Derm Cases · Dermatology / Clinical pharmacology / Allergy
OSCE — fever, rash and eosinophilia after a new drug: DRESS/AGEP/morbilliform spectrum
An 8-minute OSCE station distinguishing morbilliform exanthem from DRESS and AGEP, applying latency and RegiSCAR concepts, stopping culprits, and outlining SCAR-level management.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station distinguishing morbilliform exanthem from DRESS and AGEP, applying latency and RegiSCAR concepts, stopping culprits, and outlining SCAR-level management.
Brief (to candidate)
A 45-year-old woman started allopurinol 5 weeks ago. She now has fever, facial oedema, a widespread morbilliform rash, cervical lymphadenopathy, ALT 180 U/L and eosinophils 1.8 × 10⁹/L. You have 8 minutes to classify the reaction, name likely culprits, and manage safely.
Candidate instructions
- Classify the reaction (DRESS vs morbilliform vs AGEP vs SJS/TEN).
- Use latency and drug list to identify the culprit.
- Apply RegiSCAR-type diagnostic criteria for DRESS.
- Stop the drug and outline first-line management.
- Plan organ monitoring and long-term counselling (cross-reactivity, future labelling).
- Safety-net for deterioration (mucosal necrolysis, shock).
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Pattern recognition | Latency 2–8 weeks, fever, facial oedema, morbilliform/exfoliative rash, lymphadenopathy, eosinophilia, hepatitis → DRESS/DIHS, not simple viral exanthem[1][2] |
| Differential SCAR | AGEP: sterile pustules, fever, latency often <4 days, beta-lactams/macrolides; SJS/TEN: pain, necrolysis, mucosal erosions; morbilliform: milder, no organ failure[5][3] |
| Culprits | Classic DRESS drugs: allopurinol, aromatic anticonvulsants, sulfonamides, minocycline, vancomycin, etc.; consider HLA associations (e.g. allopurinol HLA-B*5801 in some populations)[1][4] |
| Work-up | Stop culprit; FBC (eos), LFTs, renal, CRP; viral serologies as needed; RegiSCAR scoring; consider biopsy if uncertain; exclude infection/sepsis mimics[2] |
| Management | Immediate drug withdrawal; systemic corticosteroids for moderate–severe DRESS with organ involvement; supportive care; slow steroid taper (flare risk); ICU/derm if severe[1][2] |
| AGEP note | Stop drug; often self-limited with supportive care ± topical/short systemic steroids; distinguish from pustular psoriasis and candidiasis[5] |
| Communication | Document allergy prominently; warn about cross-reactive agents; delayed relapse possible as steroids taper |
Model key actions
- Diagnose DRESS using latency + systemic features after allopurinol.[1][4]
- Stop the culprit immediately; start systemic steroids when organ involvement is present; monitor LFTs/renal/FBC.[2]
- Differentiate from AGEP and SJS/TEN using morphology and timing.[3][5]
Common errors
- Calling DRESS a "simple drug rash" and continuing the culprit.
- Missing organ involvement (liver/kidney/heart/lung).
- Confusing DRESS latency (weeks) with AGEP (days) or urticaria (hours).
- Rapid steroid stop without plan for flare.
- No allergy documentation or future-avoidance counselling.
References5ShowHide
- [1]Calle AM, Aguirre N, Ardila JC, et al. DRESS syndrome: A literature review and treatment algorithm. The World Allergy Organization journal, 2023.PMID 37082745
- [2]Cabañas R, Ramírez E, Sendagorta E, et al. Spanish Guidelines for Diagnosis, Management, Treatment, and Prevention of DRESS Syndrome. Journal of investigational allergology & clinical immunology, 2020.PMID 31932268
- [3]Wilkerson RG. Drug Hypersensitivity Reactions. Immunology and allergy clinics of North America, 2023.PMID 37394254
- [4]Sharifzadeh S, Mohammadpour AH, Tavanaee A, et al. Antibacterial antibiotic-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: a literature review. European journal of clinical pharmacology, 2021.PMID 33025080
- [5]Parisi R, Shah H, Navarini AA, et al. Acute Generalized Exanthematous Pustulosis: Clinical Features, Differential Diagnosis, and Management. American Journal of Clinical Dermatology, 2023.PMID 37156992