tropical fevers are defined as infections that are prevalent in or are unique to tropical and subtropical regions .
they occur in different parts of the indian subcontinent throughout the year , especially in rainy and postrainy season .
these fevers include leptospirosis , enteric fever , malaria , dengue , scrub typhus ( can be remembered as mnemonic lemds ) and some other fevers .
they have overlapping clinical presentation , multi - system involvement , require intensive care unit ( icu ) care , and are associated with high morbidity and mortality .
clinical picture of these diseases is usually so overlapping that it is not always possible to achieve differential diagnosis in emergency and icu settings .
a  syndromic approach  is usually followed for diagnosis and treatment of these infections .
the major five clinical syndromes are undifferentiated fever , fever with rash or thrombocytopenia , fever with acute respiratory distress syndrome , fever with encephalopathy , and fever with multi - organ dysfunction syndrome ( mods ) . here
, we report a case presented in rainy season with fever , rash , and mods , which was initially investigated and managed as tropical fever , but later , a diagnosis of drug rash with eosinophilia and systemic symptoms ( dress ) was established .
a 32-year - old woman presented with fever , skin rash , dyspnea , jaundice , and decreased urine output in the emergency department on july 5 , 2015 . the patient had been well until 10 days before admission when low - grade fever developed .
two days after the onset of fever , she went to a local practitioner and was prescribed oral ciprofloxacin .
next day , she became afebrile but she developed maculopapular skin rash with itching , which started on the bilateral upper limbs and progressed to involve whole body in the next 2448 h [ figure 1 ] .
the same day , she developed shortness of breath which progressed to dyspnea at rest within 2 days with dry cough and orthopnea .
three days before admission , the patient developed jaundice with high - colored urine without cholestatic symptoms , and her urine output reduced to 500 ml / day .
her menstrual cycles were normal , and she was married with two children without abortions . on examination , she was conscious and oriented with blood pressure of 110/56 mm of hg , pulse rate of 110/min , respiratory rate of 26/min , temperature of 39c , and oxygen saturation 96% on oxygen supplementation with fio2 0.5 and flow 12 l / min .
she had icterus , facial and bilateral hand swelling , as well as bilateral symmetrical pitting pedal edema .
there were nontender discrete lymph nodes in the bilateral cervical regions ; the largest was on the right side and measured 2 cm in diameter .
skin rash was diffuse maculopapular involving whole body ( > 90% body surface area ) , nonblanching with occasional pustules .
a presumptive diagnosis of tropical fever with rash and multi - organ involvement was made , and the patient was empirically started of ceftriaxone and doxycycline .
laboratory investigation showed hemoglobin of 9.1 g / dl ; total leukocyte count of 21.2  10/l with 48% neutrophils , 15% lymphocytes , 1% monocytes , and 36% eosinophils ( absolute eosinophil count  7.6 10/l ) ; platelet counts of 281  10/l ; creatinine level of 2.4 mg / dl ; total bilirubin of 7.3 mg / dl with conjugated fraction of 6.7 mg / dl ; aspartate aminotransferase ( ast ) , alanine aminotransferase ( alt ) , and alkaline phosphatase ( alp ) of 1048
iu / l , 965 iu / l , and 332 iu / l , respectively ; international normalized ratio of 1.8 ; and serum albumin of 2.0 g / dl .
serum lipase and amylase levels were 381 u / l and 375 u / l , respectively .
chest x - ray showed bilateral mild pleural effusion and ultrasonography abdomen revealed hepatosplenomegaly with moderate ascites .
rapid kit test and peripheral smear for malaria , serological tests for dengue ( ns1 ag , igm and igg antibody ) , leptospirosis ( igm antibody ) , scrub typhus ( igm antibody ) , widal , viral hepatitis ( hepatitis a virus igm , hepatitis e virus igm , hepatitis b surface antigen , anti - hepatitis c virus antibody ) , hiv elisa , and antinuclear antibody gave negative results .
a skin biopsy was done which was suggestive of drug rash with thinned out epidermis , flattening of rete pegs , spongiosis and vacuolization of dermoepidermal junction , presence of apoptotic keratinocytes , and dermis showing perivascular lymphocytic inflammatory infiltrates .
a diagnosis of dress secondary to ciprofloxacin with hepatic , hematological , renal , and pulmonary involvement was made .
antibiotics were stopped and she was started on prednisolone 1 mg / kg / day , following which she had a rapid improvement in systemic symptoms and eosinophilia . at discharge on july 17 ,
absolute eosinophil count was 0.35  10/l , serum creatinine 0.43 mg / dl , total bilirubin 2.0 mg / dl , and ast , alt , and alp 166 , 335 , and 200 , iu / l respectively .
on outpatient department follow - up , the patient had flare of skin rash on steroid withdrawal .
common culprit drugs are aromatic anticonvulsants , antidepressants , allopurinol , antimicrobials , sulfonamides and sulfones , and nonsteroidal anti - inflammatory drugs .
antimicrobial commonly involved are abacavir , nevirapine , minocycline , linezolid , doxycycline , nitrofurantoin , metronidazole , piperacillin - tazobactam , and ceftriaxone .
rash is symmetric , confluent , pruritic , maculopapular and affects face , upper trunk , upper extremities first , followed by lower extremities .
hepatic involvement occurs in 50%70% cases , which presents as tender hepatomegaly , transaminitis , granulomatous hepatitis , and even fulminant hepatic failure .
renal involvement is seen in 10%30% patients and manifests as hematuria , mild proteinuria , interstitial nephritis , or acute renal failure .
hematological abnormalities occur as eosinophilia , atypical lymphocytosis , and lymphadenopathy . lung ( interstitial pneumonitis , pleural effusion ) ,
heart ( eosinophilic myocarditis , pericarditis ) , pancreas ( pancreatitis ) , muscle ( myositis ) , and other organs may be involved .
the regiscar scoring system is most commonly used criteria to diagnose dress [ table 1 ] .
our case was diagnosed as a definite case of dress with score 8 ( fever > 38c , lymphadenopathy , eosinophilia 36% , typical rash , multi - organ involvement with excluding other potential causes and resolution in > 15 days ) .
regiscar diagnosis score for drug rash with eosinophilia and systemic symptoms prompt diagnosis and withdrawal of the offending drug are important .
high - dose corticosteroids ( 0.51 mg / kg / day ) are the cornerstone of therapy .
a dramatic improvement is seen soon after corticosteroids ; however , it should be slowly tapered while the function of affected organs is closely monitored to minimize recurrences .
 we report a case of ciprofloxacin - related drug rash with eosinophilia and systemic symptoms ( dress ) which was initially diagnosed and managed on the line of tropical fever . 
 later , a diagnosis of definite case of dress was made according to the regiscar scoring system and the patient was managed with the removal of ciprofloxacin along with steroids . 
 dress is a great masquerader 
 . the diagnosis should be highly suspected in the presence of fever , skin rash , liver involvement , and hypereosinophilia . 
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