Login Register Cart 0
Generic placeholder image

Coronaviruses

Editor-in-Chief

ISSN (Print): 2666-7967
ISSN (Online): 2666-7975

Back
Journal Home About Journal Editorial Board Current Issue Volumes/Issues
Subscribe
Case Report

Hydroxychloroquine Induced DRESS (Drug Rash with Eosinophilia and Systemic Symptoms Syndrome) Mimicking SARS-COV-2 Illness: A Case Report with Review

Author(s): Maitri M. Patel, Dhruvkumar M. Patel*, Mukundkumar V. Patel, Jayanti K. Gurumukhani, Suyog Y Patel and Harsh D. Patel

Volume 2, Issue 4, 2021

Published on: 29 September, 2020

Page: [521 - 526] Pages: 6

DOI: 10.2174/2666796701999200929123836

Abstract

Background: In the current pandemic of COVID-19, hydroxychloroquine (HCQ) is recommended as an experimental drug for prophylaxis and treatment of the illness. Although it is a safe drug, it can rarely produce a severe drug reaction ‘drug rash with eosinophilia and systemic symptoms syndrome (DRESS)’, and to differentiate it from systemic viral infections is challenging.

Case Presentation: A 45-year old male nurse working in a COVID-19 ward consumed HCQ weekly for two weeks for prevention of SARS-COV-2 illness. He presented with fever, pruritic maculopapular palmar rash, cervical lymphadenopathy for 12 hours and was quarantined as a suspected COVID-19 case. His laboratory tests revealed lymphopenia, eosinophilia, atypical lymphocytes, raised liver enzymes along with IgM negative, IgG positive rapid antibody test of SARS-COV-2. However, his throat swabs for SARS-COV-2 by real-time PCR were negative on day 1 and 7. He was finally diagnosed as definite DRESS based on the RegiSCAR score of six. He responded to levocetirizine 5 mg OD and oral prednisolone 60 mg daily tapered over 7 days.

Conclusion: DRESS due to HCQ is ‘probable’, ‘of moderate severity’, and ‘not preventable’ adverse effect mimicking SARS-COV-2 illness.

Keywords: Hydroxychloroquine, DRESS, drug rash with eosinophilia and systemic symptoms, COVID-19, SARS-COV-2, DRESS syndrome.

Graphical Abstract

[1]
Haładyj E, Sikora M, Felis-Giemza A, Olesińska M. Antimalarials - are they effective and safe in rheumatic diseases? Reumatologia 2018; 56(3): 164-73.
[http://dx.doi.org/10.5114/reum.2018.76904] [PMID: 30042604]
[2]
Jover JA, Leon L, Pato E, et al. Long-term use of antimalarial drugs in rheumatic diseases. Clin Exp Rheumatol 2012; 30(3): 380-7.
[PMID: 22339928]
[3]
Al-Bari MA. Chloroquine analogues in drug discovery: new directions of uses, mechanisms of actions and toxic manifestations from malaria to multifarious diseases. J Antimicrob Chemother 2015; 70(6): 1608-21.
[http://dx.doi.org/10.1093/jac/dkv018] [PMID: 25693996]
[4]
Singh AK, Singh A, Shaikh A, Singh R, Misra A. Chloroquine and hydroxychloroquine in the treatment of COVID-19 with or without diabetes: A systematic search and a narrative review with a special reference to India and other developing countries. Diabetes Metab Syndr 2020; 14(3): 241-6.
[http://dx.doi.org/10.1016/j.dsx.2020.03.011] [PMID: 32247211]
[5]
Devaux CA, Rolain JM, Colson P, Raoult D. New insights on the antiviral effects of chloroquine against coronavirus: what to expect for COVID-19? Int J Antimicrob Agents 2020; 55(5): 105938.
[http://dx.doi.org/10.1016/j.ijantimicag.2020.105938] [PMID: 32171740]
[6]
Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB. Pharmacologic treatments for coronavirus disease 2019 (COVID-19): A Review. JAMA 2020; 323(18): 1824-36.
[http://dx.doi.org/10.1001/jama.2020.6019] [PMID: 32282022]
[7]
Keyaerts E, Li S, Vijgen L, et al. Antiviral activity of chloroquine against human coronavirus OC43 infection in newborn mice. Antimicrob Agents Chemother 2009; 53(8): 3416-21.
[http://dx.doi.org/10.1128/AAC.01509-08] [PMID: 19506054]
[8]
Rathi S, Ish P, Kalantri A, Kalantri S. Hydroxychloroquine prophylaxis for COVID-19 contacts in India. Lancet Infect Dis 2020; 20: 1118-9.
[http://dx.doi.org/10.1016/S1473-3099(20)30313-3 ]
[9]
Yazdany J, Kim AH. Use of hydroxychloroquine and chloroquine during the covid-19 pandemic: what every clinician should know. Ann Intern Med 2020; 172(11): 754-5.
[10]
O’Laughlin JP, Mehta PH, Wong BC. Life threatening severe qtc prolongation in patient with systemic lupus erythematosus due to hydroxychloroquine. Case Rep Cardiol 2016; 20164626279
[http://dx.doi.org/10.1155/2016/4626279] [PMID: 27478650]
[11]
Chen CY, Wang FL, Lin CC. Chronic hydroxychloroquine use associated with QT prolongation and refractory ventricular arrhythmia. Clin Toxicol (Phila) 2006; 44(2): 173-5.
[http://dx.doi.org/10.1080/15563650500514558] [PMID: 16615675]
[12]
Leckie MJ, Rees RG. Stevens-Johnson syndrome in association with hydroxychloroquine treatment for rheumatoid arthritis. Rheumatology (Oxford) 2002; 41(4): 473-4.
[http://dx.doi.org/10.1093/rheumatology/41.4.473] [PMID: 11961185]
[13]
Yu J, Brandling-Bennett H, Co DO, Nocton JJ, Stevens AM, Chiu YE. Toxic epidermal necrolysis-like cutaneous lupus in pediatric patients: a case series and review. Pediatrics 2016; 137(6)e20154497
[http://dx.doi.org/10.1542/peds.2015-4497] [PMID: 27245834]
[14]
Pelle MT, Callen JP. Adverse cutaneous reactions to hydroxychloroquine are more common in patients with dermatomyositis than in patients with cutaneous lupus erythematosus. Arch Dermatol 2002; 138(9): 1231-3.
[http://dx.doi.org/10.1001/archderm.138.9.1231] [PMID: 12224986]
[15]
Abou Assalie N, Durcan R, Durcan L, Petri MA. Hydroxychloroquine-induced erythema multiforme. J Clin Rheumatol 2017; 23(2): 127-8.
[http://dx.doi.org/10.1097/RHU.0000000000000417] [PMID: 28099213]
[16]
Volpe A, Marchetta A, Caramaschi P, Biasi D, Bambara LM, Arcaro G. Hydroxychloroquine-induced DRESS syndrome. Clin Rheumatol 2008; 27(4): 537-9.
[http://dx.doi.org/10.1007/s10067-007-0772-1] [PMID: 17952481]
[17]
Girijala RL, Siddiqi I, Kwak Y, Wright D, Patel DB, Goldberg LH. Pustular DRESS syndrome secondary to hydroxychloroquine with ebv reactivation. J Drugs Dermatol 2019; 18(2): 207-9.
[PMID: 30811149]
[18]
Arora A, Mohamed MA, Thompson AD. Addressing DRESS: a case of a hydroxychloroquine-induced reaction. Consultant 2017; 57(11): 648-50.
[19]
Cacoub P, Musette P, Descamps V, et al. The DRESS syndrome: a literature review. Am J Med 2011; 124(7): 588-97.
[http://dx.doi.org/10.1016/j.amjmed.2011.01.017] [PMID: 21592453]
[20]
Horsfield P, Deshpande S, Ellis R. Killing with kindness? Drug reaction eosinophilia with systemic symptoms (DRESS) masquerading as acute severe sepsis. J Antimicrob Chemother 2009; 64(3): 663-5.
[http://dx.doi.org/10.1093/jac/dkp236] [PMID: 19570755]
[21]
Shanoj KC, Joseph S, Shenoy P. Drug reaction with eosinophilia and systemic symptoms syndrome. Indian J Rheumato 2019; 14(Suppl. S1): 59-66.
[22]
Tian Y, Rong L, Nian W, He Y. Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther 2020; 51(9): 843-51.
[http://dx.doi.org/10.1111/apt.15731] [PMID: 32222988]
[23]
Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol 2020; 34(5): e212-3.
[http://dx.doi.org/10.1111/jdv.16387] [PMID: 32215952]
[24]
Fox RI. Mechanism of action of hydroxychloroquine as an antirheumatic drug. Semin Arthritis Rheum 1993; 23(2)(Suppl. 1): 82-91.
[http://dx.doi.org/10.1016/S0049-0172(10)80012-5] [PMID: 8278823]
[25]
Savarino A, Di Trani L, Donatelli I, Cauda R, Cassone A. New insights into the antiviral effects of chloroquine. Lancet Infect Dis 2006; 6(2): 67-9.
[http://dx.doi.org/10.1016/S1473-3099(06)70361-9] [PMID: 16439323]
[26]
Vincent MJ, Bergeron E, Benjannet S, et al. Chloroquine is a potent inhibitor of SARS coronavirus infection and spread. Virol J 2005; 2: 69.
[http://dx.doi.org/10.1186/1743-422X-2-69] [PMID: 16115318]
[27]
Kang JH. Febrile illness with skin rashes. Infect Chemother 2015; 47(3): 155-66.
[http://dx.doi.org/10.3947/ic.2015.47.3.155] [PMID: 26483989]
[28]
Kingston ME, Mackey D. Skin clues in the diagnosis of life-threatening infections. Rev Infect Dis 1986; 8(1): 1-11.
[http://dx.doi.org/10.1093/clinids/8.1.1] [PMID: 3513282]
[29]
Levin S, Goodman L. An approach to acute fever and rash in the adult. Curr Clin Top Infect Dis 1995; 15: 19-75.
[30]
Schlossberg D. Fever and rash. Infect Dis Clin North Am 1996; 10(1): 101-10.
[http://dx.doi.org/10.1016/S0891-5520(05)70289-0] [PMID: 8698985]
[31]
Moriceau F, Prothet J, Blaise BJ, et al. DRESS syndrome in the icu: when a patient is treated with multiple drugs. Case Rep Crit Care 2016; 20169453286
[http://dx.doi.org/10.1155/2016/9453286 ]
[32]
Tsyrulnik A, Landman A. Drug rash with eosinophilia and systemic symptoms: two emergency department cases. West J Emerg Med 2011; 12(4): 559-62.
[http://dx.doi.org/10.5811/westjem.2010.11.2077] [PMID: 22224160]
[33]
Kim DH, Koh YI. Comparison of diagnostic criteria and determination of prognostic factors for drug reaction with eosinophilia and systemic symptoms syndrome. Allergy Asthma Immunol Res 2014; 6(3): 216-21.
[http://dx.doi.org/10.4168/aair.2014.6.3.216] [PMID: 24843796]
[34]
Cho YT, Yang CW, Chu CY. Drug reaction with Eosinophilia and Systemic Symptoms (DRESS): an interplay among drugs, viruses, and immune system. Int J Mol Sci 2017; 18(6): 1243.
[http://dx.doi.org/10.3390/ijms18061243] [PMID: 28598363]
[35]
Castellazzi ML, Esposito S, Claut LE, Daccò V, Colombo C. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome in two young children: the importance of an early diagnosis. Ital J Pediatr 2018; 44(1): 93.
[http://dx.doi.org/10.1186/s13052-018-0535-4] [PMID: 30111350]
[36]
Singhal T. A Review of coronavirus disease-2019 (COVID-19). Indian J Pediatr 2020; 87(4): 281-6.
[http://dx.doi.org/10.1007/s12098-020-03263-6] [PMID: 32166607]
[37]
Li H, Liu SM, Yu XH, Tang SL, Tang CK. Coronavirus disease 2019 (COVID-19): current status and future perspectives. Int J Antimicrob Agents 2020; 55(5)105951
[http://dx.doi.org/10.1016/j.ijantimicag.2020.105951] [PMID: 32234466]
[38]
Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions Clin Pharmacol Ther 1981; 30(2): 239-45.
[http://dx.doi.org/10.1038/clpt.1981.154] [PMID: 7249508]

Rights & Permissions Print Cite
Article Metrics
11
1
© 2025 Bentham Science Publishers | Privacy Policy