Dear Editor,

I have read the article titled “Drug-induced enterocolitis, a new condition under consideration” by Marín et al. with great interest.¹ While reading this exciting report of rare and not well-known case studies, a few questions about the first and second cases came to my mind that, if clarified, could be useful for the reader.

What is not discussed in this case report, other than antibiotics, is that the second case, which is different from the first case reported,¹ presented with drug-induced enterocolitis syndrome (DIES) with nonsteroidal anti-inflammatory drugs (NSAIDs) and cross-reactive medications. It has not been reported before, to the best of my knowledge, in Pubmed or other indexes. Apart from amoxicillin and pantoprazole, NSAID becomes the third class of medication in which DIES is seen,^2–4 which makes this case report all the more important.

In the second case,¹ there were also clinical findings (lip edema, pharyngeal pruritus, etc.) that were puzzling and suggested that some immunoglobulin E (IgE)-mediated reaction might also be present in this patient.¹ As generally recognized, the diagnosis of DIES requires the absence of classical IgE-mediated allergic skin manifestations. Also, it was not mentioned whether the vomiting was recurrent or not in the second case.¹ Moreover, the findings with cross-reactive acetylsalicylic acid (ASA) provocation test and partial antihistamine response suggest a partially IgE-mediated reaction. This raises doubts and confusion as to whether this case is a real NSAID-induced DIES or not.

I wonder if blood gas, oxygen saturation, and complete blood count (CBC) tests were done, even though both patients went to the emergency room for blood tests. In DIES cases, laboratory findings such as increased leukocyte counts and neutrophilia, methemoglobinemia, and more are expected. Were they detected in these patients? These were expected parameters in these patients and were considered minor criteria in the near past.^5,6 Again, did these patients have hypotension and hypothermia when they came to the emergency room? These were never mentioned or discussed.

There is no mention of how tolerance to paracetamol was proven.¹ Again, an abbreviation PEOC is used and its acronym is not given. Also, PEOC with cyclooxygenase-2 (COX-2) inhibitor is mentioned.¹ Was this test with COX-2 inhibitor used to look for alternative drugs?

In conclusion, I thank the authors for presenting this high-quality report of two rare cases of DIES, leading to a better understanding of DIES.