Correct!
5. All of the above
All would seem possible. Culture negative sepsis is common and quite possible. although cultures remained negative, the patient was on multiple antibiotics.
Hemophagocytic lymphohistiocytosis or HLH is disease of severe hyperinflammation caused by uncontrolled proliferation of activated lymphocytes and macrophages (2). Fulfillment of five out of the eight criteria listed below is considered presumptive evidence for HLH:
Our patient met many of these criteria with an elevated ferritin level (5190 ng/mL), hypertriglyceridemia (1158 mg/dL) and soluble IL-2R > 2500 U/ml. However, bone marrow aspiration and biopsy did not show hemophagocytosis or histiocytosis.
Drug Reaction with Eosinophila and Systemic Symptoms, or DRESS syndrome, is used to describe patients exhibiting a drug-induced condition characterized by an extensive rash, fever, lymphadenopathy, hematologic abnormalities, hepatitis, and involvement of the kidneys, lungs, heart, or pancreas. More than 50 drugs have been linked to DRESS syndrome. The drugs most often reported with DRESS include anticonvulsants (particularly those with aromatic structures), sulfa derivatives, antidepressants, nonsteroidal anti-inflammatory drugs, and antimicrobials. The onset of symptoms is often delayed, occurring 2–6 weeks after drug initiation. DRESS syndrome shares many characteristics in common with anticonvulsant hypersensitivity syndrome (AHS), also referred to as drug-induced hypersensitivity syndrome (DIHS), and appears to represent a variation in presentation rather than a distinctly different syndrome. One definition of DRESS is that patients must have three of the four criteria: an acute rash, fever above 38°C, lymphadenopathy at two sites, involvement of at least one internal organ, and abnormalities in lymphocyte and eosinophil counts. Additional criteria include hospitalization and that the reaction is suspected to be drug-related. Our patient meant many of these criteria but pancytopenia is uncommon in DRESS syndrome.
Because of the possibility of DRESS syndrome, a toxicology consult was obtained. Additional history from various members of the patient’s family revealed that the patient was a Muslim-immigrant lesbian married to a cousin in Iraq in an arranged marriage. She had attempted suicide with an acetaminophen and oxycodone overdose when she broke up with her girlfriend.
Based on her clinical presentation, the toxicologist raised what additional possible drug toxicity? (Click on the correct answer to proceed to the fifth and final page)