Phenytoin-Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome with Severe Hepatic Involvement in a Patient with Symptomatic Epilepsy: A Case Report
DOI:
https://doi.org/10.26911/theijmed.2026.11.4.967Abstract
Background: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a severe, life-threatening hypersensitivity reaction frequently caused by aromatic anticonvulsants like phenytoin. It is characterized by a long latency period, extensive rash, haematological abnormalities, and internal organ involvement. This case report explores the diagnostic challenges and management strategies for DRESS syndrome presenting as severe hepatitis and exfoliative erythroderma in an epilepsy patient.
Case presentation: A 47-year-old male with cerebral meningioma and symptomatic epilepsy presented with a 41°C fever and generalized erythematous rash following one month of phenytoin consumption. Physical examination revealed exfoliative erythroderma, facial oedema, cheilitis, and jaundice. Investigations confirmed significant eosinophilia (11.7%), monocytosis, and severe heaptitis with massive transaminase elevation and hyperbilirubinemia. Diagnosed with DRESS syndrome (RegiSCAR score: 5, probable) and Stevens-Johnson Syndrome as a differential, management included immediate phenytoin cessation. To prevent cross-reactivity, levetiracetam was substituted. Patient also received systemic corticosteroids (dexamethasone) and aggressive hepatoprotective therapy. The patient showed excellent clinical improvement, marked by normalized temperature, hemodynamic stability, and skin desquamation by the fifth day.
Discussion: DRESS syndrome carries significant mortality, primarily due to fulminant hepatic failure. The 4- to 6-week latency period is pathognomonic, distinguishing it from other exanthems. Its pathogenesis involves complex interactions among toxic metabolite accumulation, Th2-type immune activation triggering eosinophilia, and potential herpesvirus reactivation. Prompt discontinuation of the offending drug and selecting a non-aromatic anticonvulsant, such as levetiracetam, are essential steps in safely managing this patient’s epilepsy.
Keywords:
DRESS syndrome, phenytoin, eosinophilia, severe hepatitis, levetiracetamHow to Cite
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