Drug Induced Hypersensitivity Syndrome (DIHS) in a 12 Month Old Child

Introduction: Drug rash with eosinophilia and systemic symptoms syndrome (DRESS)/DIHS is a complex syndrome characterized by a broad spectrum of clinical features, like fever, lymphadenopathy, cutaneous manifestations and visceral involvement, eosinophilia and atypical lymphocytosis.

Beta-lactams, anticonvulsants, allopurinol, sulfonamides are culprit drugs than can trigger this delayed hypersensitivity mechanism. Herpes virus-drug interactions are sometimes observed.

A 12-month-old female baby, with congenital heart disease and chromosomal abnormality (deletion of short arm of chromosome 8) was submitted to undergo cardiac surgery.

On day 6 post-surgery she was prescribed with intravenous vancomycin and gentamycin, for infection.

Due to loss of intravenous line, on day 7 post-surgery, a switch to oral amoxicillin and clavulanic acid was done. On day 8 of antibiotic, she presented an urticarial maculopapular rash with facial edema and fever, hepatomegaly and lymphadenopathy, associated with laboratorial abnormalities >10% atypical lymphocytes, and elevated AST 429 U/L and ALT 621U/L, suggestive of a mononucleosic syndrome. On day 11 of amoxicillin and clavulanic acid, this antibiotic was suspended. Epstein Barr virus, cytomegalovirus and toxoplasmosis were IgG positive. Parainfluenza virus type 3 was also positive. HHV 6 and 7 serologies and measles virus RNA were negative. On day 18 of admission, the child was seriously ill and vancomycin and ceftriaxone were again started. On day 29 post-surgery, endocarditis was confirmed by cardiac ultrasound, and daptomycin, cefepime and ciprofloxacin was started with clinical improvement. The baby was discharged on day 48 post-surgery, a subtle rash in her legs was still observed.

Four months later, she was inadvertly prescribed amoxicillin and clavulanic acid for an upper respiratory infection. On the 3^rd day of antibiotic, she presented again with an urticarial rash that was promptly suspended.

Conclusions: The diagnosis of DRESS/DIHS was proposed, based on RegiSCAR (European registry of severe cutaneous adverse reactions to drugs) criteria.