Endocrine Abstracts

Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon severe systemic hypersensitivity drug reaction. Several studies have described the occurrence of newly developed endocrine autoimmune diseases following DRESS syndrome resolution. However, little attention has been paid by endocrinologists to this disorder. Here, we report a case of a patient with Graves’ disease following DRESS syndrome.

Clinical case: A 70-year-old man with urinary tract infection was treated with co-trimoxazole. Two weeks later, he presented to the dermatology outpatient clinic with a pruritic dermatosis, fever and peripheral lymphadenopathy. Physical examination revealed erythematous maculopapular lesions affecting his trunk and limbs and laboratory tests showed leukocytosis, eosinophilia and thrombocytopenia. Diagnosis of DRESS syndrome was made by the dermatologist, and treatment with glucocorticoids was initiated and allowed a gradual recovery. One year later, he presented is his follow-up appointment with fatigue, heat intolerance and palpitations. The blood tests revealed a Graves’ hyperthyroidism with suppressed TSH (<0.01 uU/ml), elevated free T4 (2.07 ng/dl; N:0.85-1.7 ng/dl) and positive TSH receptor antibodies (TRAbs) (137 U/l; N:<1.22). He was referred to the endocrinology outpatient clinic, with a suspected newly onset Graves’ disease succeeding DRESS syndrome resolution. By the time of his first endocrinology appointment, two months later, the laboratory evaluation revealed hypothyroidism (TSH 33.1 uU/ml; free T4 0.67 ng/dl) with persistent positive TRAbs (128 U/l). The patient started levothyroxine and, to this date, he remains euthyroid under 100 mg per day.

Discussion: There are several reports of newly developed Hashimoto’s thyroiditis as sequelae of DRESS syndrome. What is original about this case is the association between Graves’ disease and DRESS syndrome, a more uncommon association, and also the coexistence of stimulating and inhibiting TRAbs, leading to a rapid shift from hyperthyroidism to hypothyroidism, a rare condition in Graves’ disease. We believe that endocrinologists should be aware of this association and that involvement of endocrine glands should be monitored in patients with a history of DRESS syndrome.