The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Stephanie V. Sherman, M.D., Editor

Drug Reaction with Eosinophilia and

Systemic Symptoms
A B C

A
30-year-old man was admitted to the hospital with a 2-week Wei-Kai Hung, M.D.
history of rash and fever. Four weeks before presentation, he had taken Wen-Hung Chung, M.D., Ph.D.
trimethoprim–sulfamethoxazole for the treatment of folliculitis. His body Chang Gung Memorial Hospital,
temperature was 39.1°C. Physical examination revealed a morbilliform rash across Linkou Branch
the trunk, arms, and legs (Panel A), submandibular lymphadenopathy, and facial Taoyuan City, Taiwan
wenhungchung@yahoo.com
erythema with periorbital sparing (Panel B). Four days after admission, facial edema
developed (Panel C). Peak laboratory values during the hospital stay included an
absolute eosinophil count of 3028 per cubic millimeter (reference range, 40 to 350),
an alanine aminotransferase level of 989 U per liter (reference value, <36), and an
aspartate aminotransferase level of 162 U per liter (reference value, <34). The se-
rum creatinine level was normal, as were a urinalysis, chest radiograph, antinucle-
ar antibody test, and tests for viral hepatitis and Mycoplasma pneumoniae infection.
Skin biopsy revealed interface dermatitis with eosinophilic and lymphocytic infil-
tration. The European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR)
score was 7, which indicated a definitive diagnosis of drug reaction with eosino-
philia and systemic symptoms (DRESS) related to treatment with trimethoprim–
sulfamethoxazole. (RegiSCAR scores range from −4 to 9, with higher scores indicating
a more definite diagnosis; a score of >5 indicates a definitive diagnosis.) Treatment
with systemic glucocorticoids and cyclosporine was initiated, and the patient was ad-
vised to avoid sulfonamide-containing antimicrobial agents. At 1 month of follow-up,
his symptoms had abated.
DOI: 10.1056/NEJMicm2116076
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