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.