Drug Rash Eosinophilia Systemic Symptoms (DRESS) syndrome is a systemic hypersensitivity reaction characterized by exfoliative dermatitis and maculopapular rash, lymphadenopathy, fever, eosinophilia, leukocytosis, and involvement of internal organs as liver, lung, heart, and kidney; the disorder starts within 2–6 weeks after taking a drug with an incidence that ranges from 1/1000 to 1/10000 exposures. Fatal cases are reported. The exact pathogenesis of DRESS syndrome is not completely understood, while it is reported that amoxicillin could trigger it in patients who are taking allopurinol, sulfasalazine, NSAIDs, carbamazepine, strontium ranelate, lisinopril, lansoprazole, and minocycline. Amoxicillin could act directly, inducing the reactivation of a viral infection (HHV 6 and EBV) with symptoms similar to DRESS syndrome or by reducing the patients’ ability to detoxify the body from substances chronically taken. We describe a case of a patient admitted to our hospital for a DRESS syndrome flared after amoxicilline intake during treatment with sulfasalazine; this combination can activate severe reactions often with an insidious onset that can mimic an infectious disease. 1. Case Report A 53-year-old woman, Caucasian, without history of drug intolerance, heavy smoker, affected by remote diagnosis of Lyme disease, previous removal of ovarian cyst, and gastroesophageal reflux, was diagnosed in another hospital as having a seronegative spondyloarthritis with anterior right uveitis. For this reason sulfasalazine was started until the dosage of 2 grams per day; after six weeks of treatment, amoxicillin/clavulanic acid was administered for the onset of sore throat, fever and laterocervical lymphadenopathy, and sulfasalazine suspended. After 3 days, she was admitted to our hospital for an acute diffuse and itchy rash with hemorrhagic vesicles on oral cavity, facial edema, and worsening of lymphadenopathy and fever. On admission mental status was normal, body temperature was 39.2°C, blood pressure was 130/80, and the heart and respiratory rates were, respectively, 115 beats and 22 acts per minute. Laboratory tests showed neutrophilic leukocytosis with mild eosinophilia (WBC: 12200/mmc, PMNn: 8580/mmc, and Eo: 690/mmc), AST: 106？IU/L (nv < 30？IU/L), ALT: 350 IU/L (nv < 30？IU/L), GGT: 1047？IU/L (nv 5–36？IU/L), alcaline phosphatase: 2959？IU/L (nv < 240？IU/L), total bilirubin: 2,71？mg/dL (nv < 1.0？mg/dL), C-reactive protein 112？mg/L, (nv < 5.0？mg/L), and ERS 103？mm/1 hour; serum creatinine, glucose, calcium, Na eK, TSH, total gamma globulins, IgG/A/M, K/Lambda chain
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