Anti-tuberculous drug–induced DRESS syndrome in pregnancy with hepatitis E and autoimmune overlap: A case report

RATIONALE: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, potentially life-threatening hypersensitivity reaction. Its occurrence during pregnancy, especially secondary to anti-tuberculous therapy (ATT), is exceedingly uncommon and presents major diagnostic and therapeutic challenges. PATIENT CONCERNS: A 23-year-old pregnant woman (14 weeks gestation) presented with prolonged fever, jaundice, rash with desquamation, and respiratory symptoms while on first-line ATT for pulmonary tuberculosis. DIAGNOSES: Laboratory evaluation revealed severe eosinophilia, deranged liver function, hepatitis E virus co-infection, and autoimmune overlap (systemic lupus erythematosus with antiphospholipid antibody positivity). Based on clinical features and a Registry of Severe Cutaneous Adverse Reactions score of 6, a definite diagnosis of DRESS syndrome was established. INTERVENTIONS: ATT was discontinued, and she was treated with systemic corticosteroids, antihistamines, and topical therapy. Sequential drug challenges confirmed hypersensitivity to all 4 first-line agents, necessitating initiation of bedaquiline, clofazimine, and delamanid. OUTCOMES: The patient showed favorable clinical recovery with improvement in systemic manifestations and stabilization of pregnancy. She was discharged on modified ATT with multidisciplinary follow-up. LESSONS: This case highlights the complexity of diagnosing and managing DRESS in pregnancy, particularly in tuberculosis-endemic regions. Coexisting viral hepatitis and autoimmune disorders may mimic or exacerbate the syndrome, underlining the importance of high clinical suspicion, timely drug withdrawal, and individualized therapy.