Sex: M
Vaccine: COVID19
Symptoms: Alanine aminotransferase, Antinuclear antibody, Aspartate aminotransferase, Biopsy skin, Blood pressure measurement
Clinical narrative: MULTIPLE SEIZURES; PSYCHOGENIC SEIZURES; DRESS SYNDROME; This spontaneous report was received from literature. This report concerned a 31 year old male of an unspecified race and ethnicity. The objective of the study was to describe, Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, but life-threatening condition that commonly presents with a diffuse rash, fever, lymphadenopathy, eosinophilia, and multiorgan involvement commonly involving the liver after drug exposure. The incidence of DRESS associated with antiepileptic drugs is reported at one in 1000 to one in 10,000 exposures with a mortality rate of about 10%, most commonly from fulminant hepatitis with hepatic necrosis. The patient's height, and weight were not reported. The patient's past medical history included: intrauterine drug exposure. The patient was adopted as a 10-day-old infant and had normal development and health. The patient had no shortness of breath, dyspnea, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dizziness, or headaches. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin, and batch number and expiry were not reported) dose, start therapy date were not reported, 1 total administered for covid-19 prophylaxis. The batch number was not reported. Per procedure, no follow-up will be requested for this case. Concomitant medications included occasional non-steroidal anti-inflammatory drugs (NSAIDs) paracetamol for drug used for unknown indication.  On an unspecified date, 24 hours after receiving vaccine, the patient experienced acute onset of multiple seizures that required intubation and ICU admission and discharged on prophylactic Keppra (levetiracetam) and Dilantin (phenytoin). One month after being on the antiepileptic drugs, patient was re-admitted for worsening seizures. Workup during that hospitalization revealed psychogenic seizures and Keppra and Dilantin were both discontinued. After 6 weeks, The patient presented to the urgent care with a diffuse erythematous morbilliform intense pruritic rash, and high fever (103F) for five days prior to presentation. (Dress syndrome- Drug Rash with Eosinophilia and Systemic Symptoms) and was hospitalized for 4 days. The patient reported that the rash initially started five days prior to presentation as a small rash on his right upper extremity and eventually spread throughout his entire body. Three days after the onset of the rash, he was evaluated in the urgent care setting where he was prescribed oral methylprednisolone and hydroxyzine and discharged home. He reported that since taking the medications, his rash had improved in terms of redness, swelling, and itchiness but continued to spread throughout his body. Laboratory data (dates unspecified) included: Initial vitals on admission: blood pressure (BP) 125/74, heart rate (HR) 91/minute, temperature 99.1 F (37.3 °C), respiration rate 20/minute, and saturation of peripheral oxygen (SpO2) 96% on room air. The following day after admission, the patient had multiple fevers with a maximum temperature (Tmax) of 103 °F. Skin examination of the scalp, face, lips, neck, chest, axilla, back, abdomen, left arm, right arm, digits, nails, left leg and right leg were performed. All areas were normal except for morbilliform eruption with confluent erythema on the patient's chest, abdomen, back, penis, scrotum, and upper and lower extremities and approaching erythroderma with pustule formation and palpable purpura on lower extremities. No mucosal or oral lesions were noted. The patient was also noted to have bilateral inguinal, right cervical, and right axillary lymphadenopathy. The patient otherwise had normal examination findings of his heart, lung, and abdomen. Initial labs showed an elevated total white blood cell count of 19.57 (reference range 4.8-11.8 bil/L), hemoglobin at 13.2 (reference range 11.0-16.0 g/dL), and platelet at 293 (reference range 140-340 bil/L). A complete metabolic panel (CMP) revealed transaminitis with aspartate aminotransferase (AST) at 310 (reference range 0-35 U/L) and alanine transaminase (ALT) at 996 (reference range 7-45 U/L). C-reactive protein (CRP) was 6.0 (reference range 0.0-0.8 mg/dL) and erythrocyte sedimentation rate (ESR) Westergren was 31 (reference range 0-9 mm/hr). Additional labs showed an absolute eosinophil count of 1000 cells per microliter of blood. His antinuclear antibody (ANA) panel, acute hepatitis panel, syphilis, and HIV tests were all negative. Abdominal ultrasound revealed hepatomegaly with a 1.6 cm hyperechoic right lobe lesion, which is favored to represent hemangioma. A skin punch biopsy was performed on the patient's right upper back and right upper thigh. The biopsy revealed spongiotic dermatitis with subcorneal pustules along with superficial perivascular and mixed lymphocytic and neutrophilic infiltrate with dermal edema and rare eosinophils. There was no active vasculitis or atypical lymphoid infiltrate seen. Dermatologist recommended, in addition to triamcinolone ointment, starting prednisone at 1 mg/kg/day (60 mg daily) and monitoring daily complete blood count (CBC), CMP (comprehensive metabolic panel), and prothrombin time/partial thromboplastin time (PT/PTT) while hospitalized. Upon starting oral and topical steroids, the patient's rash and liver enzymes significantly improved. The patient was discharged four days after initiation of treatment on the same dose of prednisone with a plan for a close follow-up with dermatology. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient was recovering from dress syndrome, and the outcome of psychogenic seizures and multiple seizures was not reported. The authors emphasized that, The primary presentations are rash, fever, lymphadenopathy, eosinophilia, and one or more organ injury involvement. The inclusion criteria and scoring system can be used for diagnosis with scoring system being the most used. Treatment is mainly stopping the culprit drug and starting systemic steroids based on the severity of the disease. Prompt diagnosis and treatment of DRESS syndrome are critical due to its high morbidity and mortality. Close monitoring and follow-up are indicated to ensure avoiding further future complications. This report was serious (Hospitalization Caused / Prolonged, and Life Threatening).; Sender's Comments: V0: 20221240456-DRESS Syndrome. The event has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There are other factors more likely to be associated with the event. Specifically: CONMEDS-OTHER SUSPECT DRUGS. Therefore, this event is considered inconsistent with vaccine administration.   20221240456-Multiple seizures, Psychogenic seizures. The event has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event. Therefore, the WHO Causality is considered indeterminate. The company causality is considered unassessable.