D1.256 - Development of multiple drug hypersensitivity after DRESS syndrome induced by piperacillin/tazobactam
Case report
Background
DRESS is a severe hypersensitivity reaction with a mortality rate of 4%. Approximately 25% of these patients develop multiple drug hypersensitivity (MDH) to structurally unrelated drugs due to permanent T-cell activation. Patients receiving high doses of antibiotics, fixed combination therapies, or long-term treatments are particularly at risk for developing MDH. Here, we present the case of a 57-year-old woman, who experienced a DRESS syndrome to piperacillin/tazobactam and developed severe erythroderma five and seven months later following iodinated contrast media administration with iopamidol and ioxthalamate. She had several examinations with iodinated contrast media before without any complication.
Results
The LTT performed after the DRESS event (RegiSCAR 7 points) showed strong sensitization to piperacillin/tazobactam, confirmed to piperacillin but not to tazobactam. The patch test was positive for the beta lactam antibiotics amoxicillin trihydrate, dicloxacillin, and cefotaxime (Chemotechnique Diagnostics,Vellinge, Sweden) but negative for piperacillin/tazobactam (tested as is). A second LTT, conducted after the patient developed severe erythroderma—first to iopamidol and later to ioxithalamate—revealed sensitization to both iodinated contrast media, as well as to iopromide, while iobitridol and iomeron remained negative. Patch testing showed a strong reaction to iopamidol (++), as well as to other iodinated contrast media with or without a carbamoyl chain except for iomeprol and iobitridol. Ioxithalamate was not tested due to unavailability. Given the wide range of positive reactions to nearly all iodinated contrast media (ICM), trometamol, a common excipient in ICM, was also tested but yielded a negative result.
Conclusion
As Gex-Collet et al. distinguished between two forms of MDH—simultaneous and sequential—in our case a simultaneous MDH was ruled out, as only piperacillin was tested positive. But we identified a sequential drug hypersensitivity to iodinated contrast media in this case, occurring five and seven months after the DRESS reaction to piperacillin/tazobactam. The subsequent reaction to two iodinated contrast media (Group A with and without carbamoyl chain) highlights the variability of cross-reactions within this drug class. Patients with a history of DRESS should be closely monitored, particularly when they are exposed to new drugs.
