Image 51: This 48 year old returned from a week in India febrile, dyspnoec and covered with a rash. There, on day 2 of her daily Malarone, she reported chills, feverishness and moderate rhinorrhoea and took several ASA and one diphenhydramine for sleep (both used intermittently for years without problems). By day 5 she had dyspnoea, swelling of feet and a red patchy rash that, over 2 days, spread up her legs to trunk, arms and hands. She had bullae on her soles. When seen here, day 9 of the illness, she had a harsh cough, fever (38ºC), two tiny ulcers on the tip of her tongue and the rash and x-ray seen here. The rash was non-pruritic, non-tender, did not blanch with pressure nor peal when rubbed. Her WBC was 30,000/µl, with eosinophils 7,000/µl. Her liver enzymes were normal. Her chest x-ray revealed mild interstitial edema and bilateral pleural effusions. A cardiac ultrasound was normal except for a right atrial pressure of 10-15 mm Hg.  What was the diagnosis?

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Image 51: We considered this to be a Malarone induced DRESS syndrome (Drug eruption, eosinophilia and systemic symptoms). She had used Malarone for the first time, uneventfully, a year earlier. A skin biopsy revealed "perivascular lymphoplasmacytic infiltrate with occasional eosinophils, focal endothelial cell hyperplasia with dermal edema, most suggestive of a drug eruption". This was felt not compatible with Stevens Johnson, erythema multiforme or  pemphigus.  Her fever resolved in 2 days and her rash (palms and soles desquamated) and pleural effusions resolved over a week. Her eosinophilia rose to 11,800/µl two days after admission and then dropped rapidly. Her treatment consisted of stopping the Malarone. No systemic steroids were prescribed (probably should have been). She did receive Timentin (Ticarcillin and Clavulanate) for the first 3 days (shouldn't have). Stevens Johnson has been described several times with Malarone. (Emberger M et al CID 37: e5-7; 2003), but no DRESS syndrome.