Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome Caused by Pola-R-CHOP: A Case Report

Chemotherapy regimens, especially for haematologic malignancies, have been increasingly implicated in drug reactions with eosinophilia and systemic symptoms (DRESS) syndrome. We present a case of DRESS syndrome in a patient with diffuse large B-cell lymphoma (DLBCL) receiving pola-R-CHOP chemotherapy, highlighting the importance of early recognition and management. A 58-year-old woman with DLBCL, previously treated breast cancer, and other comorbidities presented three weeks after her third pola-R-CHOP cycle with fever, hypotension, lethargy, and a worsening rash. Initially suspected of peripherally inserted central catheter (PICC) line infection, she was admitted to the ICU for vasopressor support and had acute renal dysfunction. Examination revealed a widespread erythematous, purpuric rash with superficial scaling, lip erosions, and mild conjunctival involvement. Laboratory findings showed eosinophilia and elevated ALT. Despite atypically low eosinophil counts, the rash's timing, systemic symptoms, and organ involvement raised suspicion for DRESS syndrome. The patient also had a history of CMV reactivation and was on ganciclovir. However, the clinical presentation favoured DRESS as the primary diagnosis. Initial treatment included empirical antibiotics and vasopressors. With infection ruled out, IV hydrocortisone was started, followed by a switch to oral prednisolone (1 mg/kg), leading to clinical improvement. Due to a positive CMV PCR, the steroid dose was reduced, resulting in clinical deterioration, increased eosinophils, and worsening liver/renal function. Prednisolone was increased to 80 mg with subsequent improvement, then tapered gradually as per dermatology advice. The patient was discharged on a structured steroid weaning plan and scheduled for close outpatient monitoring. This case highlights the diagnostic challenge of DRESS in immunocompromised oncology patients, particularly when CMV reactivation complicates the picture. Though eosinophilia is a hallmark of DRESS, it may be mild, and clinicians should not exclude the diagnosis based solely on counts. The latency period post-chemotherapy, classic dermatologic features, and systemic organ involvement aligned with DRESS. Prompt withdrawal of the causative agent and initiation of corticosteroids are key to preventing progression to multi-organ failure. This case report highlights that DRESS syndrome, although rare, should be part of the differential in oncology patients receiving multi-agent therapies who present with systemic symptoms and rash. Early identification and management are crucial to reducing morbidity and mortality.