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\begin{document}

\title{Amoxicillin-induced DRESS syndrome without eosinophilia}



\author[1]{Baraka Alphonce}%
\author[2]{Francisca Komanya}%
\author[3]{Ng'weina Magitta}%
\author[4]{Shani Deodatus}%
\author[3]{Emmanuel Sindato}%
\affil[1]{the benjamin mkapa hospital }%
\affil[2]{The Benjamin Mkapa Hospital}%
\affil[3]{University of Dodoma, Dodoma Tanzania}%
\affil[4]{Benjamin Mkapa Hospital}%


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  \date{March 15, 2025}


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\textbf{Amoxicillin-induced DRESS syndrome without eosinophilia}

\textbf{Authors and affiliation}

Baraka Alphonce\textsuperscript{1}, Francisca
Komanya\textsuperscript{1}, Ng'weina F. Magitta\textsuperscript{3,4},
Shani Deodatus\textsuperscript{2}, Emmanuel Sindato\textsuperscript{3}

\begin{enumerate}
\tightlist
\item
  Department of Internal Medicine, Benjamin Mkapa Hospital, Dodoma
  Tanzania
\item
  Department of Dermatology, Benjamin Mkapa Hospital, Dodoma Tanzania
\item
  Department of Internal Medicine, University of Dodoma, Dodoma Tanzania
\item
  Department of Biochemistry \& Clinical Pharmacology, Mbeya College of
  Health \& Allied Sciences, University of Dar es Salaam, Tanzania
\end{enumerate}

\textbf{Corresponding author}

Baraka Alphonce.

P O Box 110881 TIBA street, IYUMBU

DODOMA, TANZANIA.

Email: alphonncebaraka@gmail.com

\textbf{Key clinical message}

Despite the name, eosinophilia is not essential for diagnosing drug
reaction with eosinophilia and systemic symptoms (DRESS syndrome).

Early recognition and stopping the offending drug are vital to managing
this condition, as it can otherwise lead to high mortality rates.

\section*{Case presentation}

{\label{case-presentation}}

A 47-year-old African female with no prior medical history was
prescribed amoxicillin 1.5 gram per day in three divided doses for acute
upper respiratory tract infection. She responded well, but eighteen days
later she reported fever, a skin rash on her limbs and trunk, widespread
body itching, yellowish discoloration of the eyes, and abdominal pain
marked on the left upper region. Physical examination was notable for
fever, sclera jaundice, facial edema, diffuse erythema and scaling
involving the trunk, limbs and the face \emph{(Figure 1A).} The oral
mucosa lining was intact. There was tenderness on left hypochondriac,
and the liver span was within the normal limit. Laboratory test results
revealed elevated serum alkaline phosphatase (233 U/L), moderately
elevated transaminases: keeping with a mixed pattern of liver injury.
conjugated bilirubin (81 \selectlanguage{greek}µ\selectlanguage{english}mol/L), alkaline phosphatase (470 U/L),
creatinine kinase (23 ng/mL) was also elevated. Peripheral eosinophils
count (0.01 x 109/L) was within the normal limit. Further testing
dismissed evidence of metabolic, autoimmune, or infectious causes of
liver injury. A Computed tomography and Magnetic resonance imaging
showed no structural abnormalities on the liver, gallbladder, pancreas
or bile ducts except for left anterolateral abdominal wall thickening
without intramuscular collection. A skin biopsy revealed dermal pigment
incontinence and localized inflammation with lymphocytic predominance.
Similarly, a liver biopsy indicated bile accumulation in centrilobular
hepatocytes and Kupffer cells, as well as inflammatory infiltrates
predominantly of lymphocytes and eosinophils

\emph{(Figure 2).}

A definitive case of DRESS related to amoxicillin was established after
she earned 6 points on the RegiSCAR criteria {[}1{]} , which included
skin rash extent \textgreater{} 50\%, face edema and scaling, hepatic
injury, myositis, atypical lymphocytes, and remission of symptoms after
2 weeks. She was prescribed prednisolone at a dose of 50 mg (1 mg/kg)
per day, along with cetirizine at a dose of 10 mg per day, and Vaseline
petrolatum twice daily. The facial edema and exfoliative dermatitis
gradually improved after the second week from the onset of
symptoms\emph{(Figure 1B)} and normalization of transaminases and
bilirubin was attained after 90 days \emph{(Figure 3 and 4).} \textbf{}

\textbf{Discussion}

DRESS is commonly characterized by a cutaneous eruption, eosinophilia,
and visceral organs involvement, the liver is the visceral organ most
commonly affected. Only 10\% of cases present atypical with normal
eosinophil count {[}1{]}. Antimicrobials (especially penicillin and
sulfonamides) are the main cause {[}2{]}. DRESS syndrome can be
life-threatening and poses a diagnostic predicament considering its
atypical presentations. Most patients recover entirely within weeks or
months of stopping the medication {[}3{]}.\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

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Figure 1: (A) Facial edema, scaling and desquamation of skin 5 days
before admission. (B) Finding after initiation of the treatment, day 18
since onset\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

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Figure 2: Skin biopsy demonstrating fragment composed of an unremarkable
epidermis with pigment incontinence in the dermis and focal inflammation
composed of mainly lymphocytes. All panels were prepared using
Hematoxylin and Eosin (H\&E) stain, with a magnification of 100x.\selectlanguage{english}
\begin{figure}[H]
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Figure 3: Evolution of transaminases until resolution\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

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Figure 4: Evolution of serum bilirubin until resolution.

\section*{Author's contribution}

{\label{authors-contribution}}

\textbf{BA} : writing -- original draft; writing -- review \&
editing.\textbf{FK} : writing -- original draft; writing -- review \&
editing.\textbf{NFM} : writing -- review \& editing. \textbf{SD} :
supervision, writing -- review \& editing. \textbf{ES} : supervision,
writing -- review \& editing.

\textbf{Funding information}

None.

\textbf{Conflict of interest statement}

The authors have no conflict of interest to declare.

\textbf{Data availability statement}

All the data underlying the results is available as part of the case,
and no additional source data is required.

\textbf{Ethical approval}

All ethical issues have been thoroughly considered by the authors before
this case and any related images were published, the patient's written
informed consent was obtained. Our institution does not require ethical
approval for reporting individual cases.

\textbf{Consent}

The patient provided written in-formed consent for the publication of
the case report

\section*{References}

{\label{references}}

1. Husain Z, Reddy BY, Schwartz RA. DRESS syndrome: Part I. Clinical
perspectives. Journal of the American Academy of Dermatology. 2013 May
1. 68(5):693.e1-693.e14. doi: 10.1016/J.JAAD.2013.01.033 2. Shiohara T,
Kano Y. Drug reaction with eosinophilia and systemic symptoms (DRESS):
incidence, pathogenesis and management. Expert opinion on drug safety.
2017 Feb 1. 16(2):139--47. doi: 10.1080/14740338.2017.1270940 3. Kardaun
SH, Sekula P, Valeyrie-Allanore L, Liss Y, Chu CY, Creamer D, et al.
Drug reaction with eosinophilia and systemic symptoms (DRESS): an
original multisystem adverse drug reaction. Results from the prospective
RegiSCAR study. The British journal of dermatology. 2013 Nov.
169(5):1071--80. doi: 10.1111/BJD.12501\selectlanguage{english}
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