A typical presentation of moxifloxacin-induced DRESS syndrome with pulmonary involvement: a case report and review of the literature

Abstract

Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a kind of hypersensitivity drug reaction involving the skin and multiple internal organ systems. Moxifloxacin has rarely been reported to be a drug that is associated with DRESS syndrome. Lungs are less frequently involved in DRESS syndrome, but their involvements may herald more serious clinical processes. We present a rare typical case of moxifloxacin-induced DRESS syndrome with lungs involved. Valuable clinical data such as changes in the pulmonary imaging and pulmonary function tests was recorded. This case is important for the differential diagnosis of DRESS syndrome with lungs involved by providing clinical manifestations, CT imaging, pulmonary function tests, and biopsy pathological characteristics. The changes in pulmonary imaging and pulmonary function tests may help us understand the mechanism of DRESS syndrome further.

Case presentation: We report a case of a 47-year-old woman who was treated with oral moxifloxacin for community-acquired pneumonia. The patient subsequently developed a cough, fever, liver injury, skin rash, hematologic abnormalities, and shortness of breath (SOB) followed by pharyngeal herpes and peripheral neuritis. These symptoms, clinical lab index, and CT scan of the lungs improved after the withdrawal of moxifloxacin. The probability of moxifloxacin-induced DRESS syndrome was rated as "Definite", with 7 scores graded by RegiSCAR. A literature search was also performed with "fluoroquinolones," "moxifloxacin," "ciprofloxacin," "levofloxacin," "delafloxacin," and "DRESS" or "drug-induced hypersensitivity syndrome (DIHS)" as the keywords that were put into PubMed. The overall pulmonary involvement was approximately 9.1% (1/11). It is a rare reported case of DRESS syndrome with pulmonary involvement induced by moxifloxacin. We summarized detailed clinical data, including pulmonary imaging and pulmonary function changes.

Conclusion: This is a rare reported case of DRESS syndrome with pulmonary involvement induced by moxifloxacin. Prompt recognition and correct diagnosis can promote appropriate treatment and accelerate recovery. This case is important for us as a reference in the differential diagnosis of DRESS syndrome and helps us further understand the mechanism of DRESS syndrome.

Keywords: Case report; Dress; Drug reaction; Eosinophilia; Moxifloxacin.

Fig. 1

Timeline summarizing the symptoms and treatment of the patient

Fig. 2

Changes in the chest CT (a–d are on D13: random pulmonary nodules (green arrow), a small amount of bilateral pleural effusion (red arrows), multiple areas of ground glass opacity (blue arrows), thickening of bronchovascular bundles (orange arrow); e–h are on D21: radiological improvement after withdrawal of the drug.)

Fig. 3

Changes in the lymph nodes at the mediastinum and hilar areas (a is on D13: mediastinal and hilar lymph nodes are larger than 1 cm; b is on D54: mediastinal and hilar lymph nodes returned to normal after withdrawal of the drug)

Fig. 4

Characteristics of DRESS syndrome induced by moxifloxacin (a is rash on the abdomen; b is peripheral blood cell image analysis: Leukocytes showed reactive changes and the proportion of eosinophils was increased (36%); c is the bone marrow cell morphological analysis that showed 1% atypical lymphocytes; d is the skin biopsy from the abdominal area: the epidermis was mildly keratinized, lymphocytes were infiltrated around the small blood vessels in the superficial dermis, collagen fibers were proliferated)

Fig. 5

Changes in EOS and liver function (a shows changes in absolute eosinophils, and b shows changes in liver enzyme content)