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Wei BM, Fox LP, Kaffenberger BH, Korman AM, Micheletti RG, Mostaghimi A, Noe MH, Rosenbach M, Shinkai K, Kwah JH, Phillips EJ, Bolognia JL, Damsky W, Nelson CA. Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part II diagnosis and management. J Am Acad Dermatol 2024; 90:911-926. [PMID: 37516356 DOI: 10.1016/j.jaad.2023.02.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/11/2023] [Accepted: 02/17/2023] [Indexed: 07/31/2023]
Abstract
Drug-induced hypersensitivity syndrome, also known as drug reaction with eosinophilia and systemic symptoms, is a severe cutaneous adverse reaction characterized by an exanthem, fever, and hematologic and visceral organ involvement. The differential diagnosis includes other cutaneous adverse reactions, infections, inflammatory and autoimmune diseases, and neoplastic disorders. Three sets of diagnostic criteria have been proposed; however, consensus is lacking. The cornerstone of management is immediate discontinuation of the suspected drug culprit. Systemic corticosteroids remain first-line therapy, but the literature on steroid-sparing agents is expanding. Longitudinal evaluation for sequelae is recommended. Adjunctive tests for risk stratification and drug culprit identification remain under investigation. Part II of this continuing medical education activity begins by exploring the differential diagnosis and diagnosis of drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms and concludes with an evidence-based overview of evaluation and treatment.
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Affiliation(s)
- Brian M Wei
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | | | - Abraham M Korman
- Department of Dermatology, The Ohio State University, Columbus, Ohio
| | - Robert G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arash Mostaghimi
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Megan H Noe
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, California
| | - Jason H Kwah
- Department of Medicine, Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jean L Bolognia
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - William Damsky
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Caroline A Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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2
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Hung SI, Mockenhaupt M, Blumenthal KG, Abe R, Ueta M, Ingen-Housz-Oro S, Phillips EJ, Chung WH. Severe cutaneous adverse reactions. Nat Rev Dis Primers 2024; 10:30. [PMID: 38664435 DOI: 10.1038/s41572-024-00514-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 06/15/2024]
Abstract
Severe cutaneous adverse reactions (SCARs), which include Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (also known as drug-induced hypersensitivity syndrome), acute generalized exanthematous pustulosis, and generalized bullous fixed drug eruption, are life-threatening conditions. The pathogenesis of SCARs involves T cell receptors recognizing drug antigens presented by human leukocyte antigens, triggering the activation of distinct T cell subsets. These cells interact with keratinocytes and various immune cells, orchestrating cutaneous lesions and systemic manifestations. Genetic predisposition, impaired drug metabolism, viral reactivation or infections, and heterologous immunity influence SCAR development and clinical presentation. Specific genetic associations with distinct SCAR phenotypes have been identified, leading to the implementation of genetic screening before prescription in various countries to prevent SCARs. Whilst systemic corticosteroids and conventional immunomodulators have been the primary therapeutic agents, evolving strategies, including biologics and small molecules targeting tumour necrosis factor, different cytokines, or Janus kinase signalling pathways, signify a shift towards a precision management paradigm that considers individual clinical presentations.
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Affiliation(s)
- Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department and Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Mayumi Ueta
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saskia Ingen-Housz-Oro
- Dermatology Department, AP-HP, Henri Mondor Hospital, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Université Paris Est Créteil EpiDermE, Créteil, France
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei/Linkou branches, and Chang Gung University, Taoyuan, Taiwan.
- Department of Dermatology, Chang Gung Memorial Hospital, Xiamen branch, Xiamen, China.
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3
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Brüggen MC, Walsh S, Ameri MM, Anasiewicz N, Maverakis E, French LE, Ingen-Housz-Oro S. Management of Adult Patients With Drug Reaction With Eosinophilia and Systemic Symptoms: A Delphi-Based International Consensus. JAMA Dermatol 2024; 160:37-44. [PMID: 37966824 PMCID: PMC10652220 DOI: 10.1001/jamadermatol.2023.4450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/28/2023] [Indexed: 11/16/2023]
Abstract
Importance Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal drug hypersensitivity reaction. To our knowledge, there is no international consensus on its severity assessment and treatment. Objective To reach an international, Delphi-based multinational expert consensus on the diagnostic workup, severity assessment, and treatment of patients with DRESS. Design, Setting, and Participants The Delphi method was used to assess 100 statements related to baseline workup, evaluation of severity, acute phase, and postacute management of DRESS. Fifty-seven international experts in DRESS were invited, and 54 participated in the survey, which took place from July to September 2022. Main Outcomes/Measures The degree of agreement was calculated with the RAND-UCLA Appropriateness Method. Consensus was defined as a statement with a median appropriateness value of 7 or higher (appropriate) and a disagreement index of lower than 1. Results In the first Delphi round, consensus was reached on 82 statements. Thirteen statements were revised and assessed in a second round. A consensus was reached for 93 statements overall. The experts agreed on a set of basic diagnostic workup procedures as well as severity- and organ-specific further investigations. They reached a consensus on severity assessment (mild, moderate, and severe) based on the extent of liver, kidney, and blood involvement and the damage of other organs. The panel agreed on the main lines of DRESS management according to these severity grades. General recommendations were generated on the postacute phase follow-up of patients with DRESS and the allergological workup. Conclusions and Relevance This Delphi exercise represents, to our knowledge, the first international expert consensus on diagnostic workup, severity assessment, and management of DRESS. This should support clinicians in the diagnosis and management of DRESS and constitute the basis for development of future guidelines.
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Affiliation(s)
- Marie-Charlotte Brüggen
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
| | - Sarah Walsh
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
- Department of Dermatology, King’s College Hospital, London, England, United Kingdom
| | - M. Milad Ameri
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
| | - Natalie Anasiewicz
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Emanual Maverakis
- Department of Dermatology, University of California, Davis, Sacramento, California
| | - Lars E. French
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Saskia Ingen-Housz-Oro
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
- Department of Dermatology, Henri Mondor University Hospital, University of Paris-Est Créteil, Créteil, France
- Toxic Bullous Dermatoses TOXIBUL Reference Center, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France
- Univ Paris Est Créteil EpiDermE, Créteil, France
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Wang ZZ, Zeng R, Wu ZW, Wang C, Jiang HQ, Wang HS. Overview and Current Advances in Dapsone Hypersensitivity Syndrome. Curr Allergy Asthma Rep 2023; 23:635-645. [PMID: 37804376 DOI: 10.1007/s11882-023-01109-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE OF REVIEW As a sulfone antibacterial agent, dapsone has been widely used to treat leprosy. Moreover, dapsone is also used in many immune diseases such as herpetic dermatitis because of its anti-inflammatory and immunomodulatory effects. However, dapsone can cause several adverse effects, the most serious being dapsone hypersensitivity syndrome. Dapsone hypersensitivity syndrome is characterized by a triad of eruptions, fever, and organ involvement, which limits the application of dapsone to some extent. RECENT FINDINGS In this article, we review current research about the interaction model between HLA-B*13:01, dapsone, and specific TCR in dapsone-induced drug hypersensitivity. In addition to the proposed mechanisms, we also discussed clinical features, treatment progress, prevalence, and prevention of dapsone hypersensitivity syndrome. These studies reveal the pathogenesis, clinical features, and prevalence from the perspectives of genetic susceptibility and innate and adaptive immunity in dapsone hypersensitivity syndrome, thereby guiding clinicians on how to diagnose, prevent, and treat dapsone hypersensitivity syndrome.
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Affiliation(s)
- Zhen-Zhen Wang
- Hospital of Skin Diseases and Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, St. 12 Jiangwangmiao, Nanjing, Jiangsu, China
| | - Rui Zeng
- Hospital of Skin Diseases and Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, St. 12 Jiangwangmiao, Nanjing, Jiangsu, China
| | - Zi-Wei Wu
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Chen Wang
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hai-Qin Jiang
- Hospital of Skin Diseases and Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, St. 12 Jiangwangmiao, Nanjing, Jiangsu, China.
| | - Hong-Sheng Wang
- Hospital of Skin Diseases and Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, St. 12 Jiangwangmiao, Nanjing, Jiangsu, China.
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China.
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5
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Manieri E, Dondi A, Neri I, Lanari M. Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome in childhood: a narrative review. Front Med (Lausanne) 2023; 10:1108345. [PMID: 37575981 PMCID: PMC10421667 DOI: 10.3389/fmed.2023.1108345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Despite being rare, the Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a serious, possibly fatal condition that may affect both adults and children who may be also burdened by delayed sequelae. It is an adverse drug reaction characterized by widespread skin involvement, fever, lymphadenopathy, visceral involvement, and laboratory abnormalities (eosinophilia, mononucleosis-like atypical lymphocytes). It is more frequently triggered by anticonvulsants, sulphonamides, or antibiotics, the latter being responsible for up to 30% of pediatric cases. The disease typically develops 2-8 weeks after exposure to the culprit medication, with fever and widespread skin eruption; mild viral prodromes are possible. Unfortunately, diagnosis is challenging due to the absence of a reliable test; however, a score by the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) allows to classify suspect patients into no, possible, probable, or definite DRESS cases. Moreover, rapid-onset DRESS syndrome has been described in recent years. It affects children more often than adults and differs from the most common form because it appears ≤15 days vs. >15 days after starting the drug, it is usually triggered by antibiotics or iodinated contrast media rather than by anticonvulsants and has a higher presence of lymphadenopathy. Differential diagnosis between rapid-onset antibiotic-driven DRESS syndrome, viral exanthems, or other drug eruptions may be challenging, but it is mandatory to define it as early as possible to start adequate treatment and monitor possible complications. The present review reports the latest evidence about the diagnosis and treatment of pediatric DRESS syndrome.
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Affiliation(s)
- Elisa Manieri
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Arianna Dondi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Iria Neri
- Division of Dermatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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6
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Zhu H, Ren V. Immunopathogenic Insights on Preferential Human Herpesvirus-6 Reactivation in Drug Rash With Eosinophilia and Systemic Symptoms: A Scoping Review. J Cutan Med Surg 2023; 27:388-398. [PMID: 37231539 PMCID: PMC10523827 DOI: 10.1177/12034754231177590] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/14/2023] [Accepted: 04/28/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Human herpesvirus-6 (HHV-6) is a ubiquitous lymphotropic betaherpesvirus that can reactivate in drug rash with eosinophilia and systemic symptoms (DRESS). Despite recent publications advancing our understanding of HHV-6 in DRESS, the exact role of HHV-6 in disease pathogenesis remains unclear. METHODS A scoping review with the PubMed query "(HHV 6 AND (drug OR DRESS OR DIHS)) OR (HHV6 AND (drug OR DRESS OR DIHS))" was conducted in accordance with PRISMA guidelines. Articles containing original data on at least one DRESS patient with HHV-6 testing were included. RESULTS Our search returned a total of 373 publications, of which 89 met eligibility criteria. HHV-6 reactivation occurred in 63% of DRESS patients (n = 748), which was significantly more often than other herpesviruses. HHV-6 reactivation was associated with worse outcomes and greater severity in controlled studies. Case reports have demonstrated sometimes fatal HHV-6-related multi-organ involvement. Temporally, HHV-6 reactivation typically occurs 2 to 4 weeks after DRESS onset and has been linked to markers of immunologic signaling, such as OX40 (CD134), an HHV-6 entry receptor. Efficacy of antiviral or immunoglobulin treatment has only been demonstrated anecdotally, and steroid use may affect HHV-6 reactivation. CONCLUSION HHV-6 is implicated in DRESS more than in any other dermatologic condition. It is still unclear whether HHV-6 reactivation is cause or consequence of DRESS dysregulation. Similar pathogenic mechanisms precipitated by HHV-6 in other contexts may be relevant in DRESS. Future randomized controlled studies to assess effects of viral suppression on clinical outcomes is needed.
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Affiliation(s)
- Harrison Zhu
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
- HHV-6 Foundation, Santa Barbara, CA, USA
| | - Vicky Ren
- Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
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Chen CB, Hung WK, Wang CW, Lee CC, Hung SI, Chung WH. Advances in understanding of the pathogenesis and therapeutic implications of drug reaction with eosinophilia and systemic symptoms: an updated review. Front Med (Lausanne) 2023; 10:1187937. [PMID: 37457584 PMCID: PMC10338933 DOI: 10.3389/fmed.2023.1187937] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/05/2023] [Indexed: 07/18/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms or drug-induced hypersensitivity syndrome (DRESS/DIHS) is one type of severe cutaneous adverse reaction (SCAR). It is featured by fever, widespread skin lesions, protracted clinical course, internal organ involvement, and possibly long-term autoimmune sequelae. The presence of high-risk human leukocyte antigen (HLA) alleles, hypersensitivity reaction after culprit drug ingestion, and human herpesvirus reactivation may all contribute to its complex clinical manifestations. Some recent studies focusing on the roles of involved cytokines/chemokines and T cells co-signaling pathways in DRESS/DIHS were conducted. In addition, some predictors of disease severity and prognosis were also reported. In this review, we provided an update on the current understanding of the pathogenesis, potential biomarkers, and the relevant therapeutic rationales of DRESS/DIHS.
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Affiliation(s)
- Chun-Bing Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wei-Kai Hung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
| | - Chih-Chun Lee
- Department of Medical Education, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
- Department of Dermatology, Beijing Tsinghua Chang Gung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
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8
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Kridin K, Brüggen MC, Walsh S, Bensaid B, Ranki A, Oppel E, Meyersburg D, Chua SL, Seeli C, Sandberg H, French LE, Vorobyev A, Ingen-Housz-Oro S. Management and treatment outcome of DRESS patients in Europe: An international multicentre retrospective study of 141 cases. J Eur Acad Dermatol Venereol 2023; 37:753-762. [PMID: 36479739 DOI: 10.1111/jdv.18808] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal drug hypersensitivity reaction. OBJECTIVE To explore treatment approaches across Europe and their impact on the disease course, as well as prognostic factors and culprit drugs. METHODS In this retrospective European multicentric study, we included patients with probable or certain DRESS (RegiSCAR score ≥ 4) between January 2016 and December 2020. Independent associations between clinical parameters and the risk of intensive care unit admission and mortality at three months were assessed using a multivariable-adjusted logistic regression model. RESULTS A total of 141 patients from 8 tertiary centres were included. Morbilliform exanthem was the most frequent cutaneous manifestation (78.0%). The mean affected body surface area (BSA) was 67%, 42% of the patients presented with erythroderma, and 24.8% had mucosal involvement. Based on systemic involvement, 31.9% of the patients had a severe DRESS. Anticonvulsants (24.1%) and sulphonamides (22.0%) were the most frequent causative agents. In all, 73% of the patients were treated with systemic glucocorticoids, and 25.5% received topical corticosteroids as monotherapy. Few patients received antiviral drugs or anti-IL5. No patients received intravenous immunoglobulins. The overall mortality was 7.1%. Independent predictors of mortality were older age (≥57.0 years; fully adjusted OR, 9.80; 95% CI, 1.20-79.93; p = 0.033), kidney involvement (fully adjusted OR, 4.70; 95% CI, 1.00-24.12; p = 0.049), and admission in intensive care unit (fully adjusted OR, 8.12; 95% CI, 1.90-34.67; p = 0.005). Relapse of DRESS and delayed autoimmune sequelae occurred in 8.5% and 12.1% of patients, respectively. CONCLUSIONS This study underlines the need for diagnostic and prognostic scores/markers as well as for prospective clinical trials of drugs with the potential to reduce mortality and complications of DRESS.
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Affiliation(s)
- Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Marie-Charlotte Brüggen
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Medical Campus Davos, Davos, Switzerland.,ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin)
| | - Sarah Walsh
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, King's College Hospital, London, UK
| | - Benoit Bensaid
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France.,Department of Dermatology, Edouard Herriot Hospital, Lyon, France
| | - Annamari Ranki
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, Allergology and Venereology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Helsinki, Finland
| | - Eva Oppel
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany
| | - Damian Meyersburg
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology and Allergology, University Hospital Salzburg of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ser-Ling Chua
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Corsin Seeli
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Heidi Sandberg
- Department of Dermatology, Allergology and Venereology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Helsinki, Finland
| | - Lars E French
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany.,Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Artem Vorobyev
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Saskia Ingen-Housz-Oro
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France.,Department of Dermatology, AP-HP, Henri Mondor Hospital, Créteil, France.,Univ Paris Est Créteil EpiDermE, Créteil, France
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9
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Calle AM, Aguirre N, Ardila JC, Cardona Villa R. DRESS syndrome: A literature review and treatment algorithm. World Allergy Organ J 2023; 16:100673. [PMID: 37082745 PMCID: PMC10112187 DOI: 10.1016/j.waojou.2022.100673] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 06/11/2022] [Accepted: 07/05/2022] [Indexed: 04/22/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms, known by its acronym in English as DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms), clinically manifests with fever, facial edema, lymphadenopathy, a morbilliform rash, and organ involvement. Laboratory results reveal leukocytosis, atypical lymphocytes, eosinophilia, and alterations of liver and kidney function tests. The actual incidence of DRESS is unknown, because it may vary depending on the type of medication and the immune status of each patient; also, because many cases remain undiagnosed or untreated. The drugs most associated with DRESS include antiepileptics, antibiotics, antituberculosis, and non-steroidal anti-inflammatory agents (NSAIDs). Its diagnosis is sometimes made late and can become a challenge. The diagnostic criteria proposed by the international Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) help to establish the diagnosis through a score system based on clinical and laboratory findings. The first step to identify the culprit is a thorough clinical history that includes all suspects, emphasizing those most known to cause DRESS syndrome according to the context and the literature. A skin biopsy may also be helpful in the diagnostic process. Patch testing is the test of choice to search for the culprit in cases of DRESS. Regarding prognosis, the estimated mortality due to DRESS is 3.8%. The main causes of mortality include fulminant hepatitis and liver necrosis. Several indicators of poor prognosis have been identified and these include an eosinophil count above 6000 × 103/μL, thrombocytopenia, pancytopenia, leukocytosis and coagulopathy. This article aims to review the evidence available regarding the epidemiology, pathophysiology, clinical and laboratory findings, diagnosis, and treatment of DRESS.
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Affiliation(s)
- Ana María Calle
- Grupo de Alergología Clínica y Experimental (GACE), Universidad de Antioquia, Medellín, Colombia
- Clinical Allergologist, Universidad de Antioquia, Medellín, Colombia
| | - Natalia Aguirre
- Grupo de Alergología Clínica y Experimental (GACE), Universidad de Antioquia, Medellín, Colombia
- Clinical Allergologist Resident, Universidad de Antioquia, Medellín, Colombia
- Corresponding author. Clinical Allergology Resident, Universidad de Antioquia, Medellín, Colombia.
| | - Juan Camilo Ardila
- Grupo de Alergología Clínica y Experimental (GACE), Universidad de Antioquia, Medellín, Colombia
- Clinical Allergologist Resident, Universidad de Antioquia, Medellín, Colombia
| | - Ricardo Cardona Villa
- Grupo de Alergología Clínica y Experimental (GACE), Universidad de Antioquia, Medellín, Colombia
- Clinical Allergologist, Universidad de Antioquia, Medellín, Colombia
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10
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Shen Q, Wang Q, Zang H, Yu L, Cong X, Chen X, Chen L. DRESS/DiHS syndrome induced by Propylthiouracil: a case report. BMC Endocr Disord 2023; 23:22. [PMID: 36691013 PMCID: PMC9869506 DOI: 10.1186/s12902-023-01273-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS), also known as Drug-induced hypersensitivity syndrome (DiHS), is a severe adverse drug reaction. Propylthiouracil, a member of thiouracils group, is widely used in medical treatment of hyperthyroidism. Propylthiouracil is associated with multiple adverse effects such as rash, agranulocytosis hepatitis and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, but rarely triggers DRESS/DiHS syndrome. Here, we describe a severe case of propylthiouracil-induced DRESS/DiHS syndrome. CASE PRESENTATION A 38-year-old female was treated with methimazole for hyperthyroidism at first. 4 weeks later, the patient developed elevated liver transaminase so methimazole was stopped. After liver function improved in 2 weeks, medication was switched to propylthiouracil therapy. The patient subsequently developed nausea and rash followed by a high fever, acute toxic hepatitis and multiple organ dysfunction (liver, lung and heart), which lasted for 1 month after propylthiouracil was started. According to the diagnostic criteria, the patient was diagnosed of DRESS/DiHS syndrome which was induced by propylthiouracil. As a result, propylthiouracil was immediately withdrawn. And patient was then treated with adalimumab, systematic corticosteroids and plasmapheresis in sequence. Symptoms were finally resolved 4 weeks later. CONCLUSIONS Propylthiouracil is a rare cause of the DRESS/DiHS syndrome, which typically consists of severe dermatitis and various degrees of internal organ involvement. We want to emphasize through this severe case that DRESS/DiHS syndrome should be promptly recognized to hasten recovery.
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Affiliation(s)
- Qiong Shen
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Qingyao Wang
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Huanhuan Zang
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Ling Yu
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Xiangguo Cong
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Xinxin Chen
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China.
| | - Lei Chen
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China.
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11
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Rubin L, Talmon A, Ribak Y, Kessler A, Martin Y, Haran TK, Shamriz O, Adini I, Tal Y. Novel targeted inhibition of the IL-5 axis for drug reaction with eosinophilia and systemic symptoms syndrome. Front Immunol 2023; 14:1134178. [PMID: 37187735 PMCID: PMC10175640 DOI: 10.3389/fimmu.2023.1134178] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
Background The drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome represents a severe hypersensitivity reaction. Up-to-date treatment is based on withdrawal of medication, supportive care, and immunosuppression using high-dose corticosteroid (CS) therapy. However, evidence-based data are lacking regarding second-line therapy for steroid-resistant or steroid-dependent patients. Objectives We hypothesize that the interleukin (IL)-5 axis plays a critical role in the pathophysiology of DRESS; hence, inhibition of this signaling pathway could offer a potential therapy for steroid-dependent and/or steroid-resistant cases, and it may offer an alternative to CS therapy in certain patients more prone to CS toxicity. Methods Herein, we collected worldwide data on DRESS cases treated with biological agents targeting the IL-5 axis. We reviewed all cases indexed in PubMed up to October 2022 and performed a total analysis including our center experience with two additional novel cases. Results A review of the literature yielded 14 patients with DRESS who were treated with biological agents targeting the IL-5 axis as well as our two new cases. Reported patients are characterized by a female-to-male ratio of 1:1 and a mean age of 51.8 (17-87) years. The DRESS-inducing drugs, as expected from the prospective RegiSCAR study, were mostly antibiotics (7/16), as follows: vancomycin, trimethoprim-sulfamethoxazole, ciprofloxacin, piperacillin-tazobactam, and cefepime. DRESS patients were treated with anti-IL-5 agents (mepolizumab and reslizumab) or anti-IL-5 receptor (IL-5R) biologics (benralizumab). All patients have clinically improved under anti-IL-5/IL-5R biologics. Multiple doses of mepolizumab were needed to achieve clinical resolution, whereas a single dose of benralizumab was often sufficient. Relapse was noted in one patient receiving benralizumab treatment. One patient receiving benralizumab had a fatal outcome, although mortality was probably related to massive bleeding and cardiac arrest due to coronavirus disease 2019 (COVID-19) infection. Conclusion Current treatment guidelines for DRESS are based on case reports and expert opinion. Understanding the central role of eosinophils in DRESS pathogenicity emphasizes the need for future implementation of IL-5 axis blockade as steroid-sparing agents, potential therapy to steroid-resistant cases, and perhaps an alternative to CS treatment in certain DRESS patients more prone to CS toxicity.
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Affiliation(s)
- Limor Rubin
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aviv Talmon
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yaarit Ribak
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Asa Kessler
- Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yossi Martin
- Psychiatric Department, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tal Keidar Haran
- Department of Pathology, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Oded Shamriz
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Lautenberg Center for Immunology and Cancer Research, Institute of Medical Research Israel-Canada, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- *Correspondence: Oded Shamriz, ; Yuval Tal,
| | - Irit Adini
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Yuval Tal
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- *Correspondence: Oded Shamriz, ; Yuval Tal,
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12
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Desai AS, Dudzinski DM, Stib MT, Chen ST, Newton-Cheh C, Blumenthal KG, Stone JR. Case 32-2022: A 76-Year-Old Man with Postoperative Cardiogenic Shock and Diffuse Rash. N Engl J Med 2022; 387:1502-1513. [PMID: 36260795 DOI: 10.1056/nejmcpc2201245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Akshay S Desai
- From the Department of Medicine, Brigham and Women's Hospital (A.S.D.), the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - David M Dudzinski
- From the Department of Medicine, Brigham and Women's Hospital (A.S.D.), the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - Matthew T Stib
- From the Department of Medicine, Brigham and Women's Hospital (A.S.D.), the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - Steven T Chen
- From the Department of Medicine, Brigham and Women's Hospital (A.S.D.), the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - Christopher Newton-Cheh
- From the Department of Medicine, Brigham and Women's Hospital (A.S.D.), the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - Kimberly G Blumenthal
- From the Department of Medicine, Brigham and Women's Hospital (A.S.D.), the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - James R Stone
- From the Department of Medicine, Brigham and Women's Hospital (A.S.D.), the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., S.T.C., C.N.-C., K.G.B.), Radiology (M.T.S.), Dermatology (S.T.C.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
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13
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Ilina YV, Fedorova TA, Tazina SY, Sotnikova TI, Semenenko NA, Loshchits NV, Bolshakov SA, Kiseleva NV, Pavlov CS. DRESS syndrome on the background of adding meropenem to carbamazepine therapy: a clinical case. SECHENOV MEDICAL JOURNAL 2022. [DOI: 10.47093/2218-7332.2022.407.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Yu. V. Ilina
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T. A. Fedorova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S. Y. Tazina
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T. I. Sotnikova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N. A. Semenenko
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N. V. Loshchits
- City Clinical Hospital named after S.P. Botkin of the Moscow Healthcare Department
| | - S. A. Bolshakov
- City Clinical Hospital named after S.P. Botkin of the Moscow Healthcare Department
| | - N. V. Kiseleva
- Sechenov First Moscow State Medical University (Sechenov University)
| | - Ch. S. Pavlov
- Sechenov First Moscow State Medical University (Sechenov University)
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14
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Shields BE, Wanat KA, Chiu YE. Undiagnosed and Rare Diseases in Critical Care. Crit Care Clin 2022; 38:243-269. [DOI: 10.1016/j.ccc.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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15
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Gottlieb M, Figlewicz MR, Rabah W, Buddan D, Long B. Drug reaction with eosinophilia and systemic symptoms: An emergency medicine focused review. Am J Emerg Med 2022; 56:1-6. [PMID: 35338896 DOI: 10.1016/j.ajem.2022.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/10/2022] [Accepted: 03/13/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe drug reaction associated with potentially severe morbidity and mortality. OBJECTIVE This narrative review evaluates the pathogenesis, diagnosis, and management of DRESS for emergency clinicians. DISCUSSION DRESS is a severe hypersensitivity reaction which can involve multiple organ systems, including the skin, lymphatic system, lungs, kidneys, and heart. Treatment is primarily supportive care combined with removal of the offending agent and initiation of corticosteroids. Additional options include cyclophosphamide, cyclosporine, intravenous immunoglobulin, and N-acetylcysteine. CONCLUSION It is important for the emergency clinician to be aware of the diagnosis and management of DRESS in order to best optimize care for these patients.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, USA.
| | | | - Willeed Rabah
- Department of Emergency Medicine, Rush University Medical Center, USA
| | - Devon Buddan
- Department of Emergency Medicine, Rush University Medical Center, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, USA
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Sim DW, Yu J, Koh YI. Efficacy of add-on therapy with intravenous immunoglobulin in steroid hyporesponsive DRESS syndrome. Clin Transl Sci 2021; 15:782-788. [PMID: 34796665 PMCID: PMC8932711 DOI: 10.1111/cts.13201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/18/2021] [Accepted: 11/08/2021] [Indexed: 12/17/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare, potentially life-threatening, delayed, drug-induced hypersensitivity reaction. Immediate withdrawal of the culprit drug and administration of systemic corticosteroids is the most widely accepted treatment. However, it is difficult to manage patients with DRESS syndrome who are not responsive to systemic steroids. We studied the efficacy of intravenous immunoglobulins (IVIGs) in patients with DRESS syndrome unresponsive to systemic steroids. We retrospectively reviewed patients with DRESS syndrome who received IVIG in addition to systemic steroids during 2012-2017 and compared the clinical features and course of DRESS syndrome, before and after IVIG treatment. Eighteen DRESS patients (9 men) were included. The most frequent offending drugs were dapsone in five patients, followed by vancomycin in three patients, and carbamazepine in three patients. Rash, fever, lymphadenopathy, atypical lymphocytes, and hepatic involvement were common clinical findings. IVIG treatment was added within a median time of 7 days from the commencement of systemic steroid therapy. After IVIG treatment (total dosage: 1-2 g/kg), the fever resolved within a median time of 1 day (range, 0-3) and liver enzymes improved substantially within a median time of 13 days (range, 0-27). No severe adverse reactions related to IVIG therapy were observed in this study; however, there was one case of mortality. The addition of IVIG in DRESS syndrome in cases refractory to systemic steroid treatment may be helpful in hastening recovery. However, comparative studies using a placebo group are needed.
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Affiliation(s)
- Da Woon Sim
- Division of Allergy, Asthma, and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Jieun Yu
- Division of Allergy, Asthma, and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Young-Il Koh
- Division of Allergy, Asthma, and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
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Villanueva-Paz M, Niu H, Segovia-Zafra A, Medina-Caliz I, Sanabria-Cabrera J, Lucena MI, Andrade RJ, Alvarez-Alvarez I. Critical Review of Gaps in the Diagnosis and Management of Drug-Induced Liver Injury Associated with Severe Cutaneous Adverse Reactions. J Clin Med 2021; 10:5317. [PMID: 34830594 PMCID: PMC8618381 DOI: 10.3390/jcm10225317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 12/12/2022] Open
Abstract
Drug-induced liver injury (DILI) encompasses the unexpected damage that drugs can cause to the liver. DILI may develop in the context of an immunoallergic syndrome with cutaneous manifestations, which are sometimes severe (SCARs). Nevirapine, allopurinol, anti-epileptics, sulfonamides, and antibiotics are the most frequent culprit drugs for DILI associated with SCARs. Interestingly, alleles HLA-B*58:01 and HLA-A*31:01 are associated with both adverse reactions. However, there is no consensus about the criteria used for the characterization of liver injury in this context, and the different thresholds for DILI definition make it difficult to gain insight into this complex disorder. Moreover, current limitations when evaluating causality in patients with DILI associated with SCARs are related to the plethora of causality assessment methods and the lack of consensual complementary tools. Finally, the management of this condition encompasses the treatment of liver and skin injury. Although the use of immunomodulant agents is accepted for SCARs, their role in treating liver injury remains controversial. Further randomized clinical trials are needed to test their efficacy and safety to address this complex entity. Therefore, this review aims to identify the current gaps in the definition, diagnosis, prognosis, and management of DILI associated with SCARs, proposing different strategies to fill in these gaps.
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Affiliation(s)
- Marina Villanueva-Paz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
| | - Hao Niu
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Antonio Segovia-Zafra
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Inmaculada Medina-Caliz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
| | - Judith Sanabria-Cabrera
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Plataforma ISCIII de Ensayos Clinicos, UICEC-IBIMA, 29071 Malaga, Spain
| | - M. Isabel Lucena
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Plataforma ISCIII de Ensayos Clinicos, UICEC-IBIMA, 29071 Malaga, Spain
| | - Raúl J. Andrade
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Ismael Alvarez-Alvarez
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
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Zhu WF, Fang DR, Fang H. Drug-induced erythroderma in patients with acquired immunodeficiency syndrome. World J Emerg Med 2021; 12:299-302. [PMID: 34512827 DOI: 10.5847/wjem.j.1920-8642.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/08/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND To explore the clinical manifestations, diagnosis, and treatment of patients with acquired immunodeficiency syndrome (AIDS) complicated with drug-induced erythroderma. METHODS The clinical data of 12 AIDS patients with drug-induced erythroderma in our hospital were retrospectively analyzed. The general information, offending medications, complications, modified severity-of-illness score for toxic epidermal necrolysis (SCORTEN) scores, and disease outcome spectrums were analyzed. RESULTS Drug-induced erythroderma was mostly caused by antiviral drugs, antituberculosis drugs, antibiotics, traditional Chinese medicine, and immune checkpoint inhibitors. The spectrum of sensitizing drugs was broad, the clinical situation was complex, and infections were common. The affected areas were greater than 40% body surface area in all patients. The modified SCOTERN score averaged 3.01±0.99. All patients were treated with glucocorticoids, and nine patients were treated with intravenous immunoglobulin (IVIG) pulse therapy at the same time. The average time to effectiveness was 7.08±2.23 days, and the average hospital stay was 17.92±8.46 days. Eleven patients were cured, and one patient died of secondary multiple infections, who had a modified SCORTEN score of 5 points. The mortality rate in this study was 8.3%. CONCLUSIONS The clinical situation of AIDS patients with drug-induced erythroderma in hospitalized patients is complex and the co-infection rate is high. The use of modified SCORTEN score may objectively and accurately assess the conditions, and the use of glucocorticoid combined with IVIG therapy may improve the prognosis.
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Affiliation(s)
- Wei-Fang Zhu
- Department of Dermatology, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, China
| | - De-Ren Fang
- Department of Dermatology, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hong Fang
- Department of Dermatology, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, China
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Bedouelle E, Ben Said B, Tetart F, Milpied B, Welfringer-Morin A, Maruani A, Catteau B, Dezoteux F, Staumont-Sallé D, Mazereeuw-Hautier J, Abasq C, Chiaverini C, Delaunay J, Mallet S, Sterling B, Puzenat E, Raynal M, Collet E, Bernier C. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Series of 49 French Pediatric Cases. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:267-274.e5. [PMID: 34332174 DOI: 10.1016/j.jaip.2021.07.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare and potentially fatal adverse reaction. It can be difficult to diagnose, even more so among children, because symptoms may mimic other commonly encountered pediatric conditions. OBJECTIVE To describe clinical and laboratory features of DRESS syndrome in the pediatric population (age ≤18 years) and establish causative agents and treatment modalities. METHODS This was a multicenter retrospective study of probable and definite DRESS cases (Registry of Sever Cutaneous Adverse Reaction score ≥ 4) in children hospitalized in 15 French university hospitals between 2000 and 2020. RESULTS We included 49 cases. All children had fever and rash, 69.4% had lymphadenopathy, and 65.3% had facial edema. The most common organ affected was the liver (83.7%). Treatment consisted of topical corticosteroid in only 30.6% and systemic corticosteroid in 55.1%; 12.2% received intravenous immunoglobulin. Among probable and likely culprit drugs, 65% were antibiotics and 27.5% were antiepileptics, median time to DRESS symptom onset after initiation of 15 days (13 days with antibiotics and 21 days with antiepileptics). Twenty-seven children had allergy assessment for causative agents, 65.4% of whom had positive tests. CONCLUSIONS Culprit drugs are frequently antibiotics and antiepileptic drugs, and onset is often less than 2 weeks after treatment starts, especially with antibiotics. Treatment with topical corticosteroids appears to be sufficient in the least severe cases. Treatment by systemic corticosteroid therapy remains the reference treatment in case of severe organ damage.
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Affiliation(s)
- Eve Bedouelle
- Service de Dermatologie, Hôtel Dieu, Centre Hospitalier Universitaire de Nantes, Nantes, France.
| | - Benoit Ben Said
- Service de Dermatologie, Centre Hospitalier Universitaire de Lyon, Lyon, France
| | - Florence Tetart
- Service de Dermatologie, Centre Hospitalier Universitaire de Rouen, Rouen, France; Centre Erik Satie, Unité d'Allergologie, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Brigitte Milpied
- Service de Dermatologie et Dermatologie Pédiatrique, Hôpital Saint-André et Pellegrin, Bordeaux, France
| | - Anne Welfringer-Morin
- Service de Dermatologie, Centre de Référence des Génodermatoses et des Maladies Rares à Expression Cutanée, Assistance Publique Hôpitaux de Paris, Hôpital Necker-Enfants Malades Université de Paris, Paris, France
| | - Annabel Maruani
- Université de Tours, INSERM 1246-SPHERE, Service de Dermatologie, Unité de Dermatologie Pédiatrique, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Benoit Catteau
- Service de Dermatologie Center Hospitalier Universitaire de Lille, Université de Lille, Institute for Translational Research in Inflammation, INSERM, Lille, France
| | - Frédéric Dezoteux
- Service de Dermatologie Center Hospitalier Universitaire de Lille, Université de Lille, Institute for Translational Research in Inflammation, INSERM, Lille, France
| | - Delphine Staumont-Sallé
- Service de Dermatologie Center Hospitalier Universitaire de Lille, Université de Lille, Institute for Translational Research in Inflammation, INSERM, Lille, France
| | | | - Claire Abasq
- Service de Dermatologie, Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | | | - Juliette Delaunay
- Service de Dermatologie, Centre Hospitalier Universitaire d'Angers site Larrey, Angers, France
| | - Stéphanie Mallet
- Service de Dermatologie et Cancérologie Cutanée, Hôpital de la Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Benoit Sterling
- Services de Pédiatrie et Pneumologie Pédiatrique, Hôpital de La Timone-Enfants et Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Eve Puzenat
- Service de Dermatologie, Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | - Margot Raynal
- Service de Dermatologie, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Evelyne Collet
- Service de Dermatologie, Hôpital Le Bocagen, Centre Hospitalier Régional Universitaire de Dijon, Dijon, France
| | - Claire Bernier
- Service de Dermatologie, Hôtel Dieu, Centre Hospitalier Universitaire de Nantes, Nantes, France.
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Drug Allergy and Cutaneous Adverse Reactions. Handb Exp Pharmacol 2021; 268:195-212. [PMID: 34219202 DOI: 10.1007/164_2021_490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Allergy or hypersensitivity to drugs often affects the skin and sometimes also mucosa. While immediate type reactions show a rather homogeneous pattern, delayed type reactions reveal a high variability. In both cases it may not always be easy to differentiate drug reactions from non-drug-induced skin conditions. Furthermore, the different types of cutaneous adverse reactions may be difficult to distinguish in the beginning. This accounts predominately for delayed hypersensitivity reactions that can occur after a variety of medications and present with manifold lesions. Most of these cutaneous adverse reactions are mild, but some are severe with high morbidity and mortality. In the clinical setting, it is important to recognize the signs that point to a more severe condition early on in order to initiate appropriate management. In addition, it is crucial to identify the potentially culprit medication on the basis of a detailed medication history and by evaluating the relevant exposure times of certain drugs that differ substantially between the various reaction types. After the acute stage of the adverse reaction is managed successfully, further allergologic testing may be undertaken to confirm the offending drug.
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21
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Mori F, Blanca-Lopez N, Caubet JC, Demoly P, Du Toit G, Gomes ER, Kuyucu S, Romano A, Soyer O, Tsabouri S, Atanaskovic-Markovic M. Delayed hypersensitivity to antiepileptic drugs in children. Pediatr Allergy Immunol 2021; 32:425-436. [PMID: 33205474 DOI: 10.1111/pai.13409] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antiepileptic drugs (AEDs) are widely used for the treatment of epilepsy, but they can be associated with the development of mainly delayed/non-immediate hypersensitivity reactions (HRs). Although these reactions are usually cutaneous, self-limited, and spontaneously resolve within days after drug discontinuation, sometime HR reactions to AEDs can be severe and life-threatening. AIM This paper seeks to show examples on practical management of AED HRs in children starting from a review of what it is already known in literature. RESULTS Risk factors include age, history of previous AEDs reactions, viral infections, concomitant medications, and genetic factors. The diagnostic workup consists of in vivo (intradermal testing and patch testing) and in vitro tests [serological investigation to exclude the role of viral infection, lymphocyte transformation test (LTT), cytokine detection in ELISpot assays, and granulysin (Grl) in flow cytometry. Treatment is based on a prompt drug discontinuation and mainly on the use of glucocorticoids. CONCLUSION Dealing with AED HRs is challenging. The primary goal in the diagnosis and management of HRs to AEDs should be trying to accurately identify the causal trigger and simultaneously identify a safe and effective alternative anticonvulsant. There is therefore an ongoing need to improve our knowledge of HS reactions due to AED medications and in particular to improve our diagnostic capabilities.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatric Medicine, Meyer Children's Hospital, Florence, Italy
| | | | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
| | - Pascal Demoly
- Département de Pneumologie et Addictologie, Centre Hospitalier Universitaire de Montpellier, Hôpital Arnaud de Villeneuve, univ Montpellier, Montpellier, France.,Institut Pierre-Louis D'épidémiologie et de Santé Publique, Équipe EPAR, Sorbonne Université, INSERM, Paris, France
| | - George Du Toit
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St Thomas', London, UK.,Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Eva R Gomes
- Allergy Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy.,Fondazione Mediterranea G.B. Morgagni, Italy
| | - Ozge Soyer
- Department of Pediatric Allergy, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Sophia Tsabouri
- Department of Paediatrics, Faculty of Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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22
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Román-Chica LM, Díaz-Duarte AM. Pericardial effusion associated with DRESS syndrome. Case report. REVISTA DE LA FACULTAD DE MEDICINA 2021. [DOI: 10.15446/revfacmed.v69n4.86390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: The DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome is a rare but serious and potentially lethal occurrence of a set of signs and symptoms associated with the use certain types of drugs. This syndrome is characterized by a heterogeneous clinical manifestation that, in many cases, results in multisystemic involvement.
Case presentation: A 24-year-old man from Calarcá, Colombia, visited the emergency department of the local hospital due to a three-day history of unquantified intermittent fever associated with asthenia, adynamia, anorexia, headache, myalgia, odynophagia, and upper abdominal pain. Due to his condition and based on laboratory findings, he was referred to the Clínica Central del Quindío. The patient, 20 days before the initial assessment, had been prescribed a pharmacological treatment with non-steroidal anti-inflammatory drugs and phenytoin due to a severe cranioencephalic trauma; he also presented with generalized skin rash, elevated transaminases, and moderate eosinophilia. Complementary studies reported mild pericardial effusion, so DRESS syndrome was suspected, and corticosteroid therapy was started, achieving the complete remission of the syndrome.
Conclusion: Although the DRESS syndrome has a low incidence, it should always be suspected, especially in patients with cardiac and pericardial involvement. In this case, pericardial involvement was evident, demonstrating that individuals with this syndrome may present with rare symptoms that have a serious impact on their health, as they may significantly increase adverse outcomes and mortality risk.
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23
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Tomani M, Caridi C, Tatarina-Nulman O, Charlot C, Narula P. Complicated Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome History in a 14-Year-Old. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e927951. [PMID: 33622999 PMCID: PMC7919229 DOI: 10.12659/ajcr.927951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a drug-induced hypersensitivity reaction that can result in a severe cutaneous adverse drug reaction (SCAR). It is a rare and potentially life-threatening condition that occurs after exposure to sulfonamides, antibiotics, or antiepileptics. Its incidence in children is not established; however, the mortality rate is documented at approximately 10%. DRESS syndrome is believed to result from an interaction between multiple factors, including genetics, abnormalities of metabolism, and reactivation of certain herpes family viruses including EBV and HHV-6. The classic presentation includes fever, rash, and lymphadenopathy. Symptoms begin approximately 3 to 8 weeks after exposure to the offending agent. CASE REPORT We present a unique case of DRESS syndrome in a 14-year-old girl occurring after the ingestion of minocycline and amoxicillin-clavulanic acid (amoxicillin). Identification of the offending agent was complicated by the patient having been on multiple antibiotics within a short timeframe of the initial presentation of symptoms. In addition to swelling and pruritus, the patient experienced vision problems due to papilledema with bilateral hemorrhage. The treatment course was further complicated by a decrease in kidney function, requiring the patient's medication regimen to be adjusted accordingly. CONCLUSIONS This is a unique case of DRESS syndrome demonstrating the potential influence of certain viruses on the severity of its presentation. This case also highlights the need to adjust the steroid regimen to reduce the potentially harmful effects on various organ systems.
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Affiliation(s)
- Michael Tomani
- Department of Pediatrics, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Cristina Caridi
- Department of Pediatrics, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Oksana Tatarina-Nulman
- Department of Pediatrics, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Cascya Charlot
- Department of Pediatrics, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Pramod Narula
- Department of Pediatrics, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
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Abstract
PURPOSE OF REVIEW To provide updates on recent advances in the diagnosis and management of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. RECENT FINDINGS The number of identified HLA allele associations with DRESS continues to grow. There is increasing evidence indicating viral infection, reactivation, and cross-reactivity may play key roles in disease. Translational work illuminated JAK/STAT activation in recalcitrant disease. There is expanding recognition of rapid-onset DRESS resulting from specific drugs. SUMMARY DRESS is a severe form of adverse drug reaction with potential for significant morbidity and mortality. Recent research advances may improve clinical care. HLA screening can now be performed to prevent disease in susceptible patients and may help identify culprit drugs in the near future. Viral testing should be performed on every patient, and if positive, patients potentially treated with antiviral therapy. JAK inhibitors may be an effective treatment option for DRESS. Early onset of disease relative to drug exposure should not exclude the diagnosis of DRESS.
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25
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Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe cutaneous drug reaction characterized by fever, lymphadenopathy, hematologic abnormalities, multisystem involvement, and viral reactivation. Although most patients with DRESS syndrome are able to fully recover, a subset of patients go on to have a prolonged course with recurrence, and/or autoimmune complications. Severe systemic involvement is associated with significant morbidity and mortality. Viral reactivation, especially of human herpes virus 6, Epstein-Barr virus, and cytomegalovirus, is a common feature of DRESS, with a high viral load and antibody titers being associated with poor outcomes. Aside from prompt discontinuation of the offending drug, treatment for patients with significant disease consists of systemic therapy with corticosteroids.
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26
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Gelincik A, Cavkaytar O, Kuyucu S. An Update on the Management of Severe Cutaneous Drug Hypersensitivity Reactions. Curr Pharm Des 2019; 25:3881-3901. [DOI: 10.2174/1381612825666191106115556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022]
Abstract
Severe cutaneous drug hypersensitivity reactions involve of different mechanisms , some of which are
life-threatening, such as Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia
and systemic symptoms, acute generalized exanthematous pustulosis, generalized bullous fixed drug eruptions,
serum sickness and serum sickness-like reaction and drug-induced vasculitis. These reactions may have substantial
morbidity and mortality. In the past years, successive studies have provided new evidence regarding the
pathogenesis of some of these severe reactions and revealed that underlying mechanisms are highly variable.
Since these reactions have unique presentations and distinct pathomechanisms, the treatment methods and response
rates might be different among various entities. Although supportive and local therapies are sufficient in
some of these reactions, targeted immunosuppressive treatments and even mechanistic therapies such as plasmapheresis
may be required in severe ones. However, there is still insufficient evidence to support the best treatment
options for these patients since number of patients and large-scale studies are limited. In this review, conventional
and new treatment options for severe cutaneous drug hypersensitivity reactions are presented in detail in
order to provide the contemporary approaches to lessen the morbidity and mortality relevant to these severe iatrogenic
diseases.
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Affiliation(s)
- Aslı Gelincik
- Division of Immunology and Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Mersin University, Faculty of Medicine, Mersin, Turkey
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27
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Making a diagnosis in severe cutaneous drug hypersensitivity reactions. Curr Opin Allergy Clin Immunol 2019; 19:283-293. [DOI: 10.1097/aci.0000000000000546] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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28
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Nguyen DV, Vidal C, Chu HC, van Nunen S. Human leukocyte antigen-associated severe cutaneous adverse drug reactions: from bedside to bench and beyond. Asia Pac Allergy 2019; 9:e20. [PMID: 31384575 PMCID: PMC6676067 DOI: 10.5415/apallergy.2019.9.e20] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 04/22/2019] [Indexed: 12/11/2022] Open
Abstract
Despite their being uncommon, severe cutaneous adverse drug reactions (SCARs) result in a very great burden of disease. These reactions not only carry with them a high mortality (10%-50%) and high morbidity (60%) with severe ocular complications, alopecia, oral and dental complications and development of autoimmune diseases, but also create a substantial economic burden for patients' families and society. SCARs are, therefore, an important medical problem needing a solution in many countries, especially in Asia. The clinical spectrum of SCARs comprises Stevens-Johnson syndrome, toxic epidermal necrolysis, DRESS (drug rash with eosinophilia and systemic symptoms) (also known as drug hypersensitivity syndrome or drug-induced hypersensitivity syndrome) and acute generalised exanthematous pustulosis. Recent crucial advances in determining genetic susceptibility and understanding how T cells recognise certain medications or their metabolites via the major histocompatibility complex and the effects of cofactors, have led to the implementation of cost-effective screening programs enabling prevention in a number of countries, and to further understanding of the patho-mechanisms involved in SCARs and their significance. In this review, we document comprehensively the journey of SCARs from bedside to bench and outline future perspectives in SCARs research.
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Affiliation(s)
- Dinh Van Nguyen
- Division of Respiratory, Allergy and Clinical Immunology, Vinmec International Hospital, Times City and VinUni Project, Hanoi, Vietnam
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Allergy and Clinical Immunology, Hanoi Medical University, Hanoi, Vietnam
| | - Christopher Vidal
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Hieu Chi Chu
- Centre of Allergology and Clinical Immunology, Bach Mai Hospital, Hanoi, Vietnam
| | - Sheryl van Nunen
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, Australia
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29
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Drug Reaction with Eosinophilia and Systemic Symptoms (DReSS): How Far Have We Come? Am J Clin Dermatol 2019; 20:217-236. [PMID: 30652265 DOI: 10.1007/s40257-018-00416-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DReSS), also known as drug-induced hypersensitivity syndrome (DiHS), is an uncommon severe adverse reaction to medications. It is important to recognize it as it is potentially fatal and can cause significant morbidity. From the first reports of drug reactions related to certain anticonvulsants characterized by fever, liver enzyme elevation, and skin changes, our continuously growing understanding of this entity has allowed us to describe its physiopathology and clinical features even further. The relationship of genetic factors, viral activation, and specific drug exposure is now known to play a role in this disease. There is still not a widely accepted marker for DReSS/DiHS, but the spectrum of clinical and laboratory features has now been better outlined. The mainstay of treatment is the use of systemic corticosteroids, but other options such as intravenous immunoglobulin, cyclosporine, mycophenolate mofetil, rituximab, and cyclophosphamide have been described. We present a comprehensive review of the literature on DReSS/DiHS, focusing on its history, etiopathogenesis, diagnosis, therapeutic approach, and outcome.
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Sharpe A, Mourad BM, Hardwick CJ, Reilly T, Dweck E, Bondarsky E. Oxacillin-Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). AMERICAN JOURNAL OF CASE REPORTS 2019; 20:345-348. [PMID: 30877266 PMCID: PMC6434607 DOI: 10.12659/ajcr.913748] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patient: Male, 52 Final Diagnosis: Drug reaction with eosinophilia and systemic symptoms Symptoms: Rash Medication: Oxacillin Clinical Procedure: — Specialty: Critical Care Medicine
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Affiliation(s)
- Alexis Sharpe
- Department of Pulmonary and Critical Care, NYU Langone, New York City, NY, USA
| | - Bashar M Mourad
- Department of Pulmonary and Critical Care, NYU Langone, New York City, NY, USA
| | - Chase J Hardwick
- Department of Pulmonary and Critical Care, NYU Langone, New York City, NY, USA
| | - Theresa Reilly
- Department of Pulmonary and Critical Care, NYU Langone, New York City, NY, USA
| | - Ezra Dweck
- Department of Pulmonary and Critical Care, NYU Langone, New York City, NY, USA
| | - Eric Bondarsky
- Department of Pulmonary and Critical Care, NYU Langone, New York City, NY, USA
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31
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Mori F, Caffarelli C, Caimmi S, Bottau P, Liotti L, Franceschini F, Cardinale F, Bernardini R, Crisafulli G, Saretta F, Novembre E. Drug reaction with eosinophilia and systemic symptoms (DRESS) in children. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:66-79. [PMID: 30830064 PMCID: PMC6502175 DOI: 10.23750/abm.v90i3-s.8167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Indexed: 02/07/2023]
Abstract
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a severe reaction to drugs. Incidence of DRESS in children is not well known and the mortality rate seems to be lower than 10%. Anticonvulsants are the main drugs involved both in adults and in children. The treatment of choice is intravenous immunoglobulins and corticosteroids used in synergy. Today there are not controlled clinical trials regarding DRESS treatment in children. Anyway, the prompt withdrawn of the offending drug is of paramount importance for a better prognosis. DRESS sequels may occur, consequently, follow-up visits are required at least until the first year after the reaction. (www.actabiomedica.it)
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy.
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Marques PS, Coelho S, Silva S, Bettencourt P. Allopurinol-induced DRESS complicated by hemophagocytic lymphohistiocytosis. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2019. [DOI: 10.23736/s0393-3660.17.03706-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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33
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Gauckler P, Shin JI, Mayer G, Kronbichler A. Eosinophilia and Kidney Disease: More than Just an Incidental Finding? J Clin Med 2018; 7:E529. [PMID: 30544782 PMCID: PMC6306805 DOI: 10.3390/jcm7120529] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 11/29/2018] [Accepted: 12/05/2018] [Indexed: 02/07/2023] Open
Abstract
Peripheral blood eosinophilia (PBE), defined as 500 eosinophils or above per microliter (µL) blood, is a condition that is not uncommon but often neglected in the management of patients with chronic kidney disease (CKD), acute kidney injury (AKI), or patients on renal replacement therapy (RRT). The nature of PBE in the context of kidney diseases is predominantly secondary or reactive and has to be distinguished from primary eosinophilic disorders. Nonetheless, the finding of persistent PBE can be a useful clue for the differential diagnosis of underdiagnosed entities and overlapping syndromes, such as eosinophilic granulomatosis with polyangiitis (EGPA), IgG4-related disease (IgG4-RD), acute interstitial nephritis (AIN), or the hypereosinophilic syndrome (HES). For patients on RRT, PBE may be an indicator for bio-incompatibility of the dialysis material, acute allograft rejection, or Strongyloides hyperinfection. In a subset of patients with EGPA, eosinophils might even be the driving force in disease pathogenesis. This improved understanding is already being used to facilitate novel therapeutic options. Mepolizumab has been licensed for the management of EGPA and is applied with the aim to abrogate the underlying immunologic process by blocking interleukin-5. The current article provides an overview of different renal pathologies that are associated with PBE. Further scientific effort is required to understand the exact role and function of eosinophils in these disorders which may pave the way to improved interdisciplinary management of such patients.
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Affiliation(s)
- Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
- Department of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea.
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
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34
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Ardérius M, Menezes MN, Marques T, Brito D, Ortins-Pina A, Mendes Pedro M, Pinto F, Veiga F. Late recurrence of fulminant myocarditis related to HSS/DRESS. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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35
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Cochran BP, Kimbrough EO, Pagán RJ. 62-Year-Old Man With Fever and Pruritic Rash. Mayo Clin Proc 2018; 93:1654-1658. [PMID: 30269943 DOI: 10.1016/j.mayocp.2018.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/26/2018] [Accepted: 01/31/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Benjamin P Cochran
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - ErinMarie O Kimbrough
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Ricardo J Pagán
- Advisor to residents and Consultant in Internal Medicine, Mayo Clinic, Jacksonville, FL.
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Urbina T, Hua C, Sbidian E, Ingen-Housz-Oro S, Duong TA, Wolkenstein P, Bosc R, Razazi K, Carteaux G, Chosidow O, Mekontso Dessap A, de Prost N. Urgences dermatologiques en réanimation : infections nécrosantes de la peau et des parties molles et toxidermies graves. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les urgences dermatologiques nécessitant une admission en réanimation sont rares mais associées à une mortalité élevée et à de lourdes séquelles à long terme. Elles sont essentiellement représentées par les infections nécrosantes des tissus mous (également appelées : dermohypodermites bactériennes nécrosantes-fasciites nécrosantes [DHBN-FN]) et par les toxidermies graves que sont les nécrolyses épidermiques (comprenant le syndrome de Lyell ou nécrolyse épidermique toxique [NET], le syndrome de Stevens-Johnson [SJS] et le DRESS (drug reaction with eosinophilia and systemic symptoms)). Elles ont pour caractéristiques communes un diagnostic souvent difficile, la nécessité d’une approche multidisciplinaire et de soins paramédicaux lourds et spécifiques, imposant fréquemment le transfert dans un centre expert. Le traitement des DHBN-FN est médicochirurgical, associant un débridement chirurgical précoce et une antibiothérapie probabiliste à large spectre. La présence de signes de gravité locaux (nécrose, crépitation, douleur intense) ou généraux (sepsis, choc septique) est une indication d’urgence à l’exploration chirurgicale. Sa précocité est le principal facteur pronostique modifiable, les recommandations de thérapeutiques complémentaires (immunoglobulines intraveineuses, oxygénothérapie hyperbare, pansement à pressions négatives, ...) reposant à ce jour sur un faible niveau de preuve. L’élément essentiel de la prise en charge des toxidermies graves est la recherche et l’arrêt du médicament imputable, facteur essentiel du pronostic. Le SJS et le NET, en général associés à une ou plusieurs atteintes muqueuses, entraînent dans les formes les plus graves une défaillance cutanée aiguë. La prise en charge repose sur les soins de support (correction des troubles hydroélectrolytiques, prévention de l’hypothermie, prévention et traitement des épisodes infectieux, analgésie et anxiolyse, soins locaux). Les complications infectieuses et respiratoires sont les principales causes de décès à la phase aiguë. Aucun traitement spécifique n’a fait la preuve de son efficacité à ce jour. Le diagnostic de DRESS est difficile, et la prise en charge doit être multidisciplinaire. Sa gravité tient aux possibles atteintes viscérales associées (hépatique, rénale et cardiaque) qui justifient dans les formes graves d’une corticothérapie urgente.
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Successful Intravenous Immunoglobulin Treatment in Pediatric Severe DRESS Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1238-1242. [DOI: 10.1016/j.jaip.2017.10.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/14/2017] [Accepted: 10/12/2017] [Indexed: 12/17/2022]
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Giavina-Bianchi P, Huang SW. Intravenous Immunoglobulin May Be Beneficial as an Add-on Therapy in DRESS. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1243-1245. [DOI: 10.1016/j.jaip.2018.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 02/07/2018] [Indexed: 12/17/2022]
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Kerneuzet I, Blind E, Darrieux L, Moreau S, Safa G. Ivermectin-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. JAAD Case Rep 2018; 4:524-527. [PMID: 30023418 PMCID: PMC6047220 DOI: 10.1016/j.jdcr.2018.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Ines Kerneuzet
- Department of Dermatology, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, France
| | - Eline Blind
- Department of Dermatology, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, France
| | - Laure Darrieux
- Department of Dermatology, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, France
| | | | - Gilles Safa
- Department of Dermatology, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, France
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Ingen-Housz-Oro S, Duong TA, de Prost N, Colin A, Fardet L, Lebrun-Vignes B, Barbaud A, Chosidow O, Wolkenstein P. Traitement des toxidermies graves. Ann Dermatol Venereol 2018; 145:454-464. [DOI: 10.1016/j.annder.2018.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/13/2018] [Accepted: 02/14/2018] [Indexed: 12/17/2022]
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Alvarado SA, Muñoz-Mendoza D, Bahna SL. High-risk drug rashes. Ann Allergy Asthma Immunol 2018; 121:552-560. [PMID: 29803714 DOI: 10.1016/j.anai.2018.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/14/2018] [Accepted: 05/17/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To provide a brief overview of the clinical presentation, common offending agents, management, prognosis, and mortality of 6 selected high-risk drug rashes, namely, Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, multiple drug hypersensitivity (MDH) syndrome, acute generalized exanthematous pustulosis (AGEP), and drug-induced bullous pemphigoid (DIBP). DATA SOURCES A review of the published literature was performed with PubMed and supplemented with our clinical experience. STUDY SELECTIONS The most recent clinically relevant studies and older seminal works were selected. RESULTS Most of the published data on these uncommon rashes were based on small observational series or case reports. SJS and TEN have specific genotypes association with certain drugs, have high morbidity and mortality, and require aggressive management by a team of multiple specialists. DRESS syndrome is a severe, prolonged multiorgan reaction, yet it has a better prognosis than TEN. MDH is a syndrome of repeated reactions to unrelated drugs that often imposes diagnostic and management difficulties. AGEP consists of generalized sterile small pustules, usually mistaken for infection with subsequent inappropriate treatment. Bullous pemphigoid presents with tense pruritic bullae and characteristic linear basement membrane deposition of IgG and C3. DIBP has much better prognosis than the autoimmune variety. CONCLUSION In such high-risk drug rashes, early recognition, immediate withdrawal of the suspected drug(s), prompt individualized management, and monitoring of vital organs function are mandatory for reducing morbidity and mortality. The lack of reliable tests for identification of the causative agent imposes difficulty, particularly in patients receiving multiple medications.
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Affiliation(s)
- Sasha A Alvarado
- Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Diana Muñoz-Mendoza
- Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Sami L Bahna
- Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana.
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Mustafa SS, Ostrov D, Yerly D. Severe Cutaneous Adverse Drug Reactions: Presentation, Risk Factors, and Management. Curr Allergy Asthma Rep 2018; 18:26. [PMID: 29574562 DOI: 10.1007/s11882-018-0778-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF STUDY Immune-mediated adverse drug reactions occur commonly in clinical practice and include mild, self-limited cutaneous eruptions, IgE-mediated hypersensitivity, and severe cutaneous adverse drug reactions (SCAR). SCARs represent an uncommon but potentially life-threatening form of delayed T cell-mediated reaction. The spectrum of illness ranges from acute generalized exanthematous pustulosis (AGEP) to drug reaction with eosinophilia with systemic symptoms (DRESS), to the most severe form of illness, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). RECENT FINDINGS There is emerging literature on the efficacy of cyclosporine in decreasing mortality in SJS/TEN. The purpose of our review is to discuss the typical presentations of these conditions, with a special focus on identifying the culprit medication. We review risk factors for developing SCAR, including HLA alleles strongly associated with drug hypersensitivity. We conclude by discussing current strategies for the management of these conditions.
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Affiliation(s)
- S Shahzad Mustafa
- Allergy and Clinical Immunology, Rochester Regional Health System, Rochester, NY, USA. .,University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - David Ostrov
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Daniel Yerly
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Bern, Switzerland
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An Updated Review of the Molecular Mechanisms in Drug Hypersensitivity. J Immunol Res 2018; 2018:6431694. [PMID: 29651444 PMCID: PMC5830968 DOI: 10.1155/2018/6431694] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/09/2017] [Indexed: 02/07/2023] Open
Abstract
Drug hypersensitivity may manifest ranging from milder skin reactions (e.g., maculopapular exanthema and urticaria) to severe systemic reactions, such as anaphylaxis, drug reactions with eosinophilia and systemic symptoms (DRESS)/drug-induced hypersensitivity syndrome (DIHS), or Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). Current pharmacogenomic studies have made important strides in the prevention of some drug hypersensitivity through the identification of relevant genetic variants, particularly for genes encoding drug-metabolizing enzymes and human leukocyte antigens (HLAs). The associations identified by these studies are usually drug, phenotype, and ethnic specific. The drug presentation models that explain how small drug antigens might interact with HLA and T cell receptor (TCR) molecules in drug hypersensitivity include the hapten theory, the p-i concept, the altered peptide repertoire model, and the altered TCR repertoire model. The broad spectrum of clinical manifestations of drug hypersensitivity involving different drugs, as well as the various pathomechanisms involved, makes the diagnosis and management of it more challenging. This review highlights recent advances in our understanding of the predisposing factors, immune mechanisms, pathogenesis, diagnostic tools, and therapeutic approaches for drug hypersensitivity.
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De A, Rajagopalan M, Sarda A, Das S, Biswas P. Drug Reaction with Eosinophilia and Systemic Symptoms: An Update and Review of Recent Literature. Indian J Dermatol 2018. [PMID: 29527023 PMCID: PMC5838752 DOI: 10.4103/ijd.ijd_582_17] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, is also known as drug induced hypersensitivity syndrome and by various other names. It is now recognised as one of the severe cutaneous adverse reaction (SCAR) and can be potentially life-threatening. Historically, it was most frequently linked with phenytoin and was initially described as phenytoin hypersensitivity syndrome. However, it was later found to be caused by various other medications. Anticonvulsants and sulfonamides are the most common offender. Characteristically DRESS has a latent period of 2 to 6 weeks. The pathophysiology remains incompletely understood but involves reactivation of viruses and activation of lymphocyte. It is manifested most commonly with a morbilliform cutaneous eruption with fever and lymphadenopathy. The severity of this syndrome is related to the systemic involvement, which can result in multi-organ failure. Most important step in the management of DRESS is early diagnosis and immediate cessation of the suspected offending drug. Patients of DRESS syndrome should be managed in an intensive care set up for appropriate supportive care and infection control. Topical corticosteroids can give symptomatic relief, but systemic therapy with steroid and other immunosuppressant is usually required.
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Affiliation(s)
- Abhishek De
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | | | - Aarti Sarda
- Department of Dermatology, Wizderm Speciality Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Sudip Das
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Projna Biswas
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
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Treatments for Severe Cutaneous Adverse Reactions. J Immunol Res 2017; 2017:1503709. [PMID: 29445753 PMCID: PMC5763067 DOI: 10.1155/2017/1503709] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 11/16/2017] [Indexed: 12/17/2022] Open
Abstract
Severe cutaneous adverse reaction (SCAR) is life-threatening. It consists of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), and generalized bullous fixed drug eruptions (GBFDE). In the past years, emerging studies have provided better understandings regarding the pathogenesis of these diseases. These diseases have unique presentations and distinct pathomechanisms. Therefore, theoretically, the options of treatments might be different among various SCARs. However, due to the rarity of these diseases, sufficient evidence is still lacking to support the best choice of treatment for patients with SCAR. Herein, we will provide a concise review with an emphasis on the characteristics and treatments of each SCAR. It may serve as a guidance based on the current best of knowledge and may shed light on the directions for further investigations.
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[Oxacillin-induced DRESS syndrome]. Presse Med 2017; 46:1234-1239. [PMID: 29129411 DOI: 10.1016/j.lpm.2017.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/04/2017] [Accepted: 05/11/2017] [Indexed: 12/17/2022] Open
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Abstract
During the past decade, major advances have been made in the accurate diagnosis of severe cutaneous adverse reactions (SCARs) to drugs, management of their manifestations, and identification of their pathogenetic mechanisms and at-risk populations. Early recognition and diagnosis of SCARs are key in the identification of culprit drugs. SCARS are potentially life threatening, and associated with various clinical patterns and morbidity during the acute stage of Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reactions with eosinophilia and systemic symptoms, and acute generalised exanthematous pustulosis. Early drug withdrawal is mandatory in all SCARs. Physicians' knowledge is essential to the improvement of diagnosis and management, and in the limitation and prevention of long-term sequelae. This Seminar provides the tools to help physicians in their clinical approach and investigations of SCARs.
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Affiliation(s)
- Tu Anh Duong
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France.
| | - Laurence Valeyrie-Allanore
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France
| | - Pierre Wolkenstein
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France
| | - Olivier Chosidow
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France; French Satellite of the Cochrane Skin Group, Créteil, France; INSERM, Centre d'Investigation Clinique 1430, Créteil, France
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Lee JY, Lee SY, Hahm JE, Ha JW, Kim CW, Kim SS. Clinical features of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: a study of 25 patients in Korea. Int J Dermatol 2017; 56:944-951. [PMID: 28718873 DOI: 10.1111/ijd.13667] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 02/24/2017] [Accepted: 05/03/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare adverse drug reaction. This study aimed to evaluate the incidence of association with individual drugs, clinical manifestations, disease course, and outcomes of DRESS. METHODS Using the criteria of the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR), the medical records of 25 patients diagnosed with DRESS between 2006 and 2015 were retrospectively reviewed. Demographic data, culprit drugs, latency periods, clinical and laboratory findings, and outcomes were investigated. RESULTS The study group comprised 11 men (44%) and 14 women (56%) with an age range of 13-93 years (mean, 58 ± 19.86 years). The drugs most commonly implicated were carbamazepine (28%), allopurinol (16%), and antituberculosis drugs (12%). Individual latency periods ranged from 4 to 40 days (mean, 17.6 ± 9.95 days). Latency periods for anticonvulsants were significantly longer than those for other drugs (P < 0.05). However, no statistical differences were found between the RegiSCAR scores for anticonvulsants and those for other drugs. Disease severity, based on RegiSCAR score, was correlated with blood count abnormalities (P < 0.05). CONCLUSIONS The results of our study revealed that anticonvulsants were the leading culprit drugs for DRESS, and carbamazepine was the individual drug most commonly associated with DRESS in Korea. Further studies of the mechanisms of action of these drugs are required in order to facilitate prompt diagnosis and effective management, which can affect prognosis and clinical outcome, of DRESS.
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Affiliation(s)
- Jin Y Lee
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Suh-Young Lee
- Department of Pulmonary, Allergy and Critical Care Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Ji E Hahm
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jae W Ha
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Chul W Kim
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sang S Kim
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Cho YT, Yang CW, Chu CY. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): An Interplay among Drugs, Viruses, and Immune System. Int J Mol Sci 2017; 18:E1243. [PMID: 28598363 PMCID: PMC5486066 DOI: 10.3390/ijms18061243] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/30/2017] [Accepted: 06/02/2017] [Indexed: 12/14/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe multiorgan hypersensitivity reaction mostly caused by a limited number of eliciting drugs in patients with a genetic predisposition. Patients with DRESS syndrome present with characteristic but variable clinical and pathological features. Reactivation of human herpesviruses (HHV), especially HHV-6, is the hallmark of the disease. Anti-viral immune responses intertwined with drug hypersensitivity make the disease more complicated and protracted. In recent years, emerging studies have outlined the disease more clearly, though several important questions remain unresolved. In this review, we provide an overview of DRESS syndrome, including clinical presentations, histopathological features, pathomechanisms, and treatments.
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Affiliation(s)
- Yung-Tsu Cho
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 10002, Taiwan.
| | - Che-Wen Yang
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 10002, Taiwan.
| | - Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 10002, Taiwan.
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