(1520) Ad-DRESS-ing an Unusual Presentation of Vancomycin-Induced DRESS Syndrome

Introduction: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS Syndrome) is a rare and life-threatening hypersensitivity reaction to certain medications. Vancomycin is a commonly used antibiotic that has rarely been linked to the development of DRESS. It is believed to involve multiple organ systems because of an immune reaction to the offending drug.

Description: A 70-year-old male with a history of Chronic Inflammatory Demyelinating Polyneuropathy presented with diffuse skin rash and altered mental status. Three weeks ago, he had left knee septic arthritis and was started on vancomycin. His synovial fluid gram stain was positive for gram-positive cocci. He was hypothermic (93.4 F) on presentation. Labs showed leukocytosis [ 13700/microlitre] with eosinophilia [1100/microlitre], normal liver function tests, and acute kidney injury with serum creatinine raised to 4.78 mg/dL. On physical examination, he was oriented only to person and had a diffuse blanchable erythematous nonpruritic maculopapular rash on the entire body. No vesicles, bullae, or mucosal lesions were identified, and there was no lymphadenopathy. Vancomycin was stopped. On day 2, he had a worsening mental status and was hemodynamically unstable requiring ICU admission for emergent intubation and vasopressor support. Blood cultures, ANA, and hepatitis serologies were negative. He scored 5 points on the European Registry of Severe Cutaneous Adverse Reactions [RegiSCAR DRESS validation score]. Skin punch biopsy showed interface dermatitis with superficial dermal lymphocytic infiltrate. The findings were consistent with a hypersensitivity reaction to vancomycin, given the temporal association. He was started on IV steroids with improvement in his condition.

Discussion: DRESS syndrome is a dermatological emergency associated with a mortality rate of around 10%. If left untreated, it can lead to life-threatening multi-organ dysfunction. Although rare, vancomycin can cause DRESS syndrome, especially in patients with certain genetic variations in Human Leukocyte Antigen (HLA). Vancomycin-induced DRESS syndrome often leads to a higher likelihood of kidney impairment. Once diagnosed, immediate discontinuation of vancomycin is crucial. Steroids should be prescribed to mitigate the severity of the reaction.