DRESS’ed in Shock and Delay in Eosinophilia Resolution: Management Dilemmas in a Complex Case of Vancomycin-Induced DRESS Syndrome

BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare hypersensitivity reaction to a medication that can affect multiple organ systems, with variably noted hematological marker trends. Severe cases requiring intensive care are not common but represent the most severe form of the disease, and the variable presentation can be confused for other diagnoses. CASE REPORT We present the case of a 61-year-old woman with vancomycin-associated DRESS syndrome who had kidney injury noted a few days prior to symptom onset. She was initially thought to have had a straightforward allergic reaction. Her case was then managed as sepsis due to persistent distributive shock, before she experienced clinical improvement with the commencement of high-dose corticosteroids. Her eosinophil and lymphocyte count continued to worsen despite steroid therapy and observable clinical improvement, before eventually resolving. CONCLUSIONS This case report highlights that observable clinical improvement should take precedence over early eosinophil and lymphocyte trends following systemic steroid initiation in severe DRESS syndrome when determining the need for therapy escalation It demonstrates kidney dysfunction as a possible early marker for severe vancomycin-induced DRESS syndrome, which can progress to shock, and which in our case was believed to be distributive in pathophysiology and required critical care. Finally, further research to help establish standardized management on the choice, route, dosage, and duration of steroids in severe DRESS syndrome would prove beneficial.