Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome  and Myocarditis: A Case Report and Literature Review on Fatal Complications  of Reactivated Viral Infections

Amin Tajerian; Ali Pourvali; Masoud Movahedi; Maryam Mohammadi; Behzad Khansarinejad; Matin Pourmatin; Yazdan Ghandi; Mohammad Ali Daneshmand

doi:10.18502/ijaai.v23i3.15643

Amin Tajerian Department of Pediatrics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
Ali Pourvali Department of Pediatrics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
Masoud Movahedi Division of Allergy and Clinical Immunology, Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
Maryam Mohammadi Department of Pediatrics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
Behzad Khansarinejad Department of Microbiology and Immunology, Arak University of Medical Sciences, Arak, Iran
Matin Pourmatin National Forensic Medicine Organization, Arak, Iran
Yazdan Ghandi Department of Pediatrics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
Mohammad Ali Daneshmand Daneshmand Pathology Laboratory, Arak, Iran

DOI: https://doi.org/10.18502/ijaai.v23i3.15643

Keywords: Cytomegalovirus; Drug hypersensitivity syndrome; Herpesvirus 6, human; Myocarditis; Sulfamethoxazole drug combination; Trimethoprim; Virus latency

Abstract

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a complex and potentially fatal hypersensitivity condition. We present a unique case report and literature review focusing on DRESS syndrome-associated myocarditis resulting from reactivated viral infections in a 21-year-old female.

3 weeks after 5-day oral co-trimoxazole consumption due to acne, she developed symptoms consistent with DRESS syndrome, including a generalized maculopapular rash. Despite prednisolone treatment, the patient developed fatal fulminant myocarditis linked to HHV-6 and CMV reactivation.

The patient's death highlights the importance of early recognition and careful management of DRESS syndrome, especially considering the potential viral reactivation that can lead to severe complications. Postmortem investigations revealed that viral reactivation caused myocarditis. Careful consideration must be given to corticosteroid usage in DRESS treatment, as inappropriate prescribing may promote viral reactivation and subsequent complications.

While high-dose corticosteroids initiated within the first week effectively suppress HHV-6 reactivation. Conversely, low-dose or late-start high-dose corticosteroids prove ineffective in preventing HHV-6 viremia. Late- onset or low- dose corticosteroids may lead to fatal complications following the primary viral reactivation.