Background:
A rare consequence of DRESS syndrome is eosinophilic myocarditis. Our case discusses this condition in conjunction with utilization of the lifesaving modality Extra-Corporeal Membrane Oxygenation, and treatment options.

Case Presentation:
A 30-year-old female patient with a PMHx of DM1, adrenal insufficiency, vitiligo and seizure disorder, which all developed following DRESS syndrome from lamotrigine exposure presented for chest pain. She had no prior cardiac history. EKG showed low voltage QRS. Echocardiogram revealed a small pericardial effusion, pericardial thickening, EF of 55 to 60%, and no tamponade physiology. Labs showed: BNP 4194, CRP 1.48, ESR 7, and a troponin peak of 3121. The patient was treated for acute pericarditis with colchicine and prednisone with resolution of her symptoms.
Sixteen days later, she presented back with recurrent chest pain and hypotension. Labs showed: BNP 14,981 CRP 2.94, troponin peak of 24,097. TTE showed EF 30-35%. EKG showed new RBBB and inferior q waves. Repeat TTE showed EF 10-15%. Left heart catherization revealed normal coronary arteries. Following LHC, multiple episodes of ventricular tachycardia were noted, requiring defibrillated and intubation. Following intubation, she became pulseless requiring CPR and placed on VA ECMO. The patient remained on ECMO support and was started on immunosuppressive modalities following endocardial biopsy confirming eosinophilic myocarditis. Four days after discontinuing ECMO, TTE showed EF 45% with normal RSVP.

Discussion:
DRESS is a rare and potentially life-threatening condition caused by delayed hypersensitivity reaction. Although many cardiac imaging tests assist in the diagnosis, the most definitive remains endomyocardial biopsy. This case report is unique in that there is no other case report that emphasizes the importance of early ECMO support and an anti-IL- 5 antibody in the treatment of eosinophilic myocarditis. In this case, the role of ECMO was significant in the bridge to recovery.
Typical, long-term treatments of eosinophilic myocarditis include steroids in adjunct with immunosuppressive strategies. Our patient’s regimen included prednisone daily, mycophenolate twice a day, and mepolizumab injections monthly. Eosinophils acquire IL-5 receptor on their surface during the early stages of differentiation, and maturation. Mepolizumab, is an anti-IL-5 recombinant humanized monoclonal antibody, which stops the interaction between IL-5 and its receptor on eosinophils.

DRESS Syndrome Associated Eosinophilic Myocarditis: A Rare Condition Leading to Life Saving Measures on ECMO

Clinical Vignettes | Internal Medicine

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DRESS Syndrome Associated Eosinophilic Myocarditis: A Rare Condition Leading to Life Saving Measures on ECMO

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