Case Presentation
A previously healthy 11-year-old female was admitted with sepsis secondary to osteomyelitis and a periosteal abscess of the left lower extremity, as well as methicillin-resistant staph aureus bacteremia. The patient was initiated on clindamycin and vancomycin for treatment of these infections. Ten days into her hospitalization, she was noted to have swelling of her left lower extremity and imaging revealed an acute deep venous thrombosis of the left popliteal vein. The patient was started on unfractionated heparin and subsequently transitioned to enoxaparin one week later.
Two weeks following enoxaparin initiation, the patient developed facial swelling, a generalized morbilliform rash over her face, trunk, and upper and lower extremities, and diffuse lymphadenopathy (palpable on physical examination and confirmed on radiologic imaging). She continued to have persistent, high-grade fevers despite multiple washouts of the extremity and appropriate antimicrobial coverage with negative blood cultures. Liver enzymes increased concurrently (AST 362 IU/L (normal 5-60 IU/L), ALT 371IU/L (normal <35 IU/L) at peak) with development of these symptoms. She had leukocytosis with atypical lymphocytes noted on peripheral smear. Eosinophilia was not present on her complete blood count (CBC) at the onset of these symptoms, though she did subsequently developed mild eosinophilia (1.1 K/ul at peak). Human herpesvirus 6 (HHV6), cytomegalovirus (CMV), and Epstein Barr Virus (EBV) serologies were all negative. Skin biopsy was performed and was consistent with a drug eruption. With a score of 6, based on the RegiSCAR criteria, the patient’s constellation of symptoms and biopsy findings were consistent with a definite case of DRESS syndrome. Given the diagnosis, treatment with high-dose steroids was initiated. Clindamycin and vancomycin were both discontinued due to their known association with DRESS syndrome, and she was transitioned to doxycycline. However, over the course of the next five days, no improvement in rash, fevers, or liver enzymes was seen. Enoxaparin, her only remaining medication, was therefore transitioned to apixaban. Within a few days, the patient improved with resolution of rash, fevers, and improvement of her laboratory abnormalities.