IMAGE | LIVER Telaprevir-Induced DRESS Syndrome Associated With

Treatment of hepatitis C virus (HCV) infection has changed with the advent of directly acting antiviral agents such as sofosbu-vir and ledipasvir, but telaprevir (TVR)-based triple therapy is still used in many developing countries. DRESS syndrome is an adverse reaction of TVR therapy that typically presents with skin rash, eosinophilia, and fever, and can be life-threatening if unrecognized.1 We present a case of a 48-year-old woman with HCV-related cirrhosis who presented with severe generalized plaque-like pruritic rash over a period of 2 weeks. The rash began during the 8th week of treatment with TVR-based triple therapy. Although TVR discontinuation was strongly recommended, the patient insisted on completing the 12-week regimen. During the 13th week, hospitalization was required due to aggravated pruritic skin rash (Figure 1), diarrhea, severe anemia (hemoglobin 6.7 g/dL), leukopenia (WBC 2,000/mm3/mL), eosinophilia (11%), and fever. Punch biopsy of the skin revealed superficial perivascular der-matitis (Figure 2). The patient was diagnosed with TVR-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, and the diagnosis was supported as “probable ” with the Naranjo score (7 points) and as “definite ” with the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR; 6 points) criteria. Fevers persisted for 8 days, and blood cultures grew Salmonella typhi. The rash was treated with topical steroids, moisturizer, ciprofloxacin, and oral H1 and H2 receptor blockers. Systemic steroids were not used due to concern that this could precipitate severe systemic infection. The patient wa