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Paper text:
drug reaction with eosinophilia and systemic symptom ( dress ) is a severe adverse drug - induced reaction with an annual incidence of 1 in 1000 to 1 in 10,000 drug exposures .
although antiepileptics are the major culprit drugs , a variety of other pharmacological agents cause dress . we here report a case of levetiracetam induced dress that has rarely been reported in the literature previously .
a 40-year - old male presented to our emergency department with acute subdural hematoma secondary to a road traffic accident . the patient was managed conservatively . however during hospital stay patient developed a generalized tonic - clonic seizure .
stay , his counts became normal , and his general condition improved . in view of the history of seizure , patient was switched over to levetiracetam and advised close follow - up after discharge .
patient , however , returned after 1 week with high - grade fever ( 103104 f ] and rash .
rash was itchy and erythematous and started from the chest and progressed to involve other body parts . on examination , the patient was conscious and oriented .
generalized erythematous maculopapular rash seen predominantly on the face , chest , trunk , back , upper limbs , and the proximal portion of lower limbs was present [ figures 14 ] .
the investigation revealed transaminitis [ table 1 ] . in view of fever , rash , transaminitis and exposure to levetiracetam , the patient was diagnosed as a case of levetiracetam induced dress .
the patient was managed with antihistaminics and dexamethasone 4 mg tid for 2 weeks followed by a taper .
the patient became afebrile on day 4 of admission and transaminitis started resolving on day 4 .
the patient was seizure free and was discharged after 6 days of hospital stay . on follow - up , the patient is doing well and seizure free .
transaminitis has resolved , and the rash has subsided [ figures 5 and 6 ] .
dress syndrome was first described in 1959 associated with phenytoin and was previously referred to as drug - induced pseudolymphoma .
the term dress syndrome was proposed by bocquet et al . , describing it as a potentially life - threatening syndrome .
the syndrome is characterized by severe skin eruption , fever , hematologic abnormalities ( eosinophilia or atypical lymphocytes ) and internal organ involvement .
although most commonly associated with antiepileptic drugs like phenytoin , dress syndrome has also been reported after exposure to a large number of medications including oxcarbazepine , vancomycin , doxycycline , linezolid , nitrofurantoin , atorvastatin , and esomeprazole .
different mechanisms have been implicated in its development that include slow acetylation and detoxification defects leading to reactive metabolite formation and subsequent immunological reactions .
reactivation of human herpes , including epstein  barr virus and human herpes virus ( hhv)-6 and 7 has also been implicated .
laboratory tests that will help to differentiate dress syndrome from other severe drug reactions and to identify internal organ involvement include complete blood cell count , liver function tests , serum creatinine level and urinalysis .
skin biopsy shows a nonspecific lymphocytic infiltrate of the papillary dermis , which may contain eosinophils and which is generally denser than in other drug reactions .
a scoring system [ regiscar scoring , table 2 ] has been devised that helps clinicians to make a diagnosis of dress in a suspected case .
regiscar scoring for drug reaction with eosinophilia and systemic symptom syndrome prompt treatment is important for speedy recovery . the offending drug should be discontinued and pharmacological treatment instituted .
the french society of dermatology recommends systemic corticosteroids at a dose equivalent to 1 mg / kg / day of prednisone in patients with any sign of severity that include transaminitis , renal involvement , pneumonia , and cardiac involvement .
they further recommend the use of intravenous immunoglobulin at a dose of 2 g / kg over 5 days for a patient with life - threatening signs such as renal failure and respiratory failure .
in addition , they also propose the use of steroids in combination with ganciclovir in patients with signs of severity and confirmation of a major viral reactivation of hhv-6 .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
drug reaction with eosinophilia and systemic symptom ( dress ) is a very rare but possible side effect of levetiracetam and should be borne in mind if a patient on levetiracetam develops a skin rashthe outcome is good if dress is recognized early and appropriate treatment instituted . 
 
drug reaction with eosinophilia and systemic symptom ( dress ) is a very rare but possible side effect of levetiracetam and should be borne in mind if a patient on levetiracetam develops a skin rash the outcome is good if dress is recognized early and appropriate treatment instituted .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
drug reaction with eosinophilia and systemic symptom ( dress ) is a very rare but possible side effect of levetiracetam and should be borne in mind if a patient on levetiracetam develops a skin rashthe outcome is good if dress is recognized early and appropriate treatment instituted . 
 
drug reaction with eosinophilia and systemic symptom ( dress ) is a very rare but possible side effect of levetiracetam and should be borne in mind if a patient on levetiracetam develops a skin rash the outcome is good if dress is recognized early and appropriate treatment instituted .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
drug reaction with eosinophilia and systemic symptom ( dress ) is a very rare but possible side effect of levetiracetam and should be borne in mind if a patient on levetiracetam develops a skin rashthe outcome is good if dress is recognized early and appropriate treatment instituted . 
 
drug reaction with eosinophilia and systemic symptom ( dress ) is a very rare but possible side effect of levetiracetam and should be borne in mind if a patient on levetiracetam develops a skin rash the outcome is good if dress is recognized early and appropriate treatment instituted .
drug reaction with eosinophilia and systemic symptom syndrome ( dress ) is a hypersensitivity drug reaction , most frequently associated with antiepileptic drugs , characterized by skin rash , fever , pharyngitis , lymphadenopathy , and visceral organ involvement , typically presenting within 8 weeks of initiation of therapy . 
 management involves prompt withdrawal of the offending drug and use of systemic corticosteroids . 
 we here present a rare case of dress secondary to levetiracetam . 
 only few case reports of dress secondary to levetiracetam have been published so far .