A 31-year-old woman was admitted to the hospital for the treatment of newly diagnosed drug-resistant (pre-extensively drug resistant) pulmonary tuberculosis (chest X-ray at time of diagnosis - Fig. 1). She was treated with second-line antituberculosis drugs: moxifloxacin, kanamycin, cycloserine, prothionamide, para-aminosalicylic acid. After 3 weeks of therapy she developed high fever (> 39 C), lymphadenopathy in the cervical and axillary regions and pruritic maculopapular eruption all over the body (Fig. 2). Hematologic abnormalities such as leukocytosis with eosinophilia (1.81 x 109/l) and monocytosis (1.85 x 109/l) were detected in peripheral blood of the patient. Hepatitis was asymptomatic and detected by the evaluation of liver function: serum aspartate aminotransferase (AST) 1379 IU/l and alanine aminotransferase (ALT) 1221 IU/l; levels of liver enzymes were increased by approximately 30-40-fold above the normal limits. The positive diagnosis of Epstein-Barr infection was based on the onset of increase in the anti-Epstein-Barr immunoglobulin (Ig) G titer (> 200 U/ml), implicating Epstein-Barr virus re-activation. Based on the clinic and laboratory findings diagnosis of DiHS/DRESS was suspected, and all the drugs were discontinued. Symptoms and laboratory abnormalities gradually resolved over 4 weeks without additional treatment.
A patch test was performed and analyzed according to the recommendations. The results of the patch test are presented in Table 1 and Figure 3. Treatment was adjusted to ethambutol, kanamycin, cycloserine, pyrazinamide, and linezolid, and no new symptoms were observed.