Sir,

We report a rare case of drug Reaction with eosinophilia and systemic symptoms (DRESS) syndrome complicated by acute pancreatitis (AP), a manifestation seldom documented in the literature.

A 37-year-old woman with no prior medical history developed DRESS syndrome following exposure to phenobarbital, chlorpromazine, amitriptyline, and sertraline. The clinical presentation included fever, facial edema (Fig. 1a), generalized morbilliform exanthema involving 90% of the body surface (Fig. 1b), and cervical lymphadenopathy. Laboratory results showed eosinophilia (2,000 cells/μL), elevated transaminases (AST 1,000 U/L, ALT 600 U/L), and 27% atypical lymphocytes. A RegiSCAR score above 5 confirmed the diagnosis, and oral corticosteroids were initiated.

Figure 1: (a) Facial edema with erythema and puffiness, particularly in the periorbital and malar regions, in the 37-year-old female patient diagnosed with DRESS syndrome. This diffuse facial swelling is a characteristic dermatologic manifestation of the syndrome, often associated with systemic involvement. (b) Widespread morbilliform exanthema involving the trunk and upper limbs in the patient with DRESS syndrome. The rash affected more than 90% of the body surface area, sparing the palms and soles, with no mucosal involvement.

Two weeks into treatment, the patient developed severe epigastric pain and bilious vomiting. Laboratory testing revealed markedly elevated lipase (1,800 U/L), and ultrasound excluded biliary pathology. Acute pancreatitis was diagnosed. Conservative management with IV fluids, corticosteroids, analgesia, and gradual refeeding led to resolution without complications.

Pancreatic involvement in DRESS syndrome is rare and underrecognized, often overshadowed by hepatic, renal, or pulmonary complications. Reported pancreatic outcomes include acute pancreatitis or autoimmune diabetes [1]. However, the true incidence remains unknown [2]. The pathogenesis is likely multifactorial, involving immune dysregulation, cytokine-mediated injury, or direct drug toxicity [3].

This case highlighted the importance of considering pancreatic involvement in DRESS syndrome, particularly when gastrointestinal symptoms are present. Prompt recognition and supportive care are critical to favorable outcomes. Raising awareness of such rare complications may improve diagnostic accuracy and management strategies in clinical practice.

REFERENCES

1.Gamonal SBL, Marques NCV, Pereira HMB, Gamonal ACC. Drug reaction with eosinophilia and systemic symptoms syndrome (DRESS) associated with pancreatitis and hepatitis following Pfizer-BioNTech mRNA COVID-19 vaccination. J Eur Acad Dermatol Venereol. 2023;37:e291-3.

2.Jevtic D, Dumic I, Nordin T, et al. Less known gastrointestinal manifestations of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome:A systematic review of the literature. J Clin Med. 2021;10:4287.

3.Vahora Z, Tamimi TA-R, Mullen K. Pancreatitis and hepatitis as manifestations of DRESS syndrome:Two case reports. Am J Gastroenterol. 2012;107(Suppl):S327.