Prednisone/quetiapine

Abstract

DRESS syndrome and lack of efficacy: case report A man in his late 60s [exact age at event onset not stated] developed DRESS syndrome during treatment with quetiapine for delirium. Additionally, he exhibited lack of efficacy during treatment with prednisone for the DRESS syndrome. The man presented to hospital due to cardiogenic shock following acute myocardial infarction. After admission, he was placed on venoarterial extracorporeal membrane oxygenation and haemodynamic support was provided with an intra-aortic balloon pump. His medical history included high BP, hypercholesterolaemia and non-insulin-dependent type 2 diabetes mellitus. His ongoing medications included atorvastatin and enalapril. Laboratory investigations revealed glomerular filtration rate was >60 mL/min/1.73 m2 and serum creatinine level was 0.9–1 mg/dL. He was then transferred to the ICU. GCS score was 2/15. He required invasive mechanical ventilation, and treatment was initiated with heparin [unfractionated heparin] and aspirin. Additionally, he received antimicrobial prophylaxis with cefazolin. On day 2 of admission, he developed atrial fibrillation requiring treatment with amiodarone. Two days later, examinations lead to suspicion of a respiratory infection. Hence, antibiotic therapy with gentamicin and piperacillin/tazobactam was started. At this time, he experienced non-oliguric renal failure with blood urea nitrogen of 238 mg/dL, serum creatinine of 2 mg/dL, estimated glomerular filtration rate of 31 mL/min/1.73m2. Hence, continuous renal replacement therapy (CRRT) was started. On day 5, his respiratory and neurological symptoms improved allowing the withdrawal of the mechanical ventilation. On day 8, he developed erythematous maculopapular rash that started on the upper chest area and expanded towards the extremities and trunk. Blood tests confirmed eosinophilia in the peripheral blood count. Twelve hours prior, he was started on oral quetiapine 25mg daily due to an episode of delirium. Based on the examination, DRESS syndrome was suspected. The man’s treatment was initiated with prednicarbate, but only minimal improvement was noted. After two days, the systemic eosinophilia and rash worsened. Antibacterial therapy was changed from gentamicin and piperacillin/tazobactam to clindamycin and aztreonam. Also, his treatment was started with oral prednisone 10mg daily, but no improvement was noted in his condition (lack of efficacy). Amiodarone was stopped on admission day 15 as it was initially suspected as the causative drug for DRESS. However, eosinophil count continued to increase and peaked on day 18. At this time, his medications were reviewed and quetiapine was eventually discontinued. Simultaneously, kidney function remained altered and interstitial nephritis was suspected. Corticosteroids were increased to 1 mg/kg/day and methylprednisolone was added to treatment regimen. Eventually, improvement was noted in his condition. Later, on day 20, he received a single dose of quetiapine 25mg for a new episode of delirium. On the following day, a rise in his blood eosinophils was again noted. Therefore, quetiapine was permanently stopped. On admission day 22, venoarterial extracorporeal membrane oxygenation was withdrawn. Based on his signs and symptoms, RegiSCAR scale showed a score 7 confirming a diagnosis of DRESS syndrome. Subsequently, his eosinophil count normalised and the skin lesions disappeared. He was then discharged home with elevated serum creatinine level. During follow-up examination after three months, persistent abnormal kidney function was noted. Causality assessment using Naranjo scale indicated a probable relationship with a score of 7 for quetiapine and DRESS syndrome.