https://www.maxhealthcare.in/max-medical-journal/issue-december-2026/MMJ3-04-8

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, delayed hypersensitivity reaction characterised by fever, extensive rash, eosinophilia, lymphadenopathy, and internal organ involvement, most often of the liver. It usually appears two to eight weeks after drug exposure and carries a mortality of up to 10%. Vancomycin, widely used for antibiotic prophylaxis and treatment in orthopaedic surgery, is an increasingly recognised trigger. We report a 65-year-old woman with Parkinsonism and hypothyroidism who developed high-grade fever with chills, a generalised pruritic erythematous rash, vomiting, and marked weakness after a left-sided total knee replacement (TKR) performed two months earlier, for which vancomycin had been given as implant-related prophylaxis. Investigations showed raised liver enzymes (serum glutamic oxaloacetic transaminase [SGOT] of 223 U/L, serum glutamate pyruvate transaminase [SGPT] of 242 U/L), eosinophilia (7.7%), mild hepatomegaly, and bilateral cervical lymphadenopathy, with reactive lymphadenitis on fine-needle aspiration cytology of a left axillary node. Blood cultures and the work-up for dengue, malaria, and typhoid were negative. Examination revealed facial erythema with exfoliative changes and a morbilliform rash over the lower limbs. DRESS syndrome was diagnosed using the Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) criteria, with vancomycin as the likely culprit. Vancomycin was discontinued, and she was treated with systemic corticosteroids, intravenous fluids, antihistamines, and supportive care, with gradual resolution of rash, fever, and systemic inflammation. DRESS syndrome should be suspected in any postoperative patient with prolonged fever, rash, and organ dysfunction, as early recognition and withdrawal of the offending drug are essential to prevent serious complications.