Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome in Pulmonary Tuberculosis Patient with Type 2 Respiratory Failure and Sepsis

While anti-tuberculosis drugs (ATDs) are essential for tuberculosis (TB) treatment, they can induce severe hypersensitivity reactions, including drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. Its occurrence presents significant diagnostic and therapeutic challenges, especially in TB patients with type 2 respiratory failure and sepsis. A 23-year-old man with pulmonary TB developed ATD-induced DRESS syndrome complicated by type 2 respiratory failure and sepsis. He developed DRESS syndrome after initiating a standard ATD regimen consisting of rifampicin (R), isoniazid (H), pyrazinamide (Z), and ethambutol (E). He developed progressive dyspnea, fever, nausea, vomiting, and a pruritic, erythematous skin rash. Laboratory findings revealed leukocytosis, eosinophilia, severe transaminitis, hyperbilirubinemia, and elevated interleukin-6 levels. DRESS syndrome was diagnosed based on RegiSCAR scoring system (total score = 6), derived from clinical, physical, and laboratory abnormalities. All ATDs were discontinued, and he received systemic corticosteroids, hepatoprotective agents, topical therapy, and supportive respiratory management. Upon clinical improvement, ATDs desensitization was successfully performed, followed by completion of a modified regimen of rifampicin 450 mg/isoniazid 200 mg/ethambutol 750 mg for 9 months, excluding pyrazinamide due to previous hepatic involvement. No recurrence of DRESS manifestations was observed, and sputum acid-fast bacilli examinations at 6 months were negative. Early recognition of ATD-induced DRESS syndrome, prompt withdrawal of the offending drugs, and appropriate treatment are crucial to prevent severe organ involvement. Desensitization protocols provide a safe and effective approach for reintroducing essential ATDs in selected patients, allowing successful completion of TB treatment without DRESS recurrence.