DILI and Dress syndrome secondary to treatment with DoTbal, in a patient with tuberculosis at the rural hospital from Papantla – IMSS Bienestar

Introduction and Objectives

The DRESS corresponds to dermatological manifestations associated with drugs and DILI corresponds to liver injury caused by drugs. Antiphymics are part of both entities, however, it is not common to find the coexistence of both syndromes and their management is even less described in a rural hospital.

Materials and Patients

This is a male patient who is arrived from his community because he has presented dermal lesions that began in April 2024. He reports that he has been under treatment with dotbal since January 2024 in the intensive phase and in March he continue in the support phase. He also lives with diabetes being treated with pioglitazone at a dose of 15 mg every 24 hours started this drug in January 2024. The lesions began as erythematous, scaly lesions in the lower extremities and subsequently spread throughout the body's economy, covering more than 90%, there is limited mobilization in flexion sites as well as with limitation to the oral feeding, has presented fever higher than 39°°C and is accompanied by itching predominantly in the extremities. For this reason we decided to carry out a diagnostic approach in our unit, where complementary studies are carried out that included BHC, QS, ES, PFH, these being the only resources our unit has.

Results

We evaluated a patient who attended a rural unit due to generalized erythema, fever and scaly lesions that occurred in the first 90 days after starting treatment with Dotbal, and was also accompanied by pruritus, fever and jaundice with data compatible with febrile erythroderma or DRESS syndrome (Drug Reaction with Eosinophilia and systemic symptoms), once this dermatological diagnosis was established, we proceeded to evaluate laboratory studies and evidenced data of DILI (Drug Induced Liver Injury) with a hepatocellular pattern, elevated transaminases more than 10 times their normal value, complying 6 points of RUCAM criteria for DILI and with an R factor of 9 points. During his hospitalization he progressed to acute kidney injury and medications were immediately discontinued. Hemodynamic support treatment was given and he is currently in the recovery phase. Exposure to isoniazid, a drug that has been described as a producer of DRESS and DILI, was established as the causal agent.

Conclusions

We present the case of care in a rural hospital, where resources are low. The importance corresponds to identifying the coexistence of DRESS and DILI, this action allows timely management and avoids serious complications of these diseases such as shock and acute liver failure.

Ethical statement: The authors declare that the article is unique, it has not been previously published in any other media services and there are informed consents signed by the participants and the patient for their participation in the hepatology congress held by the AMH 2024.

Declaration of interests: None.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Table 1.

Laboratory values before and three months after treatment

Laboratories	Start Treatment	Three months after treatment
Hemoglobine	11g/dl	10.5g/dl
Platelets	490,000	150,000
Leukocytes	6900	5300
Total bilirubin	0.8 mg/dl	3mg/dl
Direct bilirubin	0.5 mg/dl	2.5mg/dl
Indirect Bilirubin	0.3 mg/dl	0.5mg/dl
ALT	9 UI	399 UI
AST	10 UI	203 UI
ALBUMIN	3.0g/dl	1.7 g/dl
ALKALINE PHOSPHATASE	218UI	369UI
GGT	102UI	155UI
DHL	359U	377U
BUN	6.8mg/dl	14 mg/dl
UREA	14 mg/dl	30 mg/dl
CREATININE	0.4 mg/dl	1.2 mg/dl