PICTURE OF THE MONTH Reversible Vegetative State in a Child Due to Drug Reaction with Eosinophilia and Systemic Symptoms Renu Suthar 1 & Naveen Sankhyan 1 & Hansa Shree 1 & Pratibha Singhi 1 Received: 9 August 2016 /Accepted: 16 November 2016 /Published online: 7 December 2016 # Dr. K C Chaudhuri Foundation 2016 A 15-mo-old developmentally normal girl presented with his- tory of fever, erythematous rash, status epilepticus and persis- tently altered consciousness of 6 wk duration. She had 2 epi- sodes of unprovoked generalized tonic-clonic seizures at 12 mo of age and was started on oral phenobarbitone. On ex- amination she was febrile, had periorbital puffiness, conjunctivitis, generalized erythroderma (Fig. 1a) with superimposed morbilliform eruptions, fine exfoliation, seborrheic dermatitis, oral cheilitis, alopecia, dystrophic nails, generalized lymphadenopathy and hepatomegaly. Neurological examination showed complete unawareness to surroundings, no meaningful understanding or inter- action, no vocalization, cortical visual and hearing im- pairment, asymmetric quadriparesis (left > right), and continuous choreo-athetoid movements of right upper limb. However her sleep wake cycle and brain stem reflexes were preserved. Investigations showed leukocytosis, anemia, hypereosinophilia (AEC 5600/ μL), thrombocytosis and transaminitis (ALT 4364 U/L). MRI brain at 8 wk of illness showed diffuse cortical atrophy with periventricular T2, FLAIR hyper intensities (Fig. 1b). EEG showed generalized slow waves with absence of sleep markers. Cerebrospinal fluid ex- amination was acellular, with normal proteins, sugar and was negative for HSV1 and HHV6 DNA PCR. She was treated with intravenous methylprednisolone for 5 d, followed by 6 wk oral steroids. Her neurological status gradually improved over 2 mo. Over the ensuing 3 mo she gradually began to understand, her speech and language improved. Drug reaction with eosinophilia and systemic symptoms (DRESS) is characterized by a cutaneous reaction to a drug along with multiorgan involvement. The diagnosis of DRESS in index patient was supported by the onset of symptoms after phenobarbitone use, rash, lymphadenopa- thy, hypereosinophilia and transaminitis. The index child met a definite diagnosis according to the RegiSCAR criteria [1]. Neurological complications in DRESS are infrequent and include meningitis or encephalitis. Encephalopathy, seizures, and focal neurological deficits are reported in a few adults with DRESS [2, 3]. Index patient had persistent vegetative state for 12 wk and responded to immunotherapy. Pathogenesis of cen- tral nervous system (CNS) complications in DRESS is not known; reactivation of HHV6, T cell-mediated delayed Fig. 1 a Photograph of the patient showing diffuse erythroderma, superimposed morbilliform eruptions, alopecia and cheilitis. b T2 weighted axial MRI brain of the patient showing diffuse cortical atrophy, ventriculomegaly, with periventricular white matter hyperintensities (Black arrow) * Pratibha Singhi doctorpratibhasinghi@gmail.com 1 Department of Pediatrics, Unit of Pediatric Neurology and Neurodevelopment, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India Indian J Pediatr (March 2017) 84(3):249–250 DOI 10.1007/s12098-016-2265-1