Challenges in Recognizing Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) in Children. A Case Report of a 3 Years Old Male

Abstract

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but potentially life-threatening adverse drug reaction characterized by widespread cutaneous manifestations, rash, fever, hematologic abnormalities, and multiorgan involvement. We report the case of a 3-year-old male who was initially diagnosed with generalized urticaria, later identified as DRESS syndrome. The patient developed a progressive rash that initially appeared as prickly heat-like red spots on the back, spreading to the chest, limbs, and face, accompanied by dry, itchy skin, and mucosal ulceration on the lips. Examination revealed erythematous macules with erosions, without a positive Nikolsky’s sign. Systemic findings included high fever, palpebral edema, hepatomegaly, and bilateral nonpitting edema of the lower extremities. The child had been on long-term antiepileptics history, with a newly introduced drug 2 days before rash onset. Laboratory tests revealed leukocytosis, persistent eosinophilia, and elevated liver enzymes, consistent with systemic involvement. Prompt initiation of systemic methylprednisolone and supportive therapy resulted in marked clinical and laboratory improvement. This case highlights the diagnostic challenges of DRESS syndrome in children and the importance of early recognition and timely management to prevent severe complications.