Endocrine Abstracts

Introduction: Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe drug eruption with systemic involvement. Visceral manifestations consisting of fulminant hepatic failure, myocarditis, interstitial nephritis, pneumonitis and autoimmune hypothyroidism are known sequela. We report a case of DRESS syndrome post Bactrim (sulfamethoxazole and trimethoprim) therapy complicated by both myocarditis and autoimmune thyrotoxicosis.

Case report: A previously well 18 years old gentleman was prescribed Bactrim for acne vulgaris and developed DRESS syndrome 2 weeks later, He was started on high dose steroids. 2 months into steroid therapy, he presented at the Emergency Department for fever and decreased effort tolerance. He was critically ill with tachycardia (Heart Rate 150 bpm), hypotension (Blood Pressure 70/40 mmHg) and an ejection fraction of 20% on 2D-echocardiography.There were multiple episodes of unstable ventricular tachyarrhythmias requiring cardioversion and intubation. Thyroid panel revealed free T₄ 49 (RI 8–21 pmol/l), TSH 0.04 (RI 0.34–5.60 mIU/l) and free T₃ 6.4 (RI 3.5–6.0). Thyroid autoimmune markers were positive (TPO Ab 68.8 (RI 0–60 IU/ml), TRAb 14.8 (RI 0–1.5 IU/l). He was treated for possible thyroid storm with propylthiouracil and hydrocortisone. He also had severe myocarditis with hypotension refractory to inotropic support and intra-arterial balloon pump. Extracorporeal membrane oxygenation (ECMO) was initiated but patient continued to deteriorate and unfortunately passed away 5 days after admission.

Conclusion: Despite high dose immunosuppression and cessation of the causative agent post DRESS, multiple autoimmune sequelae may develop and may unfortunately be life threatening. Both patients and clinicians need to be cognisant of this. Early diagnosis and treatment may potentially be life saving.

Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.