Correct!
1. Discontinue the culprit drug

Early recognition and prompt withdrawal of the culprit drug is essential. Numerous drugs have been implicated including anticonvulsants (e.g. phenytoin, carbamazepine), antidepressants (e.g. amitriptyline, fluoxetine), anti-inflammatory agents (e.g. naproxen, ibuprofen), anti-infectives (vancomycin, piperacillin/tazobactam, doxycycline), beta-blockers and angiotensin-converting enzyme inhibitors (7,8).

Corticosteroids, given over a prolonged period of 6 to 8 weeks duration to avoid relapse, are the mainstay of therapy. There are no randomized controlled trials comparing supportive care alone to use of systemic corticosteroids however the eosinophilic disorders generally respond clinically to corticosteroid therapy. Other recommended therapeutic options include IV immunoglobulin and/or antiviral ganciclovir if symptoms progress despite corticosteroids (9).  

Currently IV immunoglobulins plus high-dose steroids are considered second-line therapy. However, one recent observational study did not find any clinical benefit when IV immunoglobulin was used as a single treatment in DRESS (10). Initiation of second line therapy with IV immunoglobulins can achieve the desired response although the exact mechanism of the therapeutic effect in DRESS syndrome is not clear. There have been a few anecdotal case reports of the therapeutic benefits of plasmapheresis in DRESS syndrome.

Both antibiotics were consequently discontinued and as per recommendations, the patient was started on high dose prednisone with plan for slow taper over 6 weeks. Improvement in the patient’s laboratory abnormalities with gradual resolution of the fever and rash was noted. By hospital day 38, his leukocytosis and eosinophilia had completely resolved.

References

  1. Cacoub P, Musette P, Descamps V, Meyer O, Speirs C, Finzi L, Roujeau JC. The DRESS syndrome: a literature review. Am J Med. 2011;124(7):588-97. [CrossRef] [PubMed]
  2. Walsh SA, Creamer D. Drug reaction with eosinophilia and systemic symptoms (DRESS): a clinical update and review of current thinking. Clin Exp Dermatol. 2011;36(1):6-11. [CrossRef] [PubMed]
  3. Fleming P, Marik PE. The DRESS syndrome: the great clinical mimicker. Pharmacotherapy. 2011;31(3):332. [CrossRef] [PubMed]
  4. Criado PR, Criado RF, Avancini JM, Santi CG. Drug reaction with Eosinophilia and Systemic Symptoms (DRESS) / Drug-induced Hypersensitivity Syndrome (DIHS): a review of current concepts. An Bras Dermatol. 2012;87(3):435-49. [CrossRef] [PubMed]
  5. Samel AD, Chia-Yu C. Drug Eruptions. In: UpToDate Corona, R. (Ed). UpToDate. Waltham, MA. Available at: http://www.uptodate.com/contents/drug-eruptions (requires subscription, accessed on February 24, 2015).
  6. Criado PR, Avancini J, Santi CG, Medrado AT, Rodrigues CE, de Carvalho JF. Drug reaction with eosinophilia and systemic symptoms (DRESS): a complex interaction of drugs, viruses and the immune system. Isr Med Assoc J. 2012;14(9):577-82. [PubMed]
  7. O'Meara P, Borici-Mazi R, Morton AR, Ellis AK. DRESS with delayed onset acute interstitial nephritis and profound refractory eosinophilia secondary to Vancomycin. Allergy Asthma Clin Immunol. 2011;7:16. [CrossRef] [PubMed]
  8. Jurado-Palomo J, Caba-as R, Prior N, Bobolea ID, Fiandor-Román AM, López-Serrano MC, Quirce S, Bellón T. Use of the lymphocyte transformation test in the diagnosis of DRESS syndrome induced by ceftriaxone and piperacillin-tazobactam: two case reports. J Investig Allergol Clin Immunol. 2010;20(5):433-6. [PubMed]
  9. Descamps V, Ben Saïd B, Sassolas B, et al. Management of drug reaction with eosinophilia and systemic symptoms (DRESS). Ann Dermatol Venereol. 2010;137(11):703-8. [CrossRef] [PubMed]
  10. Joly P, Janela B, Tetart F, et al. Poor benefit/risk balance of intravenous immunoglobulins in DRESS. Arch Dermatol. 2012;148(4):543-4. [CrossRef] [PubMed]

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