Intracellular agents Coxiella burnetii and parvovirus B19 as triggers for DRESS syndrome in a peritoneal dialysis patient

Abstract

DRESS syndrome is a rare but severe cutaneous type IV hypersensitivity drug reaction with eosinophilia and systemic symptoms. Its pathophysiology is not well known but associated with viral reactivation of herpes virus and T-cells prim-ing. It occurs 2 to 8 weeks after exposure to the accountable drug. There are less than 30 reported cases caused by vancomycin. In our case, there is an acute parvovirus B19 and Coxiella burnetii infection, intracellular microorganisms that are not traditionally associated with this syndrome. A 31-year-old woman with chronic kidney disease undergoing peritoneal dialysis developed a peritonitis treated with intra-peritoneal vancomycin. In three weeks, she initiated fever and diffuse maculopapular pruriginous rash. She had positive IgG/IgM phase-II antibodies for Coxiella burnetii, increased hepatic enzymes (cholestatic pattern), eosinophilia, increased IgE and cryoglobulins. She underwent a skin biopsy and started doxycycline, meropenem and steroids with good clinical evolution. In 2 weeks, the fever and rash relapsed and another skin biopsy was performed, with positive parvovirus B19 DNA. Vancomycin is a rare cause of DRESS, especially intra-peritoneal. Viral reactivation has been described, increasing the duration, severity and relapse probability of the syndrome. A young woman survived a DRESS syndrome vancomycin-associated with uncommon microorganisms as triggers.