A 38-year-old woman develops fever, facial oedema, cervical lymphadenopathy, and an extensive morbilliform rash 4 weeks after starting carbamazepine. Blood tests show eosinophilia 18%, atypical lymphocytosis, and ALT 420 U/L. What is the single most important immediate management step after discontinuing the offending drug?
- A Initiate systemic corticosteroids and monitor organ function ✓
- B Start intravenous immunoglobulin 2 g/kg
- C Commence cyclosporine 5 mg/kg/day
- D Begin plasmapheresis for cytokine clearance
Explanation
This presentation is DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms), characterised by delayed onset (2–8 weeks), eosinophilia, atypical lymphocytes, and multi-organ involvement. After drug withdrawal, systemic corticosteroids (prednisolone 1–2 mg/kg/day) are the mainstay treatment to suppress the HHV-6 reactivation–driven immune cascade and protect visceral organs. IVIG is used in corticosteroid-refractory cases or when corticosteroids are contraindicated. Plasmapheresis has anecdotal use but is not a first-line step. Cyclosporine is a second-line agent in severe hepatic DRESS.
Reference: Neena Khanna Illustrated Synopsis of Dermatology & STD, 6th ed.
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