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Shanbhag et al

Figure 1. Extensive rash on patient's legs.

Figure 2. Extensive rash on patient's left arm and chest.

signals, all of which can lead to antitumor activity.11-14 Its use
has been proposed in multiple myeloma, chronic lymphocytic
leukemia, mantle cell lymphoma, and myelodysplastic syndrome with the deletion of chromosome 5q.15,16 Severe dermatological reactions such as Stevens-Johnson syndrome, toxic
epidermal necrolysis, and erythema multiforme secondary to
lenalidomide have been reported,17,18 but evidence for lenalidomide causing DRESS syndrome is sparse.19-21 The precise
mechanism for DRESS syndrome with lenalidomide is not
clear; it is possible that the immunomodulatory activity of
lenalidomide contributes in the hypersensitivity reaction presenting as DRESS syndrome. Lenalidomide is known to cause
adverse medication reaction affecting the respiratory system,22
but nonpulmonary reactions have been rarely reported. We
report a case of DRESS syndrome caused by lenalidomide
used for the treatment of multiple myeloma.

mg/dL) and serum immunofixation that revealed the presence
of IgG lambda plus free lambda M-proteins. Diagnosis was
confirmed by bone marrow biopsy showing 30% plasma cells
on aspiration and 25% on core biopsy. Concurrent flow cytometric analysis showed plasma cell population with an atypical immunophenotype, comprising about 8.94% of analyzed
events. An immunohistochemical stain for CD138 and in situ
hybridization studies for kappa and lambda light chains performed on AZF-fixed, paraffin-embedded sections of the
bone marrow biopsy showed 25% plasma cells, predominantly lambda-expressing cells with the expansion of interfatty spaces by aggregates of monotypic plasma cells. She
was started on lenalidomide 5 mg by mouth daily on days 1 to
21 of a 28-day cycle and dexamethasone 40 mg by mouth on
days 1, 8, 15, and 22 every 28 days.
The patient's other significant past medical history was
type II diabetes mellitus, hypertension, heart failure with
preserved ejection fraction of 60%, atrial myxoma with
mitral valve prolapse for which the patient had received a
bioprosthetic mitral valve replacement, sacral teratoma that
had been resected, and stage III chronic kidney disease.
Home medications included metoprolol succinate 25 mg by
mouth daily, olmesartan 5 mg by mouth daily, aspirin 325 mg
by mouth daily, furosemide 80 mg by mouth daily, spironolactone 25 mg by mouth daily, and a multivitamin taken once
by mouth daily. She was known to develop an allergic rash
and swelling with blue food coloring and amitriptyline but
indicated that she had not taken either recently. She had no
history of alcohol or tobacco use.
The review of systems was significant for the new-onset
and worsening rash, malaise, and possible chills. Otherwise,
the patient denied fever, abdominal pain, arthralgia, history
of easy bruising, lymphadenopathy, and numbness or tingling in her extremities. On physical examination, initial
vital signs were blood pressure 94/55 mmHg, pulse 73 beats
per minute, temperature 99.3°F, and respiratory rate 17
breaths per minute. She was lying in bed with an ill and weak

Case Report
A 75-year-old African American female presented to our
hospital with fatigue and weakness over the previous few
days. On the morning of her presentation, she fell from a
standing position and landed on her buttocks, but she denied
syncope or presyncopal episode prior to the fall. She attributed the fall to feeling weak. On examination, she was noted
to be hypotensive and responded only partially to a 1-L bolus
of 0.9% sodium chloride. On physical examination, she had
a diffuse erythematous skin rash covering 90% to 95% of her
body surface area with evidence of skin breakdown and desquamation in addition to malodorous secretions in her skin
folds (Figures 1 and 2).
One month prior to the patient presenting to the hospital,
she was diagnosed with multiple myeloma based on serum
protein electrophoresis that revealed serum M protein of 2.3
g/dL in addition to the presence of serum kappa-free light
chains, 2.82 mg/dL (normal range: 0.22-1.94 mg/dL), and
lambda-free light chains, 73.5 mg/dL (normal range: 0.57-2.63

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