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Atypical presentations of DRESS syndrome, including elevated liver enzymes and acute respiratory distress syndrome, have previously been reported in rare cases. Here, we describe an otherwise healthy male patient in his mid-50s who presented with a rash, myalgia, shortness of breath and delayed eosinophilia that rapidly progressed to acute respiratory failure with hypoxia after starting trimethoprim-sulfamethoxazole. Prompt identification and treatment of atypical manifestations of DRESS syndrome is critical to reduce morbidity and mortality.<\/jats:p>","DOI":"10.1136\/bcr-2024-262253","type":"journal-article","created":{"date-parts":[[2025,5,8]],"date-time":"2025-05-08T03:10:20Z","timestamp":1746673820000},"page":"e262253","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["DRESS syndrome presenting with acute hypoxic respiratory failure and delayed eosinophilia"],"prefix":"10.1136","volume":"18","author":[{"given":"Audrey","family":"Lee","sequence":"first","affiliation":[{"name":"Medicine, Albert Einstein College of Medicine, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Avanzato","sequence":"additional","affiliation":[{"name":"Medicine, Albert Einstein College of Medicine, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,5,7]]},"reference":[{"key":"2025082804302451000_18.5.e262253.1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2133.2003.05584.x"},{"key":"2025082804302451000_18.5.e262253.2","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2011.01.017"},{"key":"2025082804302451000_18.5.e262253.3","doi-asserted-by":"crossref","first-page":"693","DOI":"10.1016\/j.jaad.2013.01.033","article-title":"DRESS syndrome: Part I. 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