50 yo M with fever and a rash

OBJECTIVES:

  • Evaluate a patient with fever and a rash

CASE:

50 yo M with a history of epilepsy on phenytoin and lamotrigine and developmental delay who presents with a new diffuse rash x 5 days. His rash is pruritic and appeared at the same time on his face, trunk and extremities and involves the axilla but spares the palms/soles. His family reports he has had subjective fevers, dry cough without shortness of breath and difficulty/discomfort swallowing over the same time frame. He has also had some lip swelling and “scabs” over his lips. His family denies sick contacts, recent travel or new exposures. Other ROS was only notable for mild right sided abdominal discomfort without nausea/vomiting/diarrhea.

He has a history of epilepsy (full history and medications) that was well controlled on lamotrigine until ~ 6 weeks ago when he had a breakthrough seizure and was started on phenytoin. He has been taking daily Tylenol and Vicks PM (which contains Tylenol) over the past week for his subjective fevers.

His physical exam was notable for fever of 38.2C, otherwise VSS. He has a diffuse erythematous morbilliform rash involving the upper thighs, chest, back, neck with some areas of confluence. and no areas of desquamation. The vermillion of his lips had thick brown/hemorrhagic crusting without active vesicles. No other mucus membranes were involved. His labs are notable for a Cr of 1.2 (from baseline of 0.8), BUN 28, WBC of 14, hct of 38%, and platelets of 150.

What is your differential?


What additional work-up do you want?


How does this change your differential? What additional work-up do you want? (~5 min) 


FINAL DIAGNOSIS AND OUTCOME:

What is it? (1-2 min)

When should we suspect this diagnosis? (~5 min) 

What are culprit drugs? (1 min) 

How would you evaluate a patient with this suspected syndrome? (3-5 min)

How is it treated? (2-3 min) 


TAKE HOME POINTS: 


ADDITIONAL LEARNING: 

How can we differentiate this syndrome from other severe drug reactions? (~5 min) 


REFERENCES:

  1. Cacoub, P, et al. “The DRESS Syndrome: A Literature Review.” 2011. The American Journal of Medicine. 124(7): 588-597.
  2. Husain, Z, et al. “DRESS syndrome: Part I. Clinical perspectives.” 2013. Journal of American Academy of Dermatology. 68:693.e1
  3. Husain, Z, et al. “DRESS syndrome: Part II. Management and therapeutics.” 2013. Journal of American Academy of Dermatology. 68:709.e1
  4. Roueau, JC, et al. Drug reaction with eosinophilia and systemic symptoms (DRESS). In: UpToDate, Corona, R (Ed), Waltham, MA. (Accessed on May 25, 2017)