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In the blood cultures we find growing <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> resistant to methicillin&#46; Treatment with intravenous vancomycin and cefepime antibiotics is started&#46; Transoesophageal echocardiography is performed&#44; ruling out the presence of endocarditis and embolic aetiology of spondylodiscitis&#46; Patient evolution is favourable during the first few weeks&#46; Suddenly&#44; towards the end of treatment a erythematous pruritic rash emerges with a 38 &#186;C fever and a decrease in diuresis until the patient experiences anuria and is moved to our department&#46; Upon her arrival&#44; the patient is conscious&#44; haemodynamically stable and afebrile&#46; She presents generalised maculopapular morbilliform rash as well as data suggestive of fluid overload with bibasilar crackles and lower extremity oedema&#46;</p><p class="elsevierStylePara">On the clinical analysis leukocytosis is observed with important eosinophilia and acute renal failure with creatinine&#58; 6&#46;1mg&#47;dl&#44; urea&#58; 156mg&#47;dl and vancomycin levels at 36&#46;19&#181;g&#47;ml &#40;normal levels&#58; 5-10&#181;g&#47;ml&#41;&#46; Vancomycin is immediately suspended and a catheter is placed the right femoral artery&#46; Haemodialysis session begins&#46; In the immunological study antinuclear antibodies&#44; antineutrophil cytoplasmic antibodies&#44; anti-GBM antibodies and protein electrophoresis were all within the normal range&#46; Sterile blood and urine cultures are collected&#46; Serology is extracted and tested for hepatitis B and C&#44; human immunodeficiency virus&#44; herpes virus&#44; herpes 6&#44; Epstein-Barr virus&#44; Chlamydia and Mycoplasma&#44; all with negative results&#46; Suspecting immunoallergic acute renal failure&#44; corticosteroids treatment is implemented on 3 daily doses of 250mg of methylprednisolone&#44; followed by an intravenous dose of prednisone 1mg&#47;kg&#46; Later on&#44; when the general state of the patient allows it&#44; it is decided to carry out a renal biopsy&#46; The biopsy includes 18 glomeruli&#44; 6 of them with global sclerosis of the glomerular capillary&#46; On the 12 preserved glomeruli&#44; there are no significant intra-capillary lesions&#46; A diffuse moderate tubulointerstitial lesion is detected&#44; with inflammatory infiltrates made up of polymorphs formed by small lymphocytes&#44; plasma cells and abundant eosinophils &#40;Figure 1&#41;&#44; and numerous images of tubulitis with lymphocyte infiltrates at the level of the tubular epithelium&#46; On small arteries and small intralobular arteries there were no lesions&#46; All the findings are compatible with the diagnosis of acute tubulointerstitial nephritis with eosinophils suggesting immunoallergic nephritis&#46;</p><p class="elsevierStylePara">During patient evolution&#44; we implement treatment with clavulanic-amoxicillin due to thrombophlebitis at the peripheral level&#44; a new rash appears&#44; along with increased leukocytosis with intense eosinophilia on the blood test and sudden dyspnea with wheezing related to eosinophilic pneumonitis&#46; An internal consultation with the allergy Department takes place&#59; they discourage the use of both vancomycin and beta-lactams&#46; From the pulmonary point of view&#44; we detect symptomatic improvement on the following 48 hours with some care&#46; During evolution&#44; we also found an increase in glutamic oxaloacetic transaminase &#40;GOT&#41;&#44; glutamic pyruvic transaminase &#40;GPT&#41; and &#947;-glutamyl transferase &#40;GGT&#41;&#46; The patient is diagnosed with DRESS syndrome affecting her skin&#44; lung&#44; liver and kidney&#46; Corticosteroids therapy remains in place and a progressive improvement in renal function is evident without the need for a new haemodialysis session&#46; The patient remains in the hospital for 15 days&#46; By the time the patient is dismissed&#44; there is evident improvement of the rash and renal failure is receding&#46; Three months after hospitalization the patient presents 1&#46;34 mg&#47;dl of creatinine and proteinuria comes back negative&#46;</p><p class="elsevierStylePara">The diagnosis of DRESS syndrome is established by the appearance&#44; after being exposed to a drug&#44; of skin eruptions&#44; haematological alterations as eosinophilia or atypical lymphocytosis and systemic involvement in the form of adenopathies&#44; hepatitis&#44; interstitial neumonitis&#44; carditis or interstitial nephritis&#46; The incidence of the syndrome is estimated as 1 out of every 10&#160;000 individuals exposed to the implicated drugs&#46; The drugs more frequently associated with the syndrome are anti-convulsants but there have been cases involving anti-inflammatory drugs&#44; allopurinol and antibiotics&#46;<span class="elsevierStyleSup">2</span> The symptoms appear with a latency period that may vary between 1 and 8 weeks after exposure to drugs&#46; As it has been suggested as an action mechanism&#44; the presence of an allergic hyper sensibility reaction&#44; in which medications act directly as antigens or indirectly as haptens&#46;<span class="elsevierStyleSup">3</span> We have also found an association between the reactivation of infection by human herpes 6 virus<span class="elsevierStyleSup">4</span> or Epstein-Barr virus and DRESS syndrome&#46; Treatment includes withdrawal from the suspected medication and corticosteroid treatment&#46;<span class="elsevierStyleSup">5</span> Mortality varies&#44; depending on the series&#44; between 10&#37; and 30&#37;&#44; and it comes with lung and&#47;or hepatic affectations and sometimes with bacterial ulcer lesions&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">To our knowledge&#44; this is the first case of DRESS syndrome by vancomicyn and beta-lactams&#44; with systemic involvement and a renal biopsy confirming the existence of allergic tubulointerstitial nephritis&#44; with good results after corticosteroids treatment&#46; Table 1 displays cases diagnosed with DRESS syndrome due to vancomycin described in the literature&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors have no conflict of interests to declare&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11455&#95;16025&#95;36069&#95;en&#95;f1&#95;11455&#46;jpg" class="elsevierStyleCrossRefs"><img src="11455_16025_36069_en_f1_11455.jpg" alt="Haematoxylin and Eosin staining "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Haematoxylin and Eosin staining </p><p class="elsevierStylePara"><a href="grande&#47;11455&#95;16025&#95;36070&#95;en&#95;t1&#95;11455&#46;jpg" class="elsevierStyleCrossRefs"><img src="11455_16025_36070_en_t1_11455.jpg" alt="DRESS syndrome as an effect of Vancomycin"></img></a></p><p class="elsevierStylePara">Table 1&#46; DRESS syndrome as an effect of Vancomycin</p>"
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