the rash, the diagnosis of AOSD was established. Therapy with the anti-IL-1 agent (anakinra) led to a significant improvement of symptoms and blood parameters. However, anakinra had to be converted to rituximab due to generalized drug eruption. Following therapy with rituximab, the patient has fully recovered.

Conclusion

The current case highlights AOSD as another rare and potentially life-threatening secondary autoinflammatory/autoimmune event following alemtuzumab treatment.

[DRESS syndrome secondary to pyrazinamide: An uncommon complication of tuberculosis treatment]

INTRODUCTION

The Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) is a severe drug-induced reaction.

CASE REPORT

We report the case of a 35-year-old man treated by RHEZ for a first episode of a smear positive pulmonary tuberculosis and who developed a DRESS syndrome due to pyrazinamide after twenty days of treatment, associated with a viral reactivation to Human Herpes Virus 6 (HHV6). He had a skin eruption, liver involvement and hypereosinophilia. He fully recovered after drug withdrawal, associated with local and general corticosteroids. He died two weeks after discharge.

CONCLUSIONS

Discovery of DRESS syndrome during tuberculosis treatment is an uncommon complication and requires a searching for the responsible drug. That should be difficult because tuberculosis drugs are often given as fixed-dose combination. Physicians have to bear in mind the potential role of pyrazinamide.

[The "DRESS" syndrome in antituberculosis drugs]

The DRESS syndrome is a serious drug reaction that may involve life-threatening. We have to think before any skin reaction after taking drugs. We report a clinical case of a 27-year-old patient treated for pleural tuberculosis with the DRESS syndrome induced by antituberculosis. Through this work, we underline the rarity of this syndrome to antituberculosis treatment, but it should not be underestimated.