BCCCP: DRESS Syndrome Management Critical Care Questions

Question 1 of 10

1. Question

Which statement best summarizes the epidemiology of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) in critically ill (ICU) patients?

DRESS occurs in approximately 1% of ICU patients receiving high-risk medications.
Incidence data show that ICU patients develop DRESS more frequently than the general population.
The true incidence of DRESS in ICU patients is poorly defined and likely underrecognized due to symptom overlap with sepsis and systemic inflammation.
Routine patch testing is the standard epidemiological method for determining DRESS incidence in ICU settings.

Question 2 of 10

2. Question

A 48-year-old man has been on phenytoin for 5 weeks when he develops a diffuse erythematous rash, fever (39.5 °C), marked transaminase elevations, eosinophilia, and atypical lymphocytes. Phenytoin was discontinued 3 days ago, but his rash and systemic symptoms continue to worsen. Which immune mechanism most critically drives the ongoing multi-organ injury in Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome after stopping the causative agent?

Immediate IgE-mediated mast cell degranulation leading to systemic anaphylaxis
Direct cytotoxic effect of phenytoin metabolites on hepatocytes and renal tubular cells
Formation of drug–antibody immune complexes that deposit in target organs and activate complement
Sustained activation and polyclonal expansion of drug-specific T cells and eosinophils, often amplified by herpesvirus reactivation

Question 3 of 10

3. Question

A 58-year-old man with gout developed a widespread rash, fever, facial edema, eosinophilia, and elevated liver enzymes three weeks after starting allopurinol. He was later diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. His limited English proficiency and low health literacy delayed reporting of early symptoms. Which social determinant of health should be prioritized to reduce future delays in patient recognition and timely diagnosis of severe cutaneous adverse drug reactions like DRESS?

Limited access to community health education programs delivered in the patient’s preferred language
Financial constraints that impede regular outpatient follow-up and laboratory monitoring
Insufficient patient health literacy regarding medication risks, side effects, and early symptom recognition
Limited social support networks to encourage symptom reporting and care-seeking

Question 4 of 10

4. Question

A 48-year-old man develops a diffuse erythematous rash covering more than 70% of his body surface area, facial edema, fever, and malaise three weeks after starting carbamazepine for trigeminal neuralgia. Laboratory studies show leukocytosis with eosinophilia (eosinophils 18%), elevated alanine aminotransferase (ALT) to 250 U/L (normal <45 U/L), and serum creatinine rise from 0.9 to 1.8 mg/dL. Which of the following findings would most strongly support a diagnosis of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome?

Detection of human herpesvirus 6 (HHV-6) DNA in peripheral blood by PCR
Peripheral blood eosinophil percentage rising above 30%
Skin biopsy showing interface dermatitis with eosinophilic infiltrate
Positive lymphocyte transformation test to carbamazepine

Question 5 of 10

5. Question

A 45-year-old man is admitted to the intensive care unit with a 10-day history of fever, malaise, and a rapidly spreading maculopapular rash involving more than 50% of his body surface area. He started phenytoin 3 weeks ago for seizure prophylaxis. Laboratory tests reveal eosinophilia, atypical lymphocytes, elevated liver enzymes, and lymphadenopathy. Using the RegiSCAR scoring system, his presentation is consistent with severe Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. Given the severity and critical care setting, which of the following interventions should be prioritized urgently?

Initiate intravenous immunoglobulin (IVIG) immediately to prevent further progression.
Discontinue phenytoin and initiate high-dose systemic corticosteroids.
Perform a skin biopsy to confirm the diagnosis before any systemic therapy.
Administer broad-spectrum antibiotics to cover for potential superimposed infection.

Question 6 of 10

6. Question

A 45-year-old man admitted to the ICU develops a widespread morbilliform rash, facial edema, fever of 39 °C, and malaise three weeks after starting phenytoin for seizure prophylaxis. Laboratory tests reveal eosinophilia (absolute eosinophil count 1.5 × 10^9/L), elevated liver enzymes, and rising serum creatinine. The clinical team suspects Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. Considering the patient’s critical condition, which of the following interventions represents the MOST critical immediate priority for the critical care pharmacist to recommend?

Immediate cessation of phenytoin and comprehensive review of all current medications for potential cross-reactivity.
Initiation of high-dose systemic corticosteroids (methylprednisolone 1 mg/kg/day).
Early administration of intravenous immunoglobulin (2 g/kg divided over 2 days) to modulate immune response.
Substitution of phenytoin with levetiracetam to maintain seizure prophylaxis.

Question 7 of 10

7. Question

A 48-year-old, 70 kg male in the medical ICU with severe Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome involving multi-organ dysfunction has had the offending antiepileptic drug withdrawn. Which of the following is the MOST appropriate initial systemic immunosuppressive therapy to control the immune-mediated inflammation in this critically ill patient?

Initiate intravenous methylprednisolone 1 mg/kg/day (70 mg/day) and taper based on clinical response.
Administer intravenous immunoglobulin (IVIG) 2 g/kg (140 g total) divided over 2 days.
Start oral cyclosporine 3 mg/kg/day (210 mg/day) in divided doses and monitor for improvement.
Begin oral prednisone 1 mg/kg/day (70 mg/day) and taper based on clinical response.

Question 8 of 10

8. Question

A 45-year-old man (70 kg, BMI 25 kg/m2) status post living-donor kidney transplant 8 months ago is admitted to the ICU with severe drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome attributed to allopurinol started 7 days ago. He has multiorgan dysfunction: AST 130 U/L, ALT 150 U/L, total bilirubin 2.5 mg/dL, serum creatinine 2.2 mg/dL (baseline 1.1 mg/dL; eGFR ≈ 35 mL/min/1.73 m2), and hypoalbuminemia (albumin 2.0 g/dL). He is hypotensive on low-dose norepinephrine and has received aggressive fluid resuscitation leading to third-spacing. The transplant team plans to initiate tacrolimus for immunosuppression. Considering this patient’s critical illness and altered physiology, which pharmacokinetic/pharmacodynamic principle is MOST critical to incorporate when initiating tacrolimus therapy?

Administer standard initial tacrolimus dosing (0.1 mg/kg/day) with frequent total trough level monitoring to detect early toxicity.
Select an immunosuppressant primarily cleared by the kidneys (e.g., azathioprine) to avoid further hepatic stress, with close renal function monitoring.
Prioritize an immunosuppressant with a large volume of distribution to ensure adequate tissue penetration despite fluid shifts (e.g., mycophenolate mofetil).
Initiate tacrolimus at substantially reduced doses (e.g., ~0.05 mg/kg/day), accounting for increased free drug from hypoalbuminemia and reduced clearance due to hepatic and renal impairment, with close therapeutic drug monitoring (including free levels or clinical toxicity markers).

Question 9 of 10

9. Question

A 45-year-old man in the ICU developed Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome 72 hours after initiation of allopurinol. On admission, his labs showed AST 120 U/L, ALT 140 U/L, serum creatinine 1.3 mg/dL, and an absolute eosinophil count of 1.2 × 10^9/L. He remains febrile and hypotensive on low-dose vasopressors and has a diffuse erythematous rash covering 60% of his body surface area. Given the multisystem involvement and potential for rapid progression in the critical care setting, which monitoring strategy should the critical care pharmacist prioritize to guide immediate management and assess disease evolution?

Daily complete blood count with differential, liver function tests every 12 hours, renal function tests (serum creatinine, BUN, electrolytes) every 12 hours, daily detailed skin examination, and continuous hemodynamic monitoring.
CBC with differential every 48 hours, daily liver function tests, daily serum creatinine, rash assessment only if new lesions appear, and routine vital signs every 4 hours.
Daily electrocardiography and continuous telemetry, weekly CBC with differential and liver function tests, daily serum creatinine, weekly detailed skin examination.
Serial chest radiographs every 24 hours, weekly CBC with differential and liver function tests, one-time comprehensive metabolic panel on ICU day 1, and daily photographic documentation of the rash.

Question 10 of 10

10. Question

A 45-year-old critically ill patient is admitted to the ICU with Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. The patient has fever, widespread rash, facial edema, lymphadenopathy, and multi-organ involvement (hepatitis and acute kidney injury). Laboratory tests reveal marked eosinophilia. Given the severity of systemic involvement, which first-line pharmacologic management should be prioritized for this patient?

High-dose systemic corticosteroids
Intravenous immunoglobulin (IVIG)
Combination therapy with systemic corticosteroids and IVIG
Cyclosporine