Sulfasalazine

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

An 18-year-old [sex not stated] patient developed DRESS syndrome during treatment with sulfasalazine for psoriatic arthropathy.

The patient presented to the emergency department due to dry cough, fever and pruriginous exanthema in upper limbs, chest and neck. The patient had been receiving sulfasalazine since 15 days [dosage and route not stated]. In the context of Coronavirus disease 2019 (COVID-19) pandemic emerged in April 2020, the patient started receiving empiric treatment with azithromycin and hydroxychloroquine for COVID-19 for 5 days. However, the patient's exanthema continued to spread.

The patient was therefore treated with unspecified antihistamine and topical corticosteroids. At 24h, clinical worsening was observed with persistence of fever, exanthema and diarrhoea requiring hospital admission. Physical examination revealed normal cardiopulmonary auscultation, hepatosplenomegaly and several adenopathies felt in groin and armpits. The exanthema was confluent maculopapular, with purplish lesions in declining areas and spread across the upper limbs, trunk, neck and lower limbs, with palmoplantar involvement. The patient had facial and lip oedema and periocular erythema with associated impetiginization zones. The patients started receiving empirical treatment with ceftriaxone followed by piperacillin/tazobactam and methylprednisolone. Laboratory tests revealed leukocytosis with an increase in all cellular series, elevated transaminases and coagulation alteration with PCR 85.7, procalcitonin 2.84 (units not stated). A CT angiography revealed multiple axillary and mediastinic adenopathies with the presence of pulmonary thromboembolism. Three PCRs and serology with IgG and IgM for coronavirus were negative. The presence of activated eosinophilia and lymphocytes were compatible with reactive process. Skin biopsy findings revealed orthokerosic epidermis, with spongiosis and interface dermatitis, with epithelial vacuolization, necrotic physychhinocytes and lymphocyte exocytosis. Moderate superficial and profound perivascular lymphocytic inflammation was observed in the dermis, accompanied by lymphocyte-looking neutrophils and blasts. These findings were consistent with DRESS syndrome probably related to sulfasalazine. The patient was maintained on unspecified corticosteroids and oral antihistamine, and sulfasalazine was withdrawn. Subsequently, the patients showed progressive improvement with decreased intensity and extent of exanthema, analytical parameters. Eventually, the patient was discharged home after 10 days of admission in 2020. Based on these findings and clinical presentation it was confirmed that, the patient developed DRESS syndrome associated with sulfasalazine, which was initially suspected as COVID-19.