DISCUSSION

We reported a case of Drug Reaction With Eosinophilia And Systemic Symptoms

(DRESS) Diagnosis was made based on anamnesis, physical examination, and
laboratory findings. In this case patient was a female and 36 years old.
A case of DRESS have been reported with clinical features of pruritic and
maculopapular rash appearing 2 weeks after the administration the culprit drugs
(cefadroxil, salbutamol, gliseril, guaiakolat). About 2 weeks later, patient
complain facial edema. This corresponds to the latency period commonly reported
on the literature. The syndrome developes 2 to 6 weeks or longer after initiation of
administration of specific drug.2 This is usually a delay from the beginning of
drug intake to the onset of clinical symptoms, a prolonged course follows, with
frequent flare-ups and relapses over weeks or even month after stopping the
culprit drug.3
The main drugs that cause DRESS are anticonvulsants, the anti-gout
medication allopurinol, and the antibiotics minocycline and the sulfamides. 3 In
published data by the Network of the French Pharmacovigilance Center, 216
patients with DRESS have been reported to the French pharmacovigilance
database during a 15-year period (1985-2000), where only anticonvulsants,
allopurinol, minocycline, and abacavir sulfate were considered. In this patient, the
culprit drug are cefadroxil, salbutamol, gliseril guaiakolat.. Based Naranjo Scoring
system, all drugs is classified into “possible”.
To confirm the responsible agent in DRESS, re-challenge with suspected
drug, is not advised due to the risk of life threatening reaction. Patch testing,
performed in the study of drug eruption, is not fully standardized, but it can be
helpful in confirming the imputability of a drug in several pattern of cutaneous
adverse drug reactions where delayed hypersensitivity mechanisms are involved.
Patch test is recommended to this patient after 6 weeks to 6 months after complete
healing of the adverse drug reaction, and at least 1 month after discontinuation of
systemic corticosteroid.
The clinical manifestation were pruritic and maculopapular rash involving
most of the body, facial edema, and fever. SH Kardaun et al reported

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characteristics of probable and definite cases of DRESS. Polymorphous
maculopapular was reported on 85%, fever ≥ 38,5 °C was documented in 90%
patient, lymphadenopathy was observed in 54% patient and facial edema was
found in 76% patient.10 The presence of facial edema is a characteristic
presentation in DRESS syndrome, one which might be a predictor of a more
serious reaction than drug-induced maculopapular exanthema.4
There were enlarged lymph node of left and right inguinal. SH Kardaun et
al reported lymphadenopathy incidence about 54% for DRESS. 5 Maria Ganeva et
al was observed in 70%.6
A blood analysis showed leucocytosis ( leucocyte of 13.610/mm 3 ) with
eosinophilia ( eosinophil count of 14%) and atypical lymphocyte was positive.
Total protein was decreased with hipoalbuminemia. SGOT and SGPT was
normal. This result indicate abnormal liver function was happened in this patient.
Multiple internal organs may be damage over the course of DRESS syndrome.
Liver injury is the most common type of organ damaged and has been found in 75
– 94% of patient. The liver injury seen in DRESS syndrome tend to be more
severe and to last longer.4 But there were no involvement of renal and cardiac
organ. The neurologic manifestation of DRESS syndrome include headache,
seizure, coma and motor function impairment was not happened.
Diagnosing DRESS for this patient was established based on RegiSCAR’s
Scoring System. The RegiSCAR’s Scoring System has been designed to grade
DRESS case as “no (score = <2)”, “possible (score = 2-3)”, “probable (score = 4-
5)” or “definite (score >5)” case. In this patient, the RegiSCAR score was 7 which
indicate definite case.1
This patient was initiated to be treated with an injection of prednisone 60
mg per day. The other treatment was the supportive therapy. The optimal
treatment of DRESS remains inconclusive and it is unclear whether treatment
with corticosteroids will benefit patients or prevent organ failure.7
Conclusion
 A case of Drug Reaction with Eosinophilia and Systemic Symptoms
(DRESS) associated with the use of cefadroxil, salbutamol, gliseril
guaiakolat.

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 Diagnosing DRESS for this patient was established based on RegiSCAR’s
Scoring System and classified into definite case.
 Patch test is recommended to this patient after 6 weeks to 6 months after
complete healing of the adverse drug reaction, and at least 1 month after
discontinuation of systemic corticosteroid.
 Long term follow up to be need for this patient.

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REFFERENCE

1. Cacoub Patrice, Musette Philippe, Descamps Vincent, et al. The DRESS

Syndrome: A Literature Review. The American Journal of Medicine 2011,
vol 124.
2. Peter Jonathan Grant, Lehloenya Rannakoe, Dlamini Sipho, et al. Severe
delayed cutaneous and systemic reactions to drugs: a global perspective on
the science and art of current practice. J Allergy Clin Immunol Pract
2017;547-563
3. Kano Yoko, Tohyama Mikiko, Aihara Michiko, et al. Sequelae in 145
patients with drug-induced hypersensitivity syndrome/drug reaction with
eosinophilia and systemic symptoms: Survey conducted by the Asian
Research Committee on Severe Cutaneous Adverse Reactions (ASCAR).
Journal of Dermatology 2015, 42:276-282.
4. Camous Xavier, Calbo Sebastian, Picard Damien, et al. Drug reaction with
eosinophilia and systemic symptoms: an update on phatogenesis. Current
Opinion in Immunology 2012, 24:730-735.
5. Eshky Majed, Allanore Laurence, Musette Philippe, et al. Twelve-year
analysis of severe cases of drug reaction with eosinophilia and systemic
symptoms. Arch Dermatology 2009,145(1);67-72.
6. Ganeva Maria, Gancheva Tanya, Lazarova Roumiana, et al. Carbamazepine-
induced drug reaction with eosinophilia and systemic symptoms (DRESS)
syndrome; report of flour cases and brief review. Internatiobal Journal of
Dermatology 2008, 47:853-860.
7. Cho YT, Liau JY, Chang CY, et al. Co-existence of histopathological features
is characteristic in drug reaction with eosinophilia and systemic symptoms
and correlates with high grades of cutaneous abnormalities. JEADV 2016.

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