Images in Clinical Rheumatology
Fever and Exanthema in a Young Patient: Drug Reaction With Eosinophilia and Systemic Symptoms due to Allopurinol
Fiebre y exantema en un paciente joven: reacción a medicamentos con eosinofilia y síntomas sistémicos al alopurinol al alopurinol
Francisco Gallo Puelles
, Alejandro Muñoz Jiménez, M. Luisa Velloso Feijoó, Mario Leon Garcia, Sergio Rodriguez Montero, José Luis Marenco de la Fuente
Corresponding author
UGC de Reumatología, Hospital de Valme, Sevilla, Spain
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Luisa Velloso Feijoó, Mario Leon Garcia, Sergio Rodriguez Montero, José Luis Marenco de la Fuente" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Francisco" "apellidos" => "Gallo Puelles" "email" => array:2 [ 0 => "fgallopuelles@hotmail.com" 1 => "pacoreuval@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Muñoz Jiménez" ] 2 => array:2 [ "nombre" => "M. Luisa" "apellidos" => "Velloso Feijoó" ] 3 => array:2 [ "nombre" => "Mario" "apellidos" => "Leon Garcia" ] 4 => array:2 [ "nombre" => "Sergio" "apellidos" => "Rodriguez Montero" ] 5 => array:2 [ "nombre" => "José Luis" "apellidos" => "Marenco de la Fuente" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "UGC de Reumatología, Hospital de Valme, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fiebre y exantema en un paciente joven: reacción a medicamentos con eosinofilia y síntomas sistémicos al alopurinol al alopurinol" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 761 "Ancho" => 1000 "Tamanyo" => 124257 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rash and edema on the extremities.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical Presentation</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient is a 25-year-old male with Down's syndrome who was hospitalized for 10 days due to a macular popular rash on the thorax, abdomen and extremities, with fever, abdominal pain and nausea. The patient had a history of celiac disease and hypothyroidism that were under control and had used allopurinol 20 days earlier. Upon examination the patient had a macular and popular rash on the neck, thorax, abdomen and extremities, as well as hand and feet edema (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The patient had no synovitis or other findings.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis and Progression</span><p id="par0010" class="elsevierStylePara elsevierViewall">Laboratory: leukocytosis 15<span class="elsevierStyleHsp" style=""></span>800 (990 eosinophils), aspartate-transaminase 138, alanine-aminotransferase 300. Renal function, immunology tests and serology for exanthematic diseases were normal. An abdominal ultrasound showed mild liver and spleen enlargement. Chest and abdomen x rays were normal. A punch biopsy of the skin lesion showed evidence of a spongiotic reaction to drugs. The patient had used allopurinol 20 days earlier, complying with two major criteria (skin rash and liver affection) and 3 minor criteria (leukocytosis, fever, eosinophilia) of those proposed by Zinger and Wallace for allopurinol hypersensitivity. Treatment with IV liquids, steroids and antihistamines was started (allopurinol had been suspended a week prior), with excellent clinical progression, remission of fever and the rash and a normalization of liver enzymes.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Drug related eosinophilia and systemic symptoms (DRESS), in this case allopurinol, is a type IV late hypersensitivity reaction that presents in approximately 2% of patients after 2–4 weeks of treatment.</p><p id="par0020" class="elsevierStylePara elsevierViewall">This is the favored term to refer to currently describe a drug reaction. Although most generally have a favorable outcome, mortality may reach 25%, fundamentally due to liver or renal damage or severe sepsis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Older patients, with renal failure, using thiazides and Asians seem to have a greater predisposition to developing DRESS.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Our case was a young male patient with Down's syndrome with a diffuse rash and fever, initially leading us to the diagnosis of measles. The fact that he had received treatment with allopurinol due to a prior asymptomatic hyperuricemia made it possible to suspect the drug related origin of his disease.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Ethical Responsibilities</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Protection of persons and animals</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no experiments on humans or animals were performed for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Data confidentiality</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors state that they have followed their work center protocols regarding the publication of patient data and that all included patients in the study were sufficiently informed and gave their informed consent in writing in order to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Right to privacy and informed consent</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors state that informed consent was obtained from patients and/or subjects referred to in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical Presentation" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis and Progression" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical Responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of persons and animals" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of Interest" ] 5 => array:1 [ "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0045">Further reading</span>" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gallo Puelles F, Muñoz Jiménez A, Velloso Feijoó ML, Leon Garcia M, Rodriguez Montero S, Marenco de la Fuente JL. Fiebre y exantema en un paciente joven: reacción a medicamentos con eosinofilia y síntomas sistémicos al alopurinol al alopurinol. Reumatol Clin. 2013;9:379–380.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 761 "Ancho" => 1000 "Tamanyo" => 124257 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rash and edema on the extremities.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 957 "Ancho" => 999 "Tamanyo" => 176365 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diffuse rash of the thorax and neck.</p>" ] ] ] "lecturaRecomendada" => array:1 [ 0 => array:3 [ "vista" => "all" "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0045">Further reading</span>" "seccion" => array:1 [ 0 => array:2 [ "vista" => "all" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of severe drug reactions: Stevens Johnson syndrome, toxic epidermal necrolysis and hypersensivity syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 10 | 17 |
| 2024 October | 56 | 45 | 101 |
| 2024 September | 67 | 20 | 87 |
| 2024 August | 78 | 46 | 124 |
| 2024 July | 59 | 33 | 92 |
| 2024 June | 63 | 25 | 88 |
| 2024 May | 53 | 43 | 96 |
| 2024 April | 72 | 26 | 98 |
| 2024 March | 74 | 34 | 108 |
| 2024 February | 46 | 33 | 79 |
| 2024 January | 66 | 22 | 88 |
| 2023 December | 61 | 31 | 92 |
| 2023 November | 70 | 32 | 102 |
| 2023 October | 37 | 41 | 78 |
| 2023 September | 39 | 43 | 82 |
| 2023 August | 35 | 11 | 46 |
| 2023 July | 39 | 27 | 66 |
| 2023 June | 41 | 25 | 66 |
| 2023 May | 52 | 21 | 73 |
| 2023 April | 23 | 14 | 37 |
| 2023 March | 48 | 28 | 76 |
| 2023 February | 35 | 24 | 59 |
| 2023 January | 38 | 27 | 65 |
| 2022 December | 45 | 45 | 90 |
| 2022 November | 47 | 28 | 75 |
| 2022 October | 64 | 22 | 86 |
| 2022 September | 52 | 31 | 83 |
| 2022 August | 37 | 40 | 77 |
| 2022 July | 44 | 45 | 89 |
| 2022 June | 52 | 34 | 86 |
| 2022 May | 61 | 45 | 106 |
| 2022 April | 49 | 38 | 87 |
| 2022 March | 54 | 50 | 104 |
| 2022 February | 36 | 52 | 88 |
| 2022 January | 50 | 30 | 80 |
| 2021 December | 28 | 39 | 67 |
| 2021 November | 28 | 41 | 69 |
| 2021 October | 39 | 40 | 79 |
| 2021 September | 40 | 32 | 72 |
| 2021 August | 31 | 47 | 78 |
| 2021 July | 26 | 27 | 53 |
| 2021 June | 51 | 34 | 85 |
| 2021 May | 39 | 62 | 101 |
| 2021 April | 89 | 67 | 156 |
| 2021 March | 51 | 23 | 74 |
| 2021 February | 38 | 14 | 52 |
| 2021 January | 34 | 12 | 46 |
| 2020 December | 39 | 25 | 64 |
| 2020 November | 27 | 16 | 43 |
| 2020 October | 24 | 13 | 37 |
| 2020 September | 35 | 19 | 54 |
| 2020 August | 34 | 9 | 43 |
| 2020 July | 35 | 16 | 51 |
| 2020 June | 38 | 18 | 56 |
| 2020 May | 38 | 19 | 57 |
| 2020 April | 24 | 10 | 34 |
| 2020 March | 11 | 3 | 14 |
| 2020 February | 2 | 0 | 2 |
| 2019 April | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 May | 4 | 0 | 4 |
| 2018 April | 40 | 6 | 46 |
| 2018 March | 53 | 9 | 62 |
| 2018 February | 32 | 3 | 35 |
| 2018 January | 29 | 9 | 38 |
| 2017 December | 34 | 5 | 39 |
| 2017 November | 24 | 5 | 29 |
| 2017 October | 31 | 6 | 37 |
| 2017 September | 36 | 5 | 41 |
| 2017 August | 55 | 7 | 62 |
| 2017 July | 44 | 4 | 48 |
| 2017 June | 94 | 7 | 101 |
| 2017 May | 77 | 17 | 94 |
| 2017 April | 51 | 5 | 56 |
| 2017 March | 43 | 24 | 67 |
| 2017 February | 29 | 8 | 37 |
| 2017 January | 32 | 9 | 41 |
| 2016 December | 75 | 23 | 98 |
| 2016 November | 51 | 10 | 61 |
| 2016 October | 68 | 12 | 80 |
| 2016 September | 87 | 5 | 92 |
| 2016 August | 65 | 11 | 76 |
| 2016 July | 43 | 8 | 51 |
| 2016 June | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 2 | 0 | 2 |
| 2015 September | 1 | 16 | 17 |
| 2015 July | 31 | 7 | 38 |
| 2015 June | 45 | 12 | 57 |
| 2015 May | 62 | 34 | 96 |
| 2015 April | 53 | 14 | 67 |
| 2015 March | 41 | 8 | 49 |
| 2015 February | 41 | 6 | 47 |
| 2015 January | 44 | 7 | 51 |
| 2014 December | 50 | 9 | 59 |
| 2014 November | 46 | 12 | 58 |
| 2014 October | 58 | 12 | 70 |
| 2014 September | 95 | 6 | 101 |
| 2014 August | 54 | 20 | 74 |
| 2014 July | 55 | 13 | 68 |
| 2014 June | 74 | 14 | 88 |
| 2014 May | 56 | 13 | 69 |
| 2014 April | 64 | 11 | 75 |
| 2014 March | 85 | 20 | 105 |
| 2014 February | 56 | 15 | 71 |
| 2014 January | 72 | 26 | 98 |
| 2013 December | 87 | 26 | 113 |
| 2013 November | 23 | 8 | 31 |
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