Discussion
SDRIFE aka Baboon syndrome, is a well described condition after exposure
to drugs in the general population.1 Three case
reports of SDRIFE have been previously described after use of topical or
systemic tacrolimus, however, we describe a first ever case occurring in
a child after HSCT.4-6 Acute GvHD and viral exanthems
are common causes of skin rashes after HSCT and lead to considerable
morbidity and mortality. HSCT providers are usually not familiar of
conditions like SDRIFE, thereby not even considering it in the
differential diagnoses. Our patient had 6-7 episodes of worsening skin
rashes, clinically consistent with GvHD, between 10 -18 months post
transplantation, during which multiple courses of steroids, plus other
treatment strategies were used.
While the initially our patient had acute GvHD, the later presentations
were attributable to SDRIFE with some overlap in the middle. The
prolonged steroid exposure, associated with side effects commonly
attributed to steroids (cushingoid appearance, weight gain, muscle
wasting, hypertension, decreased bone mineral density and hyperglycemia)
may have been avoided. It is important to keep SDRIFE in the
differential diagnosis of recurrent skin rashes, especially when not
associated with any other systemic signs or symptoms suggestive of acute
GvHD. A skin biopsy is usually very helpful to rule out GvHD enabling
the provider to avoid systemic steroids or other second line therapies
to treat GvHD.
SDRIFE, in comparison to acute skin GvHD, is a diagnosis of exclusion
and a biopsy is essential for its diagnosis. SDRIFE is not a common
diagnosis but is referenced in the literature to occur from a myriad of
causes. The most recent cases reported in the literature include its
occurrence as a reaction to remdesivir,7everolimus,8 and a variety of antibiotics, most
notably doxycycline.9 Within pediatric patients there
are fewer reported examples, but previous cases of SDRIFE have been
noted from augmentin.10 Tacrolimus, specifically, has
also been noted in the literature to cause other skin conditions such as
contact dermatitis. Our case serves as an important example of
considering SDRIFE as a differential diagnosis and avoid potential
exposure to further systemic steroids.