D3.245 - Positive HLA-B*13:01 Allele in a Patient with Clinical Diagnosis of Drug Induced Eosinophilia with Systemic Symptoms (DRESS)
Case report
Background
Some DRESS reactions occur more frequently in patients with certain human leukocyte antigen (HLA) types. However, current practice parameters suggest that most pharmacogenetic associations identified to date are currently unlikely to translate into clinical practice.
Methods
We present a case of a 28-year-old Thai female nurse, without underlying conditions, who was admitted for fever and hepatitis. She had been taking cotrimoxazole (CTX) for acne for 3 months. Fourteen days PTA: patient sustained needle stick injury at work and was placed on Bictegravir/Emtricitabine/Tenofovir Alafenamide (BET). Seven days PTA: she developed low grade fever. On the day of admission, fever continued and she was found to have hepatitis, CTX and BET were discontinued. Examination revealed a temperature of 39.9°C, HR 108 beats/minute, BP 103/70 mmHg, RR 20 breaths/minute. Remarkable findings included puffy face, injected pharynx with slight ulcer on soft palate, multiple enlarged cervical lymph nodes. Four days after admission, erythematous lichenoid rashes appeared on face, trunk, extremities, covering approximately 50% of the body surface area with some purplish discolorations.
Results
Over the course of the illness, abnormal laboratory works include Eosinophil 13% (WBC 3.6K/mcl), Hb 10.3 g/dL, atypical lymphocyte 3%; AST/ALT/ALP/GGT/LDH: 276/429/324/328/932 U/L, respectively, direct/total bilirubin: 3.4/4.1 mg/dL, albumin 2.92 g/dL, PT 17.2 seconds (9.1-13.4); CRP 7.79 mg/dL. Cr, UA, respiratory pathogen RT-PCR, Hepatitis profile, HIV-1-2 Ag/Ab, EBV-CA IgM, HSV IgM, CMV IgM, Dengue IgM, were unremarkable. HLA-B genotyping showed positive HLA-B*13:01 and negative HLA-B*57:01. DRESS score was 5. Tapering course of predinisolone was initiated with the current dose of 5 mg on alternate days, along with Cyclosporin A 25 mg daily by the 3rd month. Rashes, facial swelling and oral lesions have resolved. Slight cervical lymphadenopathy remains. The lab results have normalized.
Conclusions
Positive HLA-B*13:01 allele is associated with CTX-induced DRESS in Thai population. Although screening tests prior to administering CTX is not a routine practice, retrospect testing might be informative. The test to confirm exact cause would require in vivo testing (delayed drug skin /patch tests) or in vitro testing (ELISPOT or lymphocyte transformation test), which could only be performed when patient is not on systemic steroid. Consent for publication of patient data has been obtained.
