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2017 ; 9
(6
): e1359
Nephropedia Template TP
gab.com Text
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Two Catastrophes in One Patient: Drug Reaction with Eosinophilia and Systemic
Symptoms and Toxic Shock Syndrome
#MMPMID28721327
Ibrahim M
; Nunley DL
Cureus
2017[Jun]; 9
(6
): e1359
PMID28721327
show ga
A 70-year-old, immunocompromised patient presented to the emergency room (ER)
five weeks after she was started on clopidogrel. She complained of skin eruption,
mouth ulcers, fatigue, and myalgia over the past two weeks. Labs showed severe
hyponatremia, acute kidney injury, rhabdomyolysis, hyperkalemia, and elevated
liver enzymes. She was treated with steroids and discharged after her condition
improved. However, a month later, she returned to the ER, complaining of nausea,
vomiting, diarrhea, dizziness, chills, and shortness of breath over the past two
days. She was lethargic and had orthostatic hypotension. She deteriorated
clinically within a few days, with worsening lethargy and the development of
respiratory distress along with profound hypotension. She needed mechanical
ventilation and vasopressors. In addition, she had melena, severe
thrombocytopenia, and hemolytic anemia. With supportive care, she improved and
was discharged after a long stay in the intensive care unit. Retrospectively, the
first hospitalization was believed to be caused by drug reaction with
eosinophilia and systemic symptoms (DRESS). Treating that with steroids
compromised her immune system beyond her pre-existing primary immunodeficiency
status. At the time of her second hospitalization, she met the Centers for
Disease Control and Prevention (CDC) criteria for a toxic shock syndrome (TSS)
diagnosis. Her TSS started four days after a skin biopsy, which was done as part
of her skin rash workup. It was thought that the source of the exotoxin that
mediated her TSS was her skin, given the temporal relationship of the skin biopsy
to her TSS. Another potential source of the exotoxin was the gastrointestinal
tract, given the predominant gastrointestinal symptoms she had at the time of her
second admission.