More than skin deep, a rare case of DRESS secondary to Vimovo
complicated by severe, acute myocarditis.
Abstract
A sixty-year-old male presented with three-day history of a widespread
erythematous rash with associated chills, paraesthesia, and haematuria.
On review of medications, he had recently been commenced on Vimovo
(Naproxen/Esomeprazole) 500mg/20mg twice daily for a week for back pain.
Bloods showed hypereosinophilia and a moderate acute kidney injury.
Histology revealed parakeratosis, mild spongiosis with eosinophils. His
admission was complicated by the acute onset of rapid atrial
fibrillation with acute coronary syndrome. Coronary angiogram was
non-obstructive. Cardiac MRI revealed acute myocarditis. This was felt
to be a complication secondary to Drug reaction with eosinophilia and
systemic symptoms (DRESS). In addition to his cardiac management, he was
treated with oral corticosteroids and supportive care.
Naproxen/Esomeprazole was stopped. On repeat cardiac MRI 3 months later
his myocarditis had resolved, and his skin remains clear. DRESS is a
rare drug induced hypersensitivity reaction that includes skin eruption,
haematological abnormalities, lymphadenopathy, and internal organ
involvement which has morality rate of up to 10%. The objective of this
case report is to highlight the significant cardiac complications that
can ensue. Naproxen/Esomeprazole was the culprit drug which is rare.
There has been one previous case of DRESS secondary to NSAID with
myocarditis. However, it presented as cardiogenic shock. This case was
complicated by arrythmia and acute coronary syndrome. DRESS warrants
prompt recognition with identification of causative drug and withdrawal.
Multiorgan complications can be severe, and treatment should not be
delayed. DRESS should always be considered with a new onset rash in the
context of a new medication.