1. PATIENT PRESENTATION
A 71‐year‐old black female patient with a past medical history of diabetes, hypertension, and hyperlipidemia presented to the emergency department with a diffuse pruritic skin rash that had not responded to over‐the‐counter Benadryl. She was recently diagnosed with gout 3 weeks prior and began taking allopurinol, indomethacin, and colchicine at that time. Laboratory studies revealed eosinophilia (6%) without leukocytosis. Notably, she had an elevated erythrocyte sedimentation rate (49) and C‐reactive protein (74.3), new transaminitis, and worsening chronic kidney disease (Table 1). Her physical examination revealed a diffuse, non‐blanching, maculopapular rash covering her entire body, including her palms and soles, with minimal exfoliation (Figures 1, 2, 3, 4, 5, 6, 7, 8).
TABLE 1.
Patient's pertinent laboratory results that demonstrate eosinophilia, mild transaminitis, and elevated BUN/Cr, ESR, and CRP.
| Lab value | Result | Lab value | Result |
|---|---|---|---|
| WhBC count | 9.9 thou/mcL | ALT, AST | 133 IU/L, 98 U/L |
| Eosinophil (absolute, %) | 0.61 thou.mcL, 6% | Troponin | 17.2 ng/L, 15 ng/L |
| Hemoglobin | 10.3 gm/dL | Hepatitis A, B, C | Non‐reactive |
| Platelet count | 280 thou/mcL | Na | 129 mMol/L |
| RBC morphology | Abnormal (slight ovalocytes, poikilocytosis, schistocytes; moderate polychromasia) | K | 4.2 mMol/L |
| CRP | 74.3 mg/L | BUN | 57 mg/dL |
| ESR | 49 mm/h | Cr | 3.05 mg/dL |
| PT, INR | 13.6s, 1.1 | Glucose | 174 mg/dL |
Abbreviations: ALT, alanine transaminase; AST, aspartate transaminase; BUN, blood urea nitrogen; Cr, creatinine; CRP, C‐reactive protein; ESR, erythrocyte sedimentation rate; INR, international normalized ratio; K, potassium; Na, sodium; PT, prothrombin time; RBC, red blood cell; WBC, white blood cell.
FIGURE 1.
Dark brown and red maculopapular rash located on the patient's bilateral palms and forearms.
FIGURE 2.
Dark brown and red maculopapular rash demonstrated on the patient's upper arm.
FIGURE 3.
Dark brown and red maculopapular rash located on the sole of the patient's foot with evidence of exfoliation.
FIGURE 4.
Dark brown and red maculopapular rash located on the patient's bilateral thighs.
FIGURE 5.
Dark brown and red maculopapular rash located on the patient's upper back and neck.
FIGURE 6.
Dark brown and red maculopapular rash located on the patient's anterior chest and neck.
FIGURE 7.
Dark brown and red maculopapular rash located on the patient's face with evidence of mild exfoliation.
FIGURE 8.
Dark brown maculopapular rash located on the patient's right ear with evidence of exfoliation.
2. DIAGNOSIS
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome
Due to the high degree of suspicion for drug reaction with eosinophilia and systemic symptoms (DRESS), the patient was treated with Solu‐Medrol 125 mg intravenous and transferred to a tertiary care center for dermatologic evaluation. This patient's history was consistent with DRESS syndrome with allopurinol being the likely trigger; her diagnosis was further supported by meeting Bouquet's criteria. 1 The lack of diversity in skin tones in dermatology images has been well documented and is thought to contribute to health care disparities. 2 The images of this patient present an opportunity for clinicians to identify DRESS syndrome in a patient with brown skin and prevent the delayed diagnosis of an emergent dermatologic condition in future patients. Early recognition of DRESS syndrome in patients with brown skin may help lessen racial disparities.
Allen A, Co V, Kellar J, Garispe A. Maculopapular rash in brown skin. JACEP Open. 2023;4:e13067. 10.1002/emp2.13067
REFERENCES
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