A possible meropenem-associated dress syndrome

Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS)/Drug induced hypersensitivity syndrome (DiHS) is a delayed drug hypersensitivity reaction with mortality around 10%. DRESS after meropenem is rarely reported. Here we describe a case of meropenem-associated DRESS. Description: This is a 33 y/o female with recurrent pancreatitis presumed secondary to alcohol use transferred from an outside institution following a complicated course including pancreatic pseudocyst, bilateral pleural effusions with empyema, pericardial effusion and pulmonary embolism. After transfer, she underwent right VATS with decortication and partial pleurectomy for necrotic lung and was started on meropenem (hospital day [HD] 1) for intra-abdominal infection and pneumonia. Due to persistent fever, vancomycin was added on HD 9. An erythematous, blistering rash developed between HD 3-11, and an eosinophilia was noted on HD 9. Skin biopsy demonstrated spongiotic dermatitis. Initial HHV-6 level was negative. Vancomycin and meropenem were discontinued on HD 15 due to suspected drug reactions. Ceftazidime/avibactam and metronidazole were started on HD 20 but also discontinued on HD 24 as the absolute eosinophil count (AEC) continued to rise. The AEC level peaked at 20,100 on HD 26 when steroids were started. AEC then dropped on HD 27 to mild eosinophilia. Tigecycline was started on HD 25 for intra-abdominal infection to include VRE coverage and to avoid beta-lactams, with no complications. The clinical course including generalized erythematous skin eruption and peripheral eosinophilia is suggestive of a delayed drug hypersensitivity reaction including DRESS/DiHS. REGISCAR score is 3-4. Calculated meropenem DRESS reaction Naranjo score is 7. Discussion: Attribution of causality in cases of DRESS/DiHS is difficult due to the delayed onset of reaction following initiation of medication (often 2-8 wks) and absence of testing to definitively determine causality. This challenge has significant implications for medication reintroduction. We suspect meropenem was the causative agent and have judiciously limited antibiotic treatments due to the diagnosis of a severe cutaneous adverse reaction (SCAR). In cases of SCAR, re-introduction of causative medications is contraindicated due to high mortality risk.