Hospital Pharmacy - June 2017 - 410
410
Hospital Pharmacy 52(6)
Question
Response
Score
Are there previous conclusive reports of this reaction?
Yes
+1
Did the adverse event appear after the suspected drug was administered?
Yes
+2
Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered?
Yes
+1
Did the adverse reaction reappear when the drug was readministered?
Yes
+2
Are there alternative causes (other than the drug) that could on their own have caused the reaction?
No
+2
Did the reaction reappear when a placebo was given?
Do not know
0
Was the drug detected in the blood (or other fluids) in concentrations known to be toxic?
Do not know
0
Was the reaction more severe when the dose was increased or less severe when the dose was decreased?
Do not know
0
Did the patient have a similar reaction to the same or similar drug in any previous exposure?
Do not know
0
Was the adverse event confirmed by any objective evidence?
Yes
+1
Total
+9
Figure 3. Naranjo Adverse Drug Reaction Probability Scale.
appearance but was well oriented to time, place, and person.
Her cardiac and respiratory exams were unremarkable, and
no organomegaly or tenderness to palpation was noted on
abdominal exam. Majorly, she had an expanded rash extending from her face, chest, and back to the extremities but sparing her palms, soles, and nails. The rash was erythematous,
scaly, and showed evidence of desquamation and malodorous secretions.
Labs on admission were remarkable for a white blood
cell count of 17.01 K/µL with 55% eosinophils (lab standard: 1%-7%), hemoglobin 12.4 g/dL, hematocrit of 39.9%,
blood urea nitrogen 27 mg/dL, serum creatinine 1.6 mg/dL,
and lactate 3.7 mmol/L. Chest radiograph at admission did
not show any pulmonary vascular congestion, consolidation, effusion, or hyperinflation. Urinalysis was unremarkable. Radiograph of the pelvis and upper extremities was
performed to rule out the possibility of fractures due to her
recent fall and was negative as well. Given her presentation
with generalized rash, hypotension, and acute on chronic
kidney disease, sepsis secondary to skin or soft tissue infection was high on the initial differential diagnosis. However,
a peripheral smear showing eosinophilia combined with
the white count differential revealing 55% eosinophils
suggested the possibility of lenalidomide-induced rash;
therefore, lenalidomide was held on admission and methylprednisolone 80 mg by intravenous injection 3 times daily
was initiated. She was resuscitated with fluids and later
admitted to the intensive care unit for hemodynamic instability requiring vasopressors. Following 2 blood cultures
being drawn, she was initiated on vancomycin and cefepime.
Four days after admission and lenalidomide discontinuation, vasopressors were discontinued. Blood cultures did not
exhibit any growth and infection as a cause of her symptoms
was later thought to be unlikely. Significant improvement in
the rash and a decrease in eosinophilia were observed prior
to discharge. In the follow-up clinic appointment 4 months
after her discharge, the patient was restarted on lenalidomide at the same dose and frequency. However, the rash
resurfaced within a day, and lenalidomide was discontinued
immediately and indefinitely.
Discussion
Nonspecific rash has been noted in approximately 27% of
patients treated with lenalidomide for an oncological disorder.15
Lenalidomide has been used more commonly in hematologic disorders only recently, and hence, there are only 3
cases of lenalidomide-associated DRESS syndrome in the
literature.19-21 Shaaban et al reported a case of DRESS syndrome with manifestations of fever, pruritic rash, and cough
with acute interstitial nephritis resulting from the first course
of lenalidomide given for multiple myeloma, which improved
following discontinuation of the medication.19 Similarly,
Vlachopanos and colleagues provided care for a patient who
was dependent on dialysis and developed DRESS syndrome
after receiving lenalidomide at an appropriate dose for her
renal function for 5 days prior to admission. The diffuse and
infiltrating rash did not abate following discontinuation, and
the patient succumbed from relapsed multiple myeloma 8
weeks after admission.20 Finally, another patient reported by
Foti et al also experienced DRESS syndrome from lenalidomide, which improved with the termination of the drug. No
recurrences of rash, facial edema, lymphadenopathy, or fever
were noted on follow-up visits over 6 months.21
In our patient, the Naranjo Adverse Drug Reaction
Probability Scale score was 9, suggesting lenalidomide was a
highly probable cause of DRESS syndrome23 (Figure 3).
Limitations of the case report include our inability to measure
serum concentrations of lenalidomide and lack of biopsy results.
However, the chronological relation of lenalidomide administration with the clinical symptoms including a classic DRESS
syndrome rash, improvement of manifestations with discontinuation of lenalidomide, presence of significantly elevated eosinophils, and reappearance of the rash on a rechallenge of the
agent strengthen the suspicion of lenalidomide-associated
DRESS syndrome.
Table of Contents for the Digital Edition of Hospital Pharmacy - June 2017
Formal Leadership: Thrilling (and Scary) Like a Roller Coaster Ride
ISMP Medication Error Report Analysis
Cancer Chemotherapy Update: Bevacizumab, Etoposide, and Cisplatin Regimen for Refractory Brain Metastases
Formulary Drug Reviews: Plecanatide
Calcitonin Gene-Related Peptide Receptor Antagonists for Migraine Prophylaxis: A Review of a Drug Class or Therapeutic Class in a Late Stage of Clinical Development
Highly Probable Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome Associated With Lenalidomide
Significant Published Articles for Pharmacy Nutrition Support Practice in 2016
Financial Effect of a Drug Distribution Model Change on a Health System
Limited Influence of Excipients in Extemporaneous Compounded Suspensions
Improved Outcomes and Cost Savings Associated With Pharmacist Presence in the Emergency Department
Patients Given Take Home Medications Instead of Paper Prescriptions Are More Likely to Return to Emergency Department
Hospital Pharmacy - June 2017 - 381
Hospital Pharmacy - June 2017 - 382
Hospital Pharmacy - June 2017 - 383
Hospital Pharmacy - June 2017 - 384
Hospital Pharmacy - June 2017 - 385
Hospital Pharmacy - June 2017 - 386
Hospital Pharmacy - June 2017 - 387
Hospital Pharmacy - June 2017 - Formal Leadership: Thrilling (and Scary) Like a Roller Coaster Ride
Hospital Pharmacy - June 2017 - 389
Hospital Pharmacy - June 2017 - ISMP Medication Error Report Analysis
Hospital Pharmacy - June 2017 - 391
Hospital Pharmacy - June 2017 - 392
Hospital Pharmacy - June 2017 - 393
Hospital Pharmacy - June 2017 - Cancer Chemotherapy Update: Bevacizumab, Etoposide, and Cisplatin Regimen for Refractory Brain Metastases
Hospital Pharmacy - June 2017 - 395
Hospital Pharmacy - June 2017 - 396
Hospital Pharmacy - June 2017 - 397
Hospital Pharmacy - June 2017 - 398
Hospital Pharmacy - June 2017 - 399
Hospital Pharmacy - June 2017 - Formulary Drug Reviews: Plecanatide
Hospital Pharmacy - June 2017 - 401
Hospital Pharmacy - June 2017 - 402
Hospital Pharmacy - June 2017 - 403
Hospital Pharmacy - June 2017 - 404
Hospital Pharmacy - June 2017 - 405
Hospital Pharmacy - June 2017 - Calcitonin Gene-Related Peptide Receptor Antagonists for Migraine Prophylaxis: A Review of a Drug Class or Therapeutic Class in a Late Stage of Clinical Development
Hospital Pharmacy - June 2017 - 407
Hospital Pharmacy - June 2017 - Highly Probable Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome Associated With Lenalidomide
Hospital Pharmacy - June 2017 - 409
Hospital Pharmacy - June 2017 - 410
Hospital Pharmacy - June 2017 - 411
Hospital Pharmacy - June 2017 - Significant Published Articles for Pharmacy Nutrition Support Practice in 2016
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Hospital Pharmacy - June 2017 - Limited Influence of Excipients in Extemporaneous Compounded Suspensions
Hospital Pharmacy - June 2017 - 429
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Hospital Pharmacy - June 2017 - 431
Hospital Pharmacy - June 2017 - 432
Hospital Pharmacy - June 2017 - Improved Outcomes and Cost Savings Associated With Pharmacist Presence in the Emergency Department
Hospital Pharmacy - June 2017 - 434
Hospital Pharmacy - June 2017 - 435
Hospital Pharmacy - June 2017 - 436
Hospital Pharmacy - June 2017 - 437
Hospital Pharmacy - June 2017 - Patients Given Take Home Medications Instead of Paper Prescriptions Are More Likely to Return to Emergency Department
Hospital Pharmacy - June 2017 - 439
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