drug rash with eosinophilia and systemic symptoms ( dress ) syndrome is an acute , potentially life - threatening , idiosyncratic , severe cutaneous adverse drug reaction characterized by fever , skin eruption , hematological abnormalities including eosinophilia or atypical lymphocytes , and internal organ involvement . the most commonly involved internal organ is the liver , followed by the kidney and lungs . although the estimated incidence of this syndrome varies from 1 in 1000 to 1 in 10,000 drug exposures , its true incidence is unknown because of variable presentation and inaccurate reporting . aromatic anticonvulsant drugs such as phenytoin , carbamazepine , and phenobarbital are mainly implicated in dress . newer antiepileptic drugs such as oxcarbazepine - induced dress are reported a few , whereas definite oxcarbazepine - induced dress presenting as exfoliative dermatitis is rare in literature . here , we present a case of a 35-year - old male who developed dress syndrome presenting as exfoliative dermatitis after taking oxcarbazepine for the past 3 weeks . a 35-year - old male was admitted with generalized scaling and erythema of the whole body for the past 5 days . he was on tablet oxcarbazepine for the past 3 weeks for seizure disorder diagnosed recently . he was not known to have allergy to any drug in the past . on examination , the patient was toxic , febrile ( 101f ) , icteric , with tachypnea ( 25/min ) , tachycardia ( 110/min ) , conjunctival congestion , and cervical and inguinal lymphadenopathy . there was a diffuse swelling of the face with pitting edema of both the legs [ figure 1 ] . brown - to - black semi - adherent scaling was present on more than 90% of the body surface area with the underlying erythema giving rise to the dull red appearance of the skin [ figure 2 ] . diffuse facial edema with scaling and erythema over the face and upper trunk brown - to - black semi - adherent scaling with underlying erythema involving most of the body parts initial investigation revealed leukocytosis ( total leukocyte count = 12,440/cm ) with eosinophilia ( absolute eosinophil count his liver function test was deranged with elevation of bilirubin ( total bilirubin  5.6 mg / dl ) and liver enzymes ( alanine transaminase = 784 iu / l ; aspartate aminotransferase = 1324 iu / l ; and alkaline phosphatase = 184 serological test for hepatitis a virus , hepatitis b virus , hepatitis c virus , human immunodeficiency virus , chlamydia , and mycoplasma was negative . based on the european registry of severe cutaneous adverse reactions ( regiscar ) criteria , a definitive diagnosis of oxcarbazepine - induced dress was made . oxcarbazepine was stopped , and the patient was treated with injection dexamethasone 1 ml ( 4 mg / ml ) , twice a day for initial 5 days with antihistaminic , topical corticosteroids , and emollient lotion . after 48 h of treatment , the patient started improving clinically and became afebrile after 72 h. skin eruption gradually cleared over 10 days and his hematological and other laboratory parameters started improving after 72 h and became normal after 18 days of starting treatment . a systemic severe allergic reaction to anticonvulsant therapy was first described by chaiken et al . in 1950 and was named as  anticonvulsant hypersensitivity syndrome ,  which was associated with phenytoin therapy . since then , it has been also known as drug hypersensitivity syndrome and now popularized as dress syndrome which was coined by bocquet et al . in 1996 characterized by fever , skin eruption , hematological abnormalities including eosinophilia or atypical lymphocytes , and internal organ involvement ( hepatitis , nephritis , pneumonitis , myocarditis , and colitis ) . aromatic antiepileptic drugs such as phenytoin , carbamazepine , and phenobarbital are the most common causes of dress although other drugs such as lamotrigine , valproic acid , allopurinol , minocycline , sulfasalazine , dapsone , gold salts , nonsteroidal anti - inflammatory drugs and antiretroviral drugs such as nevirapine , abacavir , and beta - lactam antibiotics may also cause dress . the pathogenesis proposed is a failure of detoxification of the drugs led to the accumulation of toxic metabolites and arene oxides which may trigger immunological cascade through cd4 + t and cd8 + t cells which , in turn , releases interleukin-5 leading to the activation of eosinophil . reactivation of herpes virus , including epstein  barr virus and human herpes virus-6 , 7 , is also implicated in the pathogenesis of dress . the diagnosis is difficult and challenging and often confuses the treating physician as symptoms mimic various infections , intoxication , neoplasia , and rheumatological diseases . to properly evaluate and diagnose dress , different criteria have been framed and among all , regiscar criteria scoring system is most widely accepted now [ table 1 ] . registry of severe cutaneous adverse reactions criteria for diagnosing drug rash with eosinophilia and systemic symptoms oxcarbazepine is a relatively new drug which is a structural derivative of carbamazepine , with a ketone in the place of the carbon  carbon double bond on the dibenzazepine ring at the 10 position ( 10-keto ) [ figure 3 ] . structure of oxcarbazepine dress is a well - known adverse drug reaction with other anticonvulsants , definite oxcarbazepine - induced dress is reported a few , and definite oxcarbazepine - induced dress presenting as exfoliative dermatitis is very rare in literature , to our knowledge . our patient fulfilled all the regiscar criteria and had a score of 9 , so he was marked as the definite case . as per naranjo scale for assessing the causality of adverse drug reaction , the case was marked as probable . the patient was treated as oxcarbazepine - induced dress syndrome , and he showed uneventful recovery with steroids and on discontinuation of the offending drug . early withdrawal of offending medication or dechallenge is the first and foremost step of the treatment . glucocorticoids still remain the most widely used agent for the treatment of dress syndrome although relapse can occur during tapering of glucocorticoids . other modalities such as the use of intravenous immunoglobulins and n - acetylcysteine are also reported in literature . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
drug rash with eosinophilia and systemic symptoms ( dress ) syndrome is a type of severe adverse cutaneous drug reaction characterized by fever , skin eruption , hematological abnormalities , and internal organ involvement . although anticonvulsant drugs are mainly implicated in dress , newer anticonvulsants such as oxcarbazepine - induced definite cases of dress syndrome are rare and oxcarbazepine - induced dress syndrome presenting as exfoliative dermatitis is even rarer . 
 we report a case of a 35-year - old male who developed dress syndrome presenting as exfoliative dermatitis after taking oxcarbazepine for 3 weeks .