drug rash with eosinophilia and systemic symptoms ( dress ) syndrome was first described by bocquet et al . in 1996 .
however , the most frequent causes are anticonvulsants , sulfonamides , dapsone , allopurinol , minocycline , and gold salts [ 13 ] .
in addition to hematologic , hepatic , cardiac , neurological , gastrointestinal , and endocrine abnormalities , pulmonary involvement is observed rarely . in this study ,
dress syndrome was presented with multiorgan involvement based on carbamazepine use in a 14-year - old female patient .
pulmonary involvement presented in the form of pleurisy and atelectasis , different from the literature , and as a long - term sequela , type 2 diabetes was observed in our case .
a 14-year - old female patient presented at our clinic due to skin rash and fever lasting for 1 week .
it was found in her history that carbamazepine treatment had been initiated owing to epilepsy 15 days before her symptoms began .
there had been no transmitted chronic disease history such as viral , bacterial , or parasitic infection before the patient 's reaction in question . on the physical examination , she had 38.5c core temperature , and there was a bilateral crepitant rale condition determined by listening on her respiratory system examination .
, there were maculopapular rashes in the process of healing with desquamation that involved > 50% of the body ( fig .
there was microscopic hematuria in her total urinalysis . in the viral serological evaluation of the case , ebstein - barr virus ( ebv ) ,
herpes virus type 1 - 2 , hepatitis a - b - c virus , hiv , and toxoplasma were established as negative .
immunoglobulins , c3 and c4 levels , urinalysis were normal . in the punch biopsy obtained from the skin lesions ,
due to the drug intake history and the clinical , laboratory , and histopathological findings , carbamazepine treatment was discontinued in our patient .
desloratadine antihistaminic 5 mg / day treatment and systemic steroid 1 mg / kg / day ( 40 mg / day ) were added to the therapy .
owing to the chest pain and the reduction in lung sounds in basals and since the sinuses were monitored as closed in the chest radiography , thorax ultrasonography was carried out , and bilateral pleural effusion 6 mm thick was determined . in the thorax ct performed on the patient , a local consolidated area in the middle lobe segment of the right lung , atelectatic changes in the lower lobes of both lungs , and thickness in the left fissure were seen .
since there was symptomatic hyperglycemia on the second day of steroid treatment , the steroid was discontinued .
the patient was found hyperglycemic ( fasting blood glucose : 120 - 180 mg / dl , postprandial blood glucose:160 - 250 mg / dl ) .
the 33-year - old mother was diagnosed with type 2 diabetes at the age of 26 years .
physical examination revealed a weight of 52.8 kg ( 64 percentile , 0.38 sds ) , a height of 151 cm ( 8 percentile , 1.38 sds ) , body mass index of 23.56 ( 1.52 sds ) and normal vital signs .
islet cells cytoplasmic autoantibodies ( ica ) were negative as tested by indirect immunofluorescence and her glutamic acid decarboxylase autoantibodies ( gada ) , which was measured by radioimmunoassay , were also negative and fasting levels of c - peptide and insulin ( electrochemiluminescent immunoassay ; roche diagnostics , penzberg , germany ) remained detectable throughout the observation period ( c - peptide 2.1 - 6.23 ng / ml ) . with an hba1c value of 8.6% , she was diagnosed with diabetes mellitus .
the combination of long - standing non - ketotic hyperglycemia , glycosuria , at a relatively high fasting and postprandial blood glucose , and negative pancreatic auto - antibodies in a child with a diabetic mother raised the possibility of mody .
direct dna sequencing of all exons and intron - exon bounders of the mody genes revealed no mutation in our patient .
insulin treatment was discontinued as the hyperglycemia disappeared , and metformin treatment was initiated with the type 2 diabetes diagnosis .
the patient was discharged from the hospital after the lung , skin , liver , and renal findings regressed .
a patch test was performed with carbamazepine 10% concentration 6 weeks later . as a result of
the evaluation carried out 48 , 72 , and 96 h later , + 1 sensitivity was determined ( fig .
2 ) . although the skin , liver , renal and lung findings resolved during the 1-year follow - up period , regulation of type 2 diabetes with an oral antidiabetic continued . a ) maculopapular lesion in the recovery process with desquamation on the erythematous base .
b ) skin biopsy determined by lymphocytic infiltration in the papillary dermis epicutaneous patch test with carbamazepine
dress syndrome , known as drug hypersensitivity syndrome , is a quite rare acute , idiosyncratic , and life - threatening drug reaction characterized by fever , skin rash , and single or multiple internal organ involvement [ 3 , 4 ] .
there is an average 3- to 9-week latent period ( 0.5 - 16 weeks ) between drug use and the emergence of symptoms .
these findings can persist or exacerbate although the responsible drug is discontinued [ 1 , 3 , 5 ] .
fever , skin rash , liver involvement , hypereosinophilia , and lymphadenopathy can be seen in almost all patients .
there was pulmonary involvement presented by pulmonary atelectasia and pleurisy as well as maculopapular rash , fever , and hypereosinophilia , liver involvement manifested with transaminase elevation , and renal involvement was characterized by microscopic hematuria in the case .
it has been suggested that there is a delayed hypersensitivity reaction related to t lymphocytes against toxic metabolites of drugs , and viral infections ( ebv , human herpes virus , types 6 and 7 ) can also play a role in the etiology .
it has been reported in the literature that there can be a genetic predisposition , and families of patients diagnosed with dress syndrome are also at risk in terms of this syndrome .
it has been maintained in recent years that human herpes virus type 6 reactivation can also be used as a diagnostic marker [ 1 , 3 , 6 , 7 ] .
the positive result on the patch test with carbamazepine conducted 6 weeks later supports that there was a delayed hypersensitivity reaction .
the main principle in the treatment of dress syndrome is to discontinue the drug or drugs thought to be suspicious immediately and provide supportive care .
systemic steroid is particularly recommended in internal organ involvement [ 2 , 3 , 7 ] .
hyperglycemia thought to be dependent on steroid treatment in the first place preceded although steroid treatment was discontinued and insulin treatment had to be commenced .
type 1 diabetes and pancreatitis have been reported in patients with dress syndrome in the literature [ 6 , 9 ] . however , our patient 's lipase level was normal , and no laboratory finding supporting type 1 diabetes was diagnosed in our patient .
although the hyperglycemia finding in the patient was not linked to dress syndrome in the first place , it was evaluated as dress syndrome related to type 2 diabetes by the endocrine department since it had a clinical table regulated by oral antibiotic in 1-year follow - up period . in the literature , various long - term sequelae concerning dress syndrome have been observed . in a study by chen et al .
, a long - term sequelae rate was reported as 11.5% in analyses of 52 patients of whom 9 were lost and 43 recovered .
the researchers reported that a total of 4 patients had autoimmunity disease , including 2 with grave 's disease , 1 with type 1 diabetes , and 1 with autoimmune hemolytic anemia .
they also observed that lifetime hemodialysis was necessary due to renal failure in 2 patients with organ involvement . in a study in which 34 patients were evaluated ,
however , the researchers reported that autoimmune disease developed in 2 patients , including 1 with lupus erythematosus and 1 with autoimmune thyroiditis .
reported 11 patients with type 1 diabetes related to dress syndrome and observed that half of the patients developed non - autoimmune fulminant type 1 diabetes .
however , no case of type 2 diabetes associated with dress syndrome has been reported thus far . to the best of our knowledge
, this case is the first in whom dress syndrome initially developed followed by type 2 diabetes .
dress syndrome is an acute , life - threatening , and rarely seen drug reaction .
it should be considered a definitive diagnosis in patients with fever , diffuse skin rash , and internal organ involvement . the drugs used by patients should be questioned .
it should be kept in mind that a variety of organ involvement as well as long - term sequelae can also be seen in patients with dress syndrome .
 drug rash with eosinophilia and systemic symptoms ( dress ) syndrome is an uncommon , life - threatening drug reaction . 
 the basic findings are skin rash , multiorgan involvement , and eosinophilia . 
 most of the aromatic anticonvulsants , such as phenytoin , phenobarbital and carbamazepine can induce dress . 
 herein we report a 14-year - old patient with dress syndrome related to carbamazepine use . 
 the patient presented with signs of involvement of the skin , lungs , liver , and microscopic hematuria . 
 carbamazepine treatment was discontinued ; antihistamines and steroids were started . 
 hyperglycemia , commencing on the first dose of the steroid given , persisted even after the discontinuation of steroids and improvement of other signs . 
 there were no signs of pancreatitis or type 1 diabetes clinically in laboratory tests . 
 her blood glucose levels were regulated at first with insulin and later with metformin . within 1 year of follow - up , still regulated with oral antidiabetics , she has been diagnosed with type 2 diabetes . 
 formerly , long - term sequelae related to  drug rash with eosinophilia and systemic symptoms syndrome  such as hepatic and renal failure , type 1 diabetes mellitus , grave 's disease , autoimmune hemolytic anemia , and lupus have also been reported . however , up to date , no cases with type 2 diabetes have been reported as long - term sequelae . to our knowledge , this is the first case in the literature presenting with type 2 diabetes as long - term sequelae . 