The patient was admitted on a 72-hour-hold to a behavioral health program for depression and suicidal ideation. While there, she was prescribed 150 mg per day of Wellbutrin. She was discharged home on 6/17/2022, with a follow-up appointment set for 6/21/2022. It's not clear whether she made it to the follow-up.
On 7/5/2022, the patient's mother took her to an urgent care center for an itchy rash that had been present for the past 2 days, along with nausea. The patient had a temperature of 100.2, BP of 100/62, HR 137, and respiratory rate 18. She was COVID-negative, and a urinalysis was abnormal but in line with a long-time history of glucosuria and proteinuria, for which no cause had ever been found. The patient was diagnosed with folliculitis and prescribed Bactrim and a Medrol dosepack. Her mother was suspicious that the Wellbutrin was causing the rash, so the patient stopped taking it around this time. During a telehealth visit that same day to discuss previous labwork results, the patient and her mother informed her regular pediatrician about the rash and urgent care visit.
On 7/7/2022, the patient followed up in person with her pediatrician, who ordered a rapid strep test and allergy testing.
On 7/8/2022, the patient's mother took her to the emergency room for the rash, which was described as maculopapular, consistent with an allergic reaction, and present on the trunk and all extremities. The patient's vital signs were all normal. The patient was given IV Benadryl, Pepcid, and Solu-Medrol with mild improvement of itching. She was discharged home with a referral to a dermatologist and instructions to take oral Benadryl as needed and not to restart the Wellbutrin.
On 7/13/2022, the patient's mother took her back to the emergency room. The rash was still present, and now the patient also complained of fever, decreased appetite, diarrhea, weakness, joint pain, and enlarged lymph nodes. Her vitals in the ER were BP 101/56, HR 120, RR 20, O2 sats 96%, and temperature 36.8. On physical exam, she was found to have "hives all over upper extremities and back with signs of excoriation" and swollen bilateral submandibular lymph nodes. Labwork results included WBC 12.9, H/H 13.5/14, sodium 132, AST 90, ALT 138, and albumin 2.5.. Testing for mononucleosis and a viral and bacterial panels were negative. A chest x-ray was negative, and a gallbladder ultrasound showed mild hepatomegaly. The patient was given IV fluids and Benadryl and discharged home again.
On 7/15/2022, the patient followed up with her pediatrician, reporting a continuing fever, and rash on her entire body. Her mother was advised to take her to the emergency room at a local children's hospital, which she did. In the ER, the patient reported a 4-week history of rash, cough, progressive fatigue, weakness, myalgias and arthralgias, lymphadenopathy, and left-sided facial swelling that had begun earlier in the day. Blood pressure was found to be low for her age, but other vitals were normal. Lab results included: WBC 21, eosinophils normal, CRP 3.6, ESR 121, RVP negative, AST 378, ALT 394, calcium 7.9, albumin 3.1, sodium 130, procalcitonin 6.02, PT/INR 22.5/2, D-dimer 5629, ferritin 1150, and normal troponin and BNP. Ultrasound showed hepatomegaly with the liver measuring 18.3 cm with normal parenchyma, gallbladder wall thickening without stones seen, and reactive appearing periportal lymph nodes. The patient was admitted and eventually diagnosed with DRESS, felt to be most likely from the Wellbutrin. She spent 8 days in the hospital and was treated with Vitamin K, high-dose solumedrol, cyclosporine, and ursodiol, among other things. She continues to have ongoing related health problems.
I am interested in opinions on whether the patient should have been admitted to the hospital sooner, particularly during one of the ER visits. Thank you!
Files:
No questions yet!
Do you believe there might have been medical error?
Repeat visits despite treatment and lack of response from treatment along with fever. New medication and symptoms should have raised the suspicion of DRESS syndrome. Although rare, the multiple visits should have triggered higher index of suspicion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Error of omission. Failure to recognize a rare syndrome.
What makes you a good expert for this case?
I am board certified in Emergency Medicine.
How often do you encounter cases similar to this one in your practice?
The presentation is common. The diagnosis is rare.
Do you believe there might have been medical error?
The question that was posed primarily was "Should the patient have been admitted to the hospital earlier?" The patient was prescribed Wellbutrin on 06/17/22 and that was stopped by the mother on 07/05/22 due to the suspicion that Wellbutrin was the offending agent. The patient ultimately was hospitalized 10 days later, and there may have been opportunities for an earlier admission to treat symptoms on the basis of the patient's clinical condition. She was fairly ill on 07/05 with vital signs that showed low-grade fever but significant tachycardia suggestive of possible systemic inflammatory response syndrome (SIRS). At that time steroids were administered which is the part of the treatment for DRESS syndrome. Discharge home on that episode was not unreasonable especially with the close follow-up. Whether or not admission was indicated on the 7/8 ED visit is not entirely clear from the provided data given the fact that there are no vital signs provided. However, we are now 3 days and 3 doctor visits into this clinical course, which should heighten the clinical suspicion on the part of an emergency physician. If significant abnormalities of vital signs persisted, lab workup would have been indicated which might have demonstrated the liver function abnormalities pointing to a more severe issue, and a strong argument for admission could be made on that visit. The next visit on 07/13 demonstrated fairly significant progression of the disease process, and the associated lab abnormalities and vital sign abnormalities, which should have led to pediatric consultation and admission. She ended up getting admitted 2 days later on 7/15, so it is unclear whether an admission 2 days earlier would have improved the clinical course later on. A prudent emergency physician would have arranged for admission on 7/13 if not on 7/8. The only medical error would have been a judgement error on more aggressive inpatient treatment.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The fundamental question would be, "Did any delay in admission result in undue injury to the patient"? The treatment for DRESS syndrome, in addition to removal of offending agent, is steroids, IV fluids and possible cyclosporin, depending on extent of disease and organ involvement. Earlier aggressive treatment may have resulted in a more favorable clinical course.
What makes you a good expert for this case?
25 years of clinical emergency medicine practice in ED with significant pediatric population. Faculty of an emergency medicine residency program.
How often do you encounter cases similar to this one in your practice?
DRESS syndrome is very unusual. Most patients presenting with adverse drug reactions present with urticaria or respiratory issues. I don't believe I have ever personally diagnosed DRESS syndrome in the ED, but see pediatric patients with allergic reactions on a regular basis, some quite ill requiring resuscitation and admission.
Want to open a case or submit response?
Comments are accepted only from Emergency Medicine - includes all subspecialties experts.