Minocycline-induced Drug sensitivity syndrome with eosinophilia and systemic symptoms (Dress) with development of severe acute interstitial nephritis

DRESS is a severe hypersensitivity reaction to drugs, characterized by rash, fever, lymphadenopathy, systemic involvement and hematological alterations.The most frequently affected organs are skin, liver, lung, kidney, heart and central nervous system. It develops 2-6 weeks after initiation of the responsible medication. It has been described in association with multiple drugs, the most frequently involved being aromatic anticonvulsants and sulfonamides.

We report the case of a 13-year-old girl with DRESS syndrome induced by minocycline. The patient developed renal failure, requiring hemodialysis, with recovery of renal function after two weeks with corticosteroids and supportive measures.

13-year-old girl, treated with Minocycline for inflammatory acne. She consulted the emergency service due to the sudden appearance of a pruritic erythematous rash affecting  face, abdomen, chest and extremities, fever and headache. She received symptomatic treatment with diphenhydramine and ibuprofen. A swab of the fauces was performed and St. Pyogenes was recovered. She was initially medicated with Azithromycin. She developed clinically with septic shock, with laboratory results of anemia, transaminases elevated to twice the normal value, decreased glomerular filtration rate with preserved diuresis and urine with macrohematuria, without leukocyturia. A chest x-ray was performed that showed consolidation in the right base. Antibiotic therapy was modified to clindamycin and penicillin. The clinical picture was interpreted as systemic involvement due to Dress syndrome with possible invasive pyogenes infection. She was medicated with meprednisone 60 mg/day. Renal function temporarily recovers with subsequent deterioration, water overload and oligoanuria. Two steroids pulses were indicated. The patient was admitted to our hospital with acute renal failure (AKI), requiring hemodialysis. Renal biopsy was performed, with reporting of severe tubulointerstitial nephritis without primary glomerulopathy. Immunological causes were ruled out.

Management of DRESS syndrome includes discontinuation of the triggering drug, symptomatic treatment and steroids. The mortality approaches 10%, due to liver and kidney involvement. The kidney injury consisted of the development of interstitial nephritis, with severe compromise of renal function requiring dialysis therapy and steroid treatment. Minocycline is an infrequent cause of DRESS. There is still a lack of clinical trials that compare symptomatic treatment according to the organ involved with the use of steroids and studies that compare different doses of steroids. On the other hand, some case reports suggest the use of additional immunosuppressive drugs. More studies are required to evaluate the management of these patients.

Conclusions