Abstract Introduction DRESS is a severe hypersensitivity reaction characterized by fever, rash, facial oedema, lymphadenopathy, eosinophilia, and multi-organ involvement. Management typically involves prompt withdrawal of the causative drug and corticosteroid therapy. However, managing DRESS syndrome triggered with initial phase of anti-tuberculous medications is extremely challenging. A balancing decision needs to be made to control the potentially fatal hypersensitivity reaction which conflicts with the urgent need to continue effective treatment for tuberculosis. Management becomes even more complex in cases refractory to systemic corticosteroids. Case Presentation A 32-year-old woman developed DRESS syndrome two months after initiating treatment for cavitating pulmonary tuberculosis. She attended emergency department with seven day history of a widespread morbiliform rash, facial swelling and two days of fever, nausea with profound fatigue. On admission, she was febrile (39.2 °C), tachycardic (134 bpm), hypotensive (89/55 mmHg), and hypoxic, with diffuse erythematous rash and bilateral coarse crackles. Laboratory findings revealed leukocytosis (18.3 × 109/L), eosinophilia (peaking at 6.25 × 109/L), elevated IgE (5000 kU/L), and raised ALT (311 U/L). Infectious, autoimmune, and parasitic causes were excluded. Chest imaging demonstrated diffuse bilateral ground-glass opacities consistent with acute respiratory distress syndrome (ARDS). Given her recent drug history and clinical presentation, diagnosis of DRESS was made which was supported by a RegiSCAR score of 6. Anti-TB medications were stopped, and corticosteroid therapy initiated. However, the patient’s respiratory function deteriorated, necessitating mechanical ventilation. Treatment with high-dose intravenous methylprednisolone did not show sustained remission of the hypersensitivity reaction. Single dose of 30mg subcutaneous Benralizumab was administered. This resulted in rapid and sustained normalization of eosinophil count, resolution of rash, improvement in hepatic parameters, and significant recovery in pulmonary function, allowing successful extubation. Discussion This case highlights the pivotal role of IL-5 in eosinophil-driven inflammation in DRESS. It demonstrates the potential of IL-5 blockade with Benralizumab as an effective treatment in steroid-refractory DRESS. Importantly, the targeted mechanism of action allowed disease control without profound immunosuppression, minimising risk of infectious complications in a patient with partially treated tuberculosis. Conclusion IL-5 inhibition with benralizumab appears to be a promising therapeutic option for corticosteroid-resistant DRESS. This case highlights the potential role of targeted biologic therapy in managing severe and refractory cases. Further research and accumulation of clinical experience are needed to establish standardized treatment protocols. Reference Rubin et al. Front. Immunol. 14:1134178. doi: 10.3389/fimmu.2023.1134178 This abstract is funded by: None
Minn et al. (Fri,) studied this question.