Your patient gets this rash, what’s the diagnosis?
October 17, 2013
Two weeks after being started on carbamazepine, the patient develops this rash associated with itching and facial swelling. What’s the diagnosis? (Hint: look at the complete blood count differential)
This patient has drug reaction with eosinophilia and systemic symptoms (DRESS). DRESS is an immune response seen most commonly with certain drugs including anticonvulsants (lamotrigine, carbamazepine and phenytoin) and allopurinol. The diagnosis is usually made with a rash (such as in the picture) combined with eosinophilia and end-organ dysfunction (renal failure, transaminitis or lung involvement). Many other organs can be less commonly affected.
Treatment involves first stopping the offending drug then steroids if there is any end-organ involvement such as renal failure.
This patient had mild renal failure and liver involvement. He was started on steroids and saw an improvement in the first couple days. Interestingly, you see that this patient’s rash is worse in sun exposed regions including where he wore his watch. Often times sun hypersensitivity should make you think of other diagnoses such as lupus. However, this patient had no other signs or lab findings to suggest this.
A 46-year-old Vietnamese female with history of Churg-Strauss syndrome was seen for a flare-up and had the above skin changes. Based on the characteristics pattern can you diagnose the cause of this skin rash?…
37 yr old male with a history of these lesions on his the back of his hands for the past two years. Notes no other medical issues. No weakness, fatigue, fevers or rashes anywhere else on his body. He works as a chiropractor and is concerned about his patients seeing his hands. Use of various over the counter treatments such as topical steroids and moisturizers did not improve the lesions.