Case Presentation
A previously healthy 11-year-old female was admitted with sepsis
secondary to osteomyelitis and a periosteal abscess of the left lower
extremity, as well as methicillin-resistant staph aureus bacteremia. The
patient was initiated on clindamycin and vancomycin for treatment of
these infections. Ten days into her hospitalization, she was noted to
have swelling of her left lower extremity and imaging revealed an acute
deep venous thrombosis of the left popliteal vein. The patient was
started on unfractionated heparin and subsequently transitioned to
enoxaparin one week later.
Two weeks following enoxaparin initiation, the patient developed facial
swelling, a generalized morbilliform rash over her face, trunk, and
upper and lower extremities, and diffuse lymphadenopathy (palpable on
physical examination and confirmed on radiologic imaging). She continued
to have persistent, high-grade fevers despite multiple washouts of the
extremity and appropriate antimicrobial coverage with negative blood
cultures. Liver enzymes increased concurrently (AST 362 IU/L (normal
5-60 IU/L), ALT 371IU/L (normal <35 IU/L) at peak) with
development of these symptoms. She had leukocytosis with atypical
lymphocytes noted on peripheral smear. Eosinophilia was not present on
her complete blood count (CBC) at the onset of these symptoms, though
she did subsequently developed mild eosinophilia (1.1 K/ul at peak).
Human herpesvirus 6 (HHV6), cytomegalovirus (CMV), and Epstein Barr
Virus (EBV) serologies were all negative. Skin biopsy was performed and
was consistent with a drug eruption. With a score of 6, based on the
RegiSCAR criteria, the patient’s constellation of symptoms and biopsy
findings were consistent with a definite case of DRESS syndrome. Given
the diagnosis, treatment with high-dose steroids was initiated.
Clindamycin and vancomycin were both discontinued due to their known
association with DRESS syndrome, and she was transitioned to
doxycycline. However, over the course of the next five days, no
improvement in rash, fevers, or liver enzymes was seen. Enoxaparin, her
only remaining medication, was therefore transitioned to apixaban.
Within a few days, the patient improved with resolution of rash, fevers,
and improvement of her laboratory abnormalities.