B53-25 Dressing Up: Severe Drug Hypersensitivity Presenting as Shock and Multiorgan Failure in the ICU in a Patient With Recurrence of Leukemia

Abstract Introduction Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe T-Cell mediated hypersensitivity process that is characterized by clinical constellation of fever, cutaneous morbilliform eruptions without mucosal involvement, hematologic abnormalities, and organs involvement following exposure to an offending drug. The prevalence of DRESS is estimated at 2.18 per 100000 patients with an estimated 2-10% in patient mortality. Rapid clinical decompensation involving multi-organ failure results in considerable patient morbidity and its clinical presentation often mimics other forms of shock which can make it difficult to diagnose. The mainstay of DRESS treatment involves the identification of the offending drug, immediate withdrawal of the agent, and use of systemic corticosteroids. Case Presentation We present an 88-year-old female undergoing chemotherapy for classical Hodgkin’s Lymphoma (cHL). She presented from her oncology clinic with hypotension, fever, and altered mentation. The patient was admitted for suspected urinary tract infection, broad-spectrum antibiotics were initiated. A review of outside records revealed a recent previous admission, during which she developed an eruptive morbilliform rash following exposure to a cephalosporin, a recent punch skin biopsy from that hospitalization was suggestive of DRESS. However, as her macular rash improved, it was determined that her rash and associated symptoms were likely due to underlying cHL, therefore her steroid regimen was discontinued at that time. During her readmission for suspected UTI, her hospital course was complicated by acute respiratory failure and septic shock refractory to fluid resuscitation. Her symptoms required transfer to the intensive care unit (ICU). Hematologic labs were notable for persistent eosinophilia without atypical lymphocytosis. Due to worsening cutaneous eruptions and vasopressor dependence, a trial of stress-dosed steroids was initiated due to increasing clinical suspicion of DRESS. Within 12 hours of systemic corticosteroids, she significantly improved allowing for subsequent weaning of supplemental oxygen and vasopressor support. She was able to downgrade from the ICU after 2 days of close monitoring. Discussion DRESS is listed among the deadliest diseases of the integumentary system with mortality rates as high as 10% worldwide. DRESS can be difficult to diagnose due to its non-specific presentations involving multiple systems. It is imperative that clinical suspicion remains high for this condition in any patient presenting to the ICU with a new morbilliform rash with circulatory collapse requiring multiple vasopressors. However, diagnostic evaluation can become complicated by underlying lymphoma undergoing active chemotherapy treatment which can have a similar cutaneous presentation. This abstract is funded by: None