Reactions 1459 - 6 Jul 2013

SCotrimoxazole

DRESS syndrome and fulminant hepatic failure:case report

A 17-year-old Chinese boy with acne vulgaris developedDRESS syndrome and fulminant hepatic failure duringtreatment with cotrimoxazole.

The boy had been receiving cotrimoxazole [trimethoprim/sulfamethoxazole 80mg/400mg; route and frequency notstated] and isotretinoin for 28 days when a maculopapular rashdeveloped, initially over his neck and chest. Within the nextfew days, the rash spread to his limbs and the rest of his trunk;he had fever and myalgia. His rash and fever did not subsideafter symptomatic treatment by the general practitioner, andhe presented at the emergency department. At admission, hewas jaundiced, with bilateral cervical and inguinallymphadenopathy. Laboratory testing revealed a raisedeosinophil count and an elevated serum bilirubin level; his ALTlevel was 1660 U/L and his AST level was 1249 U/L. A drug-induced liver injury was suspected.

Cotrimoxazole and isotretinoin were withdrawn. The boywas treated with vitamin K [phytomenadione], acetylcysteine,empiric ceftriaxone and aciclovir, piperacillin/tazobactam,lactulose and plasma. Skin biopsy revealed features consistentwith drug exanthema. The elevation of his transaminase andbilirubin levels continued, and his rash worsened; he becameincreasingly disoriented on hospital day 8. He was in grade IIIhepatic encephalopathy, and received molecular adsorbentrecirculating system (MARS) extracorporeal liver dialysis andintubation. His condition improved; he became more orientedand alert. His hepatic encephalopathy resolved; he wasdischarged well on day 25. His rash resolved; his liver functiontests had normalised 2 months later.

Author comment: "Fulminant hepatic failure associatedwith TMP-SMZ [trimethoprim-sulfamethoxazole] is a rare butrecognised adverse drug reaction . . . In 0.01%–0.1% ofpatients, TMP-SMZ induces DRESS syndrome . . . The resultsof our employment of the Naranjo criteria which predicts thelikelihood of a medication causing an allergic reaction,indicated that TMP-SMZ was the most likely cause of theadverse drug reaction in our patient".Ng CT, et al. Successful extracorporeal liver dialysis for the treatment oftrimethoprim-sulfamethoxazole-induced fulminant hepatic failure. SingaporeMedical Journal 54: e113-e116, No. 5, May 2013. Available from: URL: http://dx.doi.org/10.11622/smedj.2013067 - Singapore 803089367

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Reactions 6 Jul 2013 No. 14590114-9954/10/1459-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved