key: cord-0726677-yysjf9ep
authors: Mesli, Farah; Dumont, Maëlle; Soria, Angèle; Groh, Matthieu; Turpin, Matthieu; Voiriot, Guillaume; Rafat, Cedric; Staumont Sallé, Delphine; Gibelin, Aude; Desnos, Cyrielle
title: Benralizumab: a potential tailored treatment for life-threatening DRESS in the COVID-19 era
date: 2021-07-15
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2021.06.047
sha: 4f4a5249e23d1e0bd51dad06c8a5e7a47fc1d5b4
doc_id: 726677
cord_uid: yysjf9ep

nan

A 43-year-old man with no past medical history presented with high grade fever, multiple enlarged nodes, diffuse maculopapular exanthema with histologic evidence of eczematiform toxidermia, facial edema, parotitis, acute kidney failure, eosinophilic pneumonia (560,000 cells/mm3, eosinophils: 15% on bronchoalveolar lavage), vasoplegic shock (with capillary leak syndrome) and prominent hypereosinophilia (6.7 x 10 3 /mm 3 ) occurring 38 days after admission in our intensive care unit (ICU) for SARS-CoV2-related acute respiratory distress syndrome. As the RegiSCAR score was 8 and that an extensive etiological workup ruled out alternate causes, the diagnosis of "definite" DRESS complicated by multiple organ failure was retained 2 . Cefepime (prescribed for ventilator-acquired pneumonia) was the most likely culprit drug (Figure 1, Figure E1 , Figure E1 ). Treatment with topical steroids, methylprednisolone pulses (2mg/kg/d, then 1g/d for 3 days), norepinephrine (infusion rate: up to 10mg/h), intravenous immunoglobulins (1g/day for 2days) and massive crystalloid replacement was started. Although the patient's hemodynamic status stabilized, worsening eosinophilia (up to 10 x 10 3 /mm 3 ) and severe hemophagocytic lymphohistiocytosis (with profound thrombocytopenia) was evidenced. Subsequently, benralizumab (30mg subcutaneous) was started, enabling dramatic improvement of the patient's condition, with spectacular decrease of eosinophilia within two days, resolution of hemophagocytic lymphohistiocytosis and improvement of both organ dysfunction and skin lesions (Figure 1,   Figure E1 , Figure E2 ). The patient ultimately withdrew dialysis and was discharged from the ICU four weeks after benralizumab. In order to safely taper systemic steroids, a second injection of benralizumab was performed at week four.

The pathophysiology of DRESS is not fully understood. In patients with genetic susceptibility, type IV hypersensitivity to culprit drugs leading to the overproduction of IL-5 and subsequent polyclonal eosinophilia is a key feature. Benralizumab has the ability to induce rapid sustained depletion of eosinophils in both blood and tissues 1, 3 . Here, we chose to use benralizumab 

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