Drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS): An update in 2019

Fluconazole-induced drug rash with eosinophilia and systemic symptoms syndrome: a case report

BACKGROUND

Drug rash with eosinophilia and systemic symptoms syndrome is a severe T-cell-mediated adverse drug reaction characterized by a skin rash, fever, hematologic abnormalities, and internal organ involvement following prolonged exposure to a causative medication. Drugs associated with drug rash with eosinophilia and systemic symptoms syndrome include anticonvulsants, allopurinol, antibiotics, and nonsteroidal anti-inflammatory drugs. Fluconazole is an exceedingly rare cause of drug rash with eosinophilia and systemic symptoms syndrome, with only one previously reported case in abstract form. We present a case of a woman with pulmonary coccidioidomycosis who developed fluconazole-induced drug rash with eosinophilia and systemic symptoms syndrome, presenting with an unusual clinical feature.

CASE PRESENTATION

A 19-year-old Hispanic woman was taking fluconazole for pulmonary coccidioidomycosis. A total of 30 days after starting fluconazole, she developed a generalized skin rash. Despite this, she continued taking the medication. Then 1 week later, she experienced facial swelling and a sensation of "throat closing." She also developed fever, axillary lymphadenopathy, eosinophilia, atypical lymphocytes, and hepatitis. Fluconazole was discontinued, and she was treated with intravenous methylprednisolone, which led to an overall improvement in her condition. During hospitalization, her antifungal therapy was switched to posaconazole. However, within 24 hours, she again experienced the "throat closing" sensation, which was relieved with an epinephrine injection. The patient was discharged on Day 6 with oral methylprednisolone. Again, 9 days after discharge, her symptoms recurred, including facial swelling and new skin rashes. She was readmitted and treated with famotidine, corticosteroids, and diphenhydramine. Her general condition and skin rashes gradually improved, with complete resolution of the rash 3 months after the initial eruption.

CONCLUSION

We present a case of a woman with pulmonary coccidioidomycosis who developed drug rash with eosinophilia and systemic symptoms syndrome induced by fluconazole. Our case meets Bocquet's diagnostic criteria and is categorized as "definite" drug rash with eosinophilia and systemic symptoms by the Registry of Severe Cutaneous Adverse Reactions. Drug rash with eosinophilia and systemic symptoms syndrome is a T-cell-mediated type IV hypersensitivity reaction; however, our patient also exhibited a unique symptom-a sensation of "throat closing"-suggestive of angioedema and a Type I hypersensitivity component. This symptom appeared while she continued fluconazole after the onset of drug rash with eosinophilia and systemic symptoms syndrome and recurred upon the initiation of posaconazole. Although both fluconazole and posaconazole belong to the triazole antifungal class, true allergic cross-reactivity medicated by IgE is rare probably due to their structural differences. This suggests cross-reactivity may occur even with structurally unrelated drugs in drug rash with eosinophilia and systemic symptoms syndrome. Clinicians managing suspected cases of drug rash with eosinophilia and systemic symptoms syndrome should promptly discontinue the offending drug and exercise caution when prescribing alternative medications to minimize the risk of further hypersensitivity reactions.

[A rare medical chameleon with fatal consequences]

The following case describes the relapsing and ultimately fatal outcome of DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome as an often misdiagnosed drug-induced hypersensitivity reaction. The disease was complicated by progressive worsening with involvement of multiple organs and profound agranulocytosis. The main goal of this article is to raise awareness of the syndrome and its potential severity. Moreover, it outlines a number of pitfalls that may face the clinician.

Morbilliform Eruptions: Differentiating Low-Risk Drug Eruptions, Severe Cutaneous Adverse Reactions, Viral Eruptions, and Acute Graft-Versus-Host Disease

Morbilliform eruptions, which are a clinical reaction pattern characterized by erythematous macules and papules coalescing into patches that cover most of the skin surface, are one of the most common cutaneous findings in the inpatient setting. In the hospital setting, most causes are benign and due to low-risk drug exanthems; however, morbilliform eruptions may also be a sign of high-risk diseases, including Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome, acute generalized exanthematous pustulosis, and graft-versus-host disease. Proper identification of the etiology and risk stratification of a morbilliform eruption is critical to ensure proper management and optimize patient outcomes. In this review, we discuss the key features that differentiate high-risk from low-risk morbilliform eruptions, as well as specific characteristics that differentiate the different high-risk eruptions. Additionally, we offer a clinical algorithm that may be applied in the management of a patient who presents with a morbilliform rash.

Diagnosing and Managing Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Amidst Remaining Uncertainty

Drug reaction with eosinophilia and systemic symptoms (DRESS), a severe cutaneous adverse reaction, represents a diagnostic and therapeutic challenge due to its varied, evolving clinical presentation, complex pathophysiology, and potential for severe systemic involvement. This article explores DRESS syndrome through 3 illustrative cases from diverse populations and with different background comorbidities. Cases highlight different challenges in DRESS care, including (1) the need for early diagnosis and severity scoring, (2) identification of offending drugs and risk stratification to consider a possible drug challenge, and (3) best practice management including long-term monitoring for emergent autoimmunity. Recent developments in our understanding of clinical spectrum of disease, genomic and nongenomic biomarkers, severity groupings, and pharmacological and longer-term management strategies are described. Critical gaps remain in several of these domains, particularly in vulnerable groups such as the immune-compromised. In the absence of robust evidence, we aim in this article to assist attending clinicians with current expert opinion in DRESS management. Finally, we highlight areas for further research needed to improve the clinical care and outcomes of DRESS.

Recent advances in the diagnosis and treatment of DIHS/DRESS in 2025

Drug-induced hypersensitivity syndrome (DIHS) or drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe drug reaction characterized by a range of clinical manifestations. These range from mild cases resolving upon cessation of the causative drug to severe cases involving complex disease progression and potential fatality. A hallmark of DIHS/DRESS is the sequential reactivation of herpesviruses, particularly human herpesvirus 6 (HHV-6), during the disease course, contributing to recurrent symptoms. Viral reactivation can lead to critical complications, including infectious DIHS/DRESS-associated complications (iDACs) and autoimmune sequelae (aDACs). Managing DIHS/DRESS remains challenging due to its complexity, requiring precise prediction and tailored treatment strategies. Recent studies suggest that early-stage classification using the DIHS/DRESS Severity (DDS) score may help identify refractory cases, including DACs. Furthermore, early intervention with anti-cytomegalovirus (anti-CMV) therapy can mitigate iDACs caused by CMV reactivation, preventing progression to severe CMV-related diseases. Long-term follow-up is crucial, as aDACs can manifest even 3 years postonset. Serial monitoring is recommended, particularly in patients treated with intravenous immunoglobulin or corticosteroid pulse therapy, which are recognized risk factors for aDAC development. This review highlights DIHS/DRESS management strategies, focusing on its clinical features, the role of viral reactivation, and therapeutic interventions.

Lady in Red: A Fatal Case of Drug Reaction With Eosinophilia and Systemic Symptoms

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, life-threatening drug-induced hypersensitivity reaction. Here, we present the case of a 72-year-old female patient who developed DRESS after starting allopurinol, a well-known causative agent. The patient initially presented to Urgent Care with rash and diarrhea where she was prescribed methylprednisolone dose pack, diphenhydramine as needed, and metronidazole for possible colitis. She had multiple outpatient clinic and emergency department visits for follow-up of fluctuating symptoms and a persistently elevated WBC count despite multiple courses of antibiotics for presumed colitis. After a prolonged clinical course, she was diagnosed with DRESS and admitted for high-dose glucocorticoids. Unfortunately, her condition deteriorated after transfer to the intensive care unit, and she passed away. This case highlights the importance of early consideration, diagnosis, and treatment of DRESS to avoid potentially fatal outcomes.

Antibiotics and Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome: Analysis of Brazilian Pharmacovigilance Registries

BACKGROUND AND PURPOSE

This study investigated the association between the use of antibiotics and the occurrence of DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) syndrome, a rare and serious adverse event characterized by eosinophilia and acute skin rash. Without early diagnosis, the syndrome can lead to complications or even death.

METHODS

In 2020, the Brazilian National Health Surveillance Agency (Anvisa) made available a system for reporting adverse drug events, called VigiMed. Reports of adverse events registered on this system between December 1, 2018 and December 31, 2022, were analyzed. Reporting odds ratio (ROR), together with the respective 95% confidence intervals (95% CI), was calculated as a measure of the association between antibiotics and DRESS syndrome.

RESULTS

A total of 160,101 reports of adverse drug events were analyzed, with 136 suspected cases of DRESS syndrome. Compared with other drugs, the following frequencies of suspected DRESS syndrome were observed for the use of any antibiotic (ROR: 4.8; 95% CI: 3.3-7.0), meropenem (ROR: 13.0; 95% CI: 8.0-21.0), vancomycin (ROR: 11.5; 95% CI: 7.4-17.6), ampicillin (ROR: 6.8; 95% CI: 2.1-21.8), amoxicillin (ROR: 4.7; 95% CI: 1.5-15.0), cefepime (ROR: 4.3; 95% CI: 1.3-13.6), piperacillin + tazobactam (ROR: 2.5; 95% CI: 1.1-5.8) and ceftriaxone (ROR: 2.4; 95% CI: 1.1-5.1). The ROR for DRESS syndrome and the use of oxacillin was 2.7 with a wide 95% CI (0.7-11.1).

CONCLUSIONS

An association was observed between reports of DRESS syndrome and the use of antibiotics, particularly those routinely used in a hospital setting. Although there is a potential risk of underreporting or unattributed causality, the information obtained in this study is valuable for the analysis of rare adverse reactions. Given the seriousness of the findings, further studies should be conducted to obtain more accurate information about this adverse reaction.

Guidelines for the management of drug-induced hypersensitivity syndrome 2023

Drug-induced hypersensitivity syndrome (DIHS) is one of the severe drug eruptions accompanied by fever and multiple organ dysfunction, and it is induced by a relatively limited range of drugs, including anticonvulsants. A distinctive feature of this condition is its association with the reactivation of herpes viruses, particularly human herpesvirus 6. The pathogenesis involves two key factors: drug allergy and herpesvirus reactivation. DIHS is often challenging to diagnose in its early stages, and its clinical course varies widely, ranging from relatively mild to life-threatening cases. Additionally, unexpected complications, such as autoimmune diseases, may occur during the convalescent phase. As a result, diagnosing, treating, and predicting the prognosis of DIHS remain complex issues. In response to these challenges, the Ministry of Health, Labour and Welfare Study Group on Severe Erythema Multiforme has taken the lead in developing new guidelines for the management of DIHS. These guidelines aim to support clinical practice by providing up-to-date, evidence-based information on the diagnosis, treatment, and prognosis of DIHS.

Cytomegalovirus complications in drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms: importance of routine monitoring and early therapeutic intervention

Fatal outcomes in drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) are reported to be associated with cytomegalovirus (CMV) reactivation. However, CMV reactivation is observed not only in DIHS/DRESS but also in other diseases when high doses of corticosteroids are administered. Currently, it is difficult to distinguish whether CMV reactivation in DIHS/DRESS is caused by steroid-induced immunosuppression or the pathology of DIHS/DRESS. In this study, we describe the characteristic of CMV reactivation in patients with DIHS/DRESS (n = 22) by comparing the frequency of reactivation and its complications with those that occur in people with pemphigus vulgaris (PV) (n = 21) treated with high doses of corticosteroids. The frequency of CMV reactivation showed no difference between the DIHS/DRESS and PV groups. On the other hand, the frequency of CMV complications was higher in the DIHS than the PV group. Our data show the importance of monitoring for CMV complications, although CMV reactivation is not a unique consequence of DIHS/DRESS compared with other diseases treated with a high dose of corticosteroids.

CCR8/CCL1 and CXCR3/CXCL10 axis-mediated memory T-cell activation in patients with recalcitrant drug-induced hypersensitivity

BACKGROUND

As a drug-induced hypersensitivity syndrome, drug reaction with eosinophilia and systemic symptoms (DRESS) is potentially fatal. Most patients with DRESS recover within a few weeks; however, some patients may suffer from a prolonged disease course and develop autoimmune sequelae.

OBJECTIVES

To investigate the immune mechanism and therapeutic targets of patients with recalcitrant DRESS with a prolonged disease course.

METHODS

Thirty-two patients with recalcitrant DRESS with a prolonged treatment course (≥ 8 weeks; 'prolonged DRESS'), 28 patients with DRESS with a short treatment course (< 2 weeks; 'short-duration DRESS') and 26 healthy donors (HDs) were enrolled.

RESULTS

Bulk transcriptome results showed that the mRNA expression levels of CCR8 and CXCR3 were significantly increased in blood samples from patients in the acute stage of prolonged DRESS [Padj = 1.50 × 10-9 (CCR8) and Padj = 2.60 × 10-4 (CXCR3), patients with prolonged DRESS compared with the HD group]. Serum and skin lesion concentrations of CCL1 and CXCL10 (ligands of CCR8 and CXCR3, respectively) were significantly increased in patients with prolonged DRESS compared with patients with short-duration DRESS. The results from high-parameter flow cytometry and autoantibody screening also identified significant increases in CD8+ GNLY+ CXCR3+ effector memory T cells, CD8+ central memory T cells, CD4+ CCR8+ T helper 2 cells and IgG anti-HES-6 autoantibodies in patients with prolonged DRESS. Furthermore, in vitro blocking assays revealed that Janus kinase inhibitors (JAKi; mainly tofacitinib and upadacitinib) significantly decreased the release of CCL1 and CXCL10. Some patients with prolonged DRESS were successfully treated with JAKi.

CONCLUSIONS

JAKi (tofacitinib and upadacitinib) were associated with decreased concentrations of CCL1 and CXCL10, suggesting that they may attenuate CCR8/CCL1 and CXCR3/CXCL10 axis-mediated memory T-cell activation, which contributes to disease pathogenesis in patients with recalcitrant DRESS and a long-term treatment course.

GRAPHICAL ABSTRACT

Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome Associated With Celecoxib: A Case Report of a Rare Entity

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, drug-induced hypersensitivity reaction characterized by widespread skin rash, multi-system involvement, and often eosinophilia. While anticonvulsants, allopurinol, and antibiotics are the most implicated agents, non-steroidal anti-inflammatory drugs (NSAIDs) such as celecoxib can be triggers in rare cases. We report the case of a 63-year-old female presenting with a 10-day history of jaundice, nausea, and right upper quadrant pain following repeated use of celecoxib. Initially diagnosed with acute hepatitis of unknown origin, she subsequently developed fever, respiratory failure, pancytopenia, and a maculopapular rash by the 20th day of hospitalization. The clinical diagnosis of DRESS syndrome was confirmed through a skin biopsy. Systemic corticosteroid therapy (methylprednisolone 0.5 mg/kg/day) led to progressive resolution of symptoms, leading to hospital discharge on day 28. This report highlights the diagnostic challenges of DRESS syndrome, particularly in the absence of eosinophilia and with rare triggers such as celecoxib.

DRESS syndrome: an interaction between drugs, latent viruses, and the immune system

Drug-induced hypersensitivity syndrome, also known as DRESS syndrome, is a serious and potentially fatal reaction that occurs in response to prolonged use (generally between 14 and 60 days) of certain drugs, and which has no predilection for gender or age group. It is believed that DRESS syndrome has a genetic basis and results from the interaction between metabolites of certain pharmacological groups, reactivation of latent viruses (especially from the Herpesviridae family), and a cellular immune response. The classic manifestation of DRESS syndrome includes a generalized rash accompanied by fever, eosinophilia, lymphadenopathy, and systemic involvement such as hepatitis, nephritis, or pneumonitis. With the continuous increase in the availability of drugs and the aging of the population, there is a favorable scenario for the development of adverse drug reactions. Physicians should be prepared for the early diagnosis of DRESS syndrome, the identification and immediate suspension of the drug involved, and also manage systemic involvement, which may require prolonged immunosuppressive therapy. This article provides an update on the clinical, physiopathological and therapeutic aspects of DRESS syndrome.

Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome following Dalbavancin and Oritavancin Administration in a Patient with Osteomyelitis

Introduction

Dalbavancin and oritavancin are newer long-acting antibiotics with potent activity against gram-positive organisms, including methicillin-resistant Staphylococcus aureus (MRSA). To our knowledge, there have been no reported cases of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome in a patient treated with dalbavancin and oritavancin.

Patient Presentation

A woman in her 20s presented with a right thumb abscess and cellulitis that failed to respond to several courses of oral antibiotics, resulting in recurrent emergency room visits over 3 weeks. Approximately 1 month after the initial skin infection, magnetic resonance imaging revealed osteomyelitis of the right thumb. She was treated with a single dose of oritavancin followed by two weekly doses of dalbavancin, which successfully resolved the infection. However, she subsequently developed fever and a rash consistent with DRESS syndrome, likely triggered by oritavancin or dalbavancin. Given the prolonged half-life of these medications, she required treatment with high-dose steroids for an extended duration.

Conclusion

Dalbavancin and oritavancin are second-generation lipoglycopeptide antibiotics that provide coverage for gram-positive organisms, including MRSA. They are approved for the treatment of acute bacterial skin and skin structure infections and are used off-label for bacteremia, endocarditis, and osteomyelitis. Their prolonged half-lives - 257 h for dalbavancin and 195 h for oritavancin - allow for less frequent dosing. However, a long half-life also leads to prolonged drug exposure in the event of adverse effects. Here, we report the first case of DRESS syndrome in a patient treated with dalbavancin and oritavancin.

Exploring recent advances in drugs severe cutaneous adverse reactions immunopathology

Severe cutaneous adverse reactions to drugs (SCARs) are rare but life-threatening delayed allergies. While they primarily affect the skin, they can also affect internal organs. Accordingly, they present with diverse clinical symptoms that vary not only between SCARs subtypes but also among patients. Despite the availability of topical and systemic treatments, these only address the symptoms and not the cause. To develop more effective therapies, it is necessary to elucidate the complexity of the pathophysiology of SCARs in relation to their severity. In line with the new type IV hypersensitivity reactions nomenclature proposed by the European Academy of Allergy and Clinical Immunology (EAACI), this review highlights the current insights into the intricate immune mechanisms engaged, the interplay between the culprit drug and genetic predisposition in drug presentation mechanisms, but also how external factors, such as viruses, are implicated in SCARs. Their relevance to the development of targeted medicine is also discussed.

A review on toxic epidermal necrolysis-like superficial wound lesions: Issue and challenge on 10 clinical entities

Toxic epidermal necrolysis (TEN) is a severe skin reaction caused by extensive epidermal and mucosal necrosis. This clinical phenomenon is known as an acute syndrome of apoptotic pan-epidermolysis (ASAP). The ASAP phenomenon is observed in conditions that mimic TEN, highlighting the challenge in distinguishing these conditions. While TEN is a well-recognized entity, distinguishing it from other TEN-like conditions presents significant diagnostic and treatment challenges. These conditions include drug rash with eosinophilia and systemic symptoms (DRESS), generalized bullous fixed drug eruption (GBFDE), acute generalized exanthematous pustulosis (AGEP), TEN-like methotrexate toxicity, mustard gas toxicity, pseudoporphyria, mycoplasma-induced rash and mucositis (MIRM), multisystem inflammatory syndrome in children (MIS-C), graft versus host disease (GVHD), and acute cutaneous lupus erythematosus and subacute cutaneous lupus erythematosus. This review explores these ten separate entities and debates their clinical features, pathophysiology, diagnosis and management.

Interleukin (IL)-1/IL-6-Inhibitor-Associated Drug Reaction With Eosinophilia and Systemic Symptoms (DReSS) in Systemic Inflammatory Illnesses

BACKGROUND

After introducing IL-1/IL-6 inhibitors, some patients with Still and Still-like disease developed unusual, often fatal, pulmonary disease. This complication was associated with scoring as DReSS (drug reaction with eosinophilia and systemic symptoms) implicating these inhibitors, although DReSS can be difficult to recognize in the setting of systemic inflammatory disease.

OBJECTIVE

To facilitate recognition of IL-1/IL-6 inhibitor-DReSS in systemic inflammatory illnesses (Still/Still-like) by looking at timing and reaction-associated features. We evaluated outcomes of stopping or not stopping IL-1/IL-6 inhibitors after DReSS reaction began.

METHODS

In an international study collaborating primarily with pediatric specialists, we characterized features of 89 drug-reaction cases versus 773 drug-exposed controls and compared outcomes of 52 cases stopping IL-1/IL-6 inhibitors with 37 cases not stopping these drugs.

RESULTS

Before the reaction began, drug-reaction cases and controls were clinically comparable, except for younger disease-onset age for reaction cases with preexisting cardiothoracic comorbidities. After the reaction began, increased rates of pulmonary complications and macrophage activation syndrome differentiated drug-reaction cases from drug-tolerant controls (P = 4.7 × 10-35 and P = 1.1 × 10-24, respectively). The initial DReSS feature was typically reported 2 to 8 weeks after initiating IL-1/IL-6 inhibition. In drug-reaction cases stopping versus not stopping IL-1/IL-6-inhibitor treatment, reaction-related features were indistinguishable, including pulmonary complication rates (75% [39 of 52] vs 76% [28 of 37]). Those stopping subsequently required fewer medications for treatment of systemic inflammation, had decreased rates of macrophage activation syndrome, and improved survival (P = .005, multivariate regression). Resolution of pulmonary complications occurred in 67% (26 of 39) of drug-reaction cases who stopped and in none who continued inhibitors.

CONCLUSIONS

In systemic inflammatory illnesses, recognition of IL-1/IL-6-inhibitor-associated reactions followed by avoidance of IL-1/IL-6 inhibitors significantly improved outcomes.

A Rare Case of Vancomycin-Induced Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially life-threatening adverse drug reaction characterized by extensive skin rash in association with hematological abnormalities, including eosinophilia and atypical lymphocytosis, lymphadenopathy, fever, and extensive visceral organ involvement. Here, we presented a rare case of vancomycin-induced DRESS syndrome in a male who was treated with IV vancomycin for a brain abscess.

Drug Reaction With Eosinophilia and Systemic Symptoms Secondary to Trimethoprim/Sulfamethoxazole: A Case Report

Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) is a rare and potentially life-threatening condition. Symptoms typically manifest two to eight weeks after exposure to an offending agent, such as anticonvulsants and antibiotics. Clinical features include fever, morbilliform rash, eosinophilia, lymphadenopathy, and, in severe cases, multiorgan dysfunction, including interstitial nephritis, hepatitis, and pneumonitis. This case report discusses a 55-year-old female who developed DRESS syndrome while being treated for a urinary tract infection with trimethoprim/sulfamethoxazole (TMP/SMX). Presenting with fever, dysuria, flank pain, and a widespread non-pruritic maculopapular rash, her lab results were remarkable for eosinophilia, while the urinalysis revealed mild hematuria. Computed tomography imaging ruled out nephrolithiasis and acute pyelonephritis, leading to the diagnosis of DRESS syndrome. Management focused on discontinuing TMP/SMX and initiating systemic glucocorticoids. The patient responded well to treatment and was discharged on hospital day two with prescriptions for topical and oral steroids, famotidine, and diphenhydramine. The patient was provided with follow-up instructions and return precautions. Drug reaction with eosinophilia and systemic symptoms poses unique diagnostic challenges due to its similarity to other cutaneous reactions and the delay between drug exposure and symptom onset. Early recognition and intervention are vital for preventing severe complications. Given its potential for multiorgan dysfunction and poor patient outcomes, healthcare providers must be vigilant when evaluating patients presenting with fever and rash. Comprehensive history taking and accurate reconciliation of active and recent medications are necessary to make the diagnosis. Immediate discontinuation of the offending agent is essential, while supportive care and topical or systemic glucocorticoids remain the treatment standards.

Untargeted metabolomics analysis reveals the potential mechanism of imatinib-induced skin rash in patients with gastrointestinal stromal tumor

Imatinib-induced skin rash poses a significant challenge for patients with gastrointestinal stromal tumor, often resulting in treatment interruption or discontinuation and subsequent treatment failure. However, the underlying mechanism of imatinib-induced skin rashes in gastrointestinal stromal tumor patients remains unclear. A total of 51 patients (27 with rash and 24 without rash) were enrolled in our study. Blood samples were collected concomitantly with the onset of clinical manifestations of rashes, and simultaneously collecting clinical relevant information. The imatinib concentration and untargeted metabolomics were performed by ultra-high-performance liquid chromatography-tandem mass spectrometry. There were no significant differences in age, gender, imatinib concentration and white blood cells count between the rash group and the control group. However, the rash group exhibited a higher eosinophil count (P<0.05) and lower lymphocyte count (P<0.05) compared to the control group. Untargeted metabolomics analysis found that 105 metabolites were significantly differentially abundant. The univariate analysis highlighted erucamide, linoleoylcarnitine, and valine betaine as potential predictive markers (AUC≥0.80). Further enriched pathway analysis revealed primary metabolic pathways, including sphingolipid signaling pathway, sphingolipid metabolism, cysteine and methionine metabolism, biosynthesis of unsaturated fatty acids, arginine and proline metabolism, and biosynthesis of amino acids. These findings suggest that the selected differential metabolites could serve as a foundation for the prediction and management of imatinib-induced skin rash in gastrointestinal stromal tumor patients.

Amoxicillin and lamotrigine-induced DRESS syndrome: A case report

This case demonstrated with importance of recognizing DRESS syndrome presenting without the typical eosinophilia due to possible cross-reactivity between amoxicillin and the well-documented inciting medication lamotrigine. Steroid tapering is an effective treatment, but medication avoidance should be stressed to avoid symptom recurrence.

[Drug reaction with eosinophilia and systemic symptoms (DRESS): a hypersensitivity reaction with various symptoms]

Drug reaction with eosinophilia and systemic symptoms (DRESS) is an illness which is difficult to diagnose because of its various symptoms. In our case, a patient with small spotted exanthema with nearly erythroderma and eosinophilia presented to the emergency room. Systemic steroid therapy was started on suspicion of a drug reaction. Over the course of time, the patient's general condition deteriorated significantly and the patient developed cholecystitis, Staphylococcus aureus bacteremia, pneumonitis and cytomegalovirus reactivation. With this case report, we want to show that DRESS is a disease that is difficult to treat and can develop after a long delay.

Drug-induced hypersensitivity syndrome due to phenytoin: Case report and review of the literature

RATIONALE

Drug hypersensitivity syndrome (DIHS) is a rare but potentially fatal adverse drug reaction characterized by fever, rash, and visceral organ damage, particularly affecting the liver. Early recognition and appropriate management are crucial to prevent serious complications. However, there is limited information on the clinical presentation and management of DIHS, especially in the context of antiepileptic drugs. This case report aims to highlight the importance of recognizing subtle clinical signs and symptoms of DIHS, which can be easily overlooked, particularly in the context of antiepileptic drug use.

PATIENT CONCERNS

We report a case of a 15-year-old male patient who developed DIHS after being prescribed phenytoin sodium for epilepsy. The patient presented with symptoms of fever, sore throat, rash, jaundice, and liver dysfunction. Initially, the patient did not receive glucocorticoids and experienced additional reactions to cefoxitin and phosphatidylcholine, likely due to cross-reactivity.

DIAGNOSES

The diagnosis of DIHS was made based on the patient's clinical presentation, including fever, extensive rash, organ involvement, and hematological abnormalities. The temporal association with the use of phenytoin sodium, along with the exclusion of other causes of fever and rash, supported the diagnosis.

INTERVENTIONS

Upon initiation of glucocorticoid therapy with dexamethasone, the patient's symptoms significantly improved. The rash and pruritus decreased, and laboratory values showed improvement, with a decrease in liver enzymes and normalization of white blood cell counts.

OUTCOMES

The patient's fever resolved within 48 hours of starting corticosteroids, and there was no evidence of ongoing inflammation as indicated by a decrease in C-reactive protein levels. Furthermore, the patient's 30-month follow-up revealed no recurrence of rash, liver dysfunction, or organic damage, indicating the long-term effectiveness of the treatment administered.

LESSONS

This case highlights the importance of recognizing the subtle clinical signs and symptoms of DIHS, especially in the context of antiepileptic drug use. It underscores the potential benefits of early initiation of glucocorticoid therapy in managing DIHS. The case also serves as a reminder of the potential for drug cross-reactivity in DIHS and the need for cautious drug selection during the acute phase of the syndrome.

Demystifying drug reaction with eosinophilia and systemic symptoms (DRESS): a review of the literature and guidelines for management

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe, adverse drug reaction that is notoriously complex in both its presentation and treatment. Although early diagnosis and cessation of the causative agent are universally accepted as the initial interventions for DRESS, the subsequent management lacks a standardized approach. Historically, systemic steroids have been used as first-line treatment, but there is debate about the optimal dosing and route of administration, and evidence persists on the long-term complications associated with steroid use. Novel treatment approaches with targeted therapy, cyclosporine, intravenous immunoglobulin, and plasmapheresis have been gaining interest as alternative mono- and adjuvant therapies, but their use has yet to be supported by clinical trials. This narrative review provides a summary of the current knowledge of DRESS, with a focus on clinical management. The various mono- and adjuvant therapy options are discussed, with literature-supported suggestions for their optimal use in clinical practice. The risks for relapses, viral reactivation, and long-term complications are also considered. The PubMed and Medline databases were searched for articles on DRESS, published between January 1, 2008, and May 1, 2023. 334 articles met the inclusion criteria. Based on the literature, a DRESS management tool with step-by-step guidance is provided. Further suggestions for management are woven throughout this review, giving clinicians a toolbelt of resources with which to approach diagnosis, treatment, and follow-up.

A Rare Presentation of an Adverse Reaction to Minocycline

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, severe adverse drug reaction, usually associated with antibiotics and anticonvulsants. A 17-year-old girl with maculopapular rash, arthralgia, fever, and facial edema (plus eosinophilia and hepatitis) repeatedly goes to the emergency department, initially omitting having started minocycline three weeks before symptom onset. Diagnosis of serum-like sickness was first established, minocycline was suspended, and a short course of corticosteroid therapy was started. However, the fast taper of corticotherapy resulted in the reappearance of previous symptoms, as well as renal dysfunction and respiratory distress. Chest CT showed interstitial pneumonitis. With these findings, the final diagnosis of DRESS was made, and the re-adjustment of corticoid therapy resulted in symptom improvement. This case highlights the diagnostic and treatment challenges of DRESS and the importance of an all-around approach to the patient.

Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome to Hemodialysis Polysulfone Membrane

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe and potentially life-threatening hypersensitivity reaction. Although commonly associated with specific drugs, there have been no reports of DRESS syndrome caused by medical devices. We report a unique case of DRESS syndrome linked to a particular hemodialysis membrane during treatment. An 83-year-old man on hemodialysis exhibited fever, rash, and elevated eosinophils. Despite medication changes and consultations with specialists, his condition persisted. A drug-induced lymphocyte stimulation test revealed a positive response to the dialysis membrane. His symptoms and lab results met DRESS syndrome diagnostic criteria. After substituting the membrane and administering glucocorticoids, the patient displayed early improvement. Diagnosing DRESS syndrome is complex due to its varied presentation and lack of specific benchmarks. This instance underscores the need to consider medical devices as potential DRESS syndrome triggers. Enhanced physician awareness can facilitate prompt detection and proper management, ultimately refining patient outcomes.

Advanced human immunodeficiency virus (HIV) does not affect ability to utilize lymphadenopathy in assessment of drug reaction with eosinophilia and systemic symptoms syndrome in HIV and tuberculosis: Prospective comparative study

Background

RegiSCAR validation criteria for drug reaction with eosinophilia and systemic symptoms (DRESS) includes lymphadenopathy, a frequent feature of both tuberculosis (TB) and human immunodeficiency virus (HIV). TB is the most common HIV-associated coinfection. Advanced HIV is associated with lymph node (LN) fibrosis. It is not clear if this negatively affects case validation in HIV-associated DRESS. To answer this question, we designed a prospective descriptive study to assess lymphadenopathy in various combinations of comorbid HIV, TB, and DRESS.

Objectives

We sought to describe the prevalence of DRESS-associated lymphadenopathy and characterize LN quality, size, and distribution in a high HIV-TB burden setting over time.

Methods

We prospectively and systematically examined LN in 25 consecutive acute DRESS cases hospitalized at a South African tertiary-care center and 10 hospitalized non-DRESS HIV-TB coinfected controls.

Results

Fourteen (56%) of 25 patients were HIV infected, with a median (interquartile range) CD4 count of 254 (66-478) cells/mm³, and 7 of 14 were coinfected with TB. Using RegiSCAR criteria, 12 (46%) of 25 were definite DRESS cases, 8 (31%) of 25 probable, and 5 (23%) of 25 possible. Possible cases were excluded in the analysis. Fifteen (75%) of 20 subjects had LN in ≥2 anatomic sites, including all 7 patients with HIV-TB coinfection. In contrast, 1 (20%) of 5 hospitalized non-DRESS HIV-TB coinfected controls had LN. Cervical LN, in 15 (88%) of 17, was most common, followed by axillary (76%) and inguinal (59%). Cervical LN ranged between 1 and 2 cm in size. Among the 8 (32%) of 25 subjects with follow-up data, LN had regressed in all within 6 weeks of stopping the offending drug and initiating TB treatment. There was no correlation with CD4 cell count and LN.

Conclusion

Lymphadenopathy is a common feature of acute DRESS, even among HIV-TB-coinfected patients with advanced immunosuppression.

Drugs and the skin: A concise review of cutaneous adverse drug reactions

Drug-induced skin disease or cutaneous adverse drug reactions (CADRs) are terms that encompass the clinical manifestations of the skin, mucosae and adnexa induced by a drug or its metabolites. The skin is the organ most frequently affected by drug reactions, which may affect up to 10% of hospitalized patients and occur in 1-3% of multimedicated patients. Most CADRs are mild or self-resolving conditions; however, 2-6.7% of could develop into potentially life-threatening conditions. CADRs represent a heterogeneous field and can be diagnostically challenging as they may potentially mimic any dermatosis. Currently, there are between 29-35 different cutaneous drug-reaction patterns reported ranging from mild dermatitis to an extensively burnt patient. The most frequently reported are maculopapular rash, urticaria/angioedema, fixed drug eruption and erythema multiforme. Less common but more severe patterns include erythroderma, drug reaction with eosinophilia and systemic symptoms, and Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum. Almost any drug can induce a CADR, but antibiotics, nonsteroidal anti-inflammatory drugs and antiepileptics are the most frequently involved. Different mechanisms are involved in the pathogenesis of CADRs, although in some cases, these remain still unknown. CADRs could be classified in different ways: (i) type A (augmented) or type B (bizarre); (ii) immediate or delayed; (iii) immune-mediated or nonimmune-mediated; (iv) nonsevere or life-threatening; and (v) by their phenotype, including exanthematous, urticarial, pustular and blistering morphology. Recognizing a specific CADR will mostly depend on the ability of the physician to perform a detailed clinical examination, the proper description of the morphology of the skin lesions and supporting laboratory and/or skin biopsy findings.

A diagnostic dilemma: distinguishing a sulfasalazine induced DRESS hypersensitivity syndrome from a CD30 + lymphoma in a young patient

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe hypersensitivity reaction characterized by cutaneous rash, lymphadenopathy, fever, eosinophilia, leukocytosis, and life-threatening organ dysfunctions. We describe the case of a 26 year old patient admitted to the Emergency Department for DRESS syndrome after sulfasalazine treatment for rheumatoid arthritis in the right knee. Whole body computer tomography showed multiple neck, chest, and abdominal lymphadenopathy with splenomegaly, massive ascites and severe hepatic cytolysis. Serology results for Epstein-Barr Virus (EBV), influenza, measles, rubella, hepatitis A and B were negative. The histologic analysis of skin, lymph node and bone marrow biopsies could not indicate a classical Hodgkin's Disease or iatrogenic immunodeficiency/EBV-associated lymphoproliferative disorder (LPD), Hodgkin type. The relatively small caliber of the CD30 + immunoreactive blastoid cells in the lymph nodes suggested reactive immunoblasts rather than Hodgkin cells. The morphologic aspects of the lymph node biopsies with predominance of T-cells were compatible with the diagnosis of a sulfasalazine-induced DRESS syndrome as the patient had a high RegiSCAR score for DRESS. [DRESS Syndrome Foundation: Diagnosis and Treatment. (2023)] The patient's complex clinical course, marked by two hospital admissions, highlights the challenges in diagnosing and managing DRESS. This case underscores the need for individualized care, close patient monitoring, and further research to better understand DRESS's underlying mechanisms and optimal therapeutic strategies.

Penicillin Allergy: Mechanisms, Diagnosis, and Management

Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.

Chronic and Acute Drug-Induced Hypersensitivity Syndrome in a Rural Patient With Cytomegalovirus Infection: A Case Report

A 50-year-old man presented with fever and a generalized rash, with chronic fatigue and lymphadenopathy for a year and a half. Initial tests ruled out lymphoproliferative disorders, showing reactive hyperplasia and cytomegalovirus. Symptoms worsened after ampicillin treatment, leading to suspected drug-induced hypersensitivity syndrome (DIHS). Upon admission, amoxicillin was discontinued, and prednisolone and antiviral treatment were initiated. The patient's condition improved with this therapy. A drug-induced lymphocyte stimulation test confirmed hypersensitivity to both ampicillin and allopurinol. This case illustrates the diagnostic challenge of chronic and acute DIHS because of the rare presentation. It underscores the need for high suspicion of DIHS in patients with chronic lymphadenopathy and fatigue, particularly with recent drug exposure. Effective management involves recognizing symptoms, withdrawing the offending drug, and using corticosteroids. Viral infections like cytomegalovirus can complicate DIHS diagnosis and treatment, necessitating a comprehensive approach. This case highlights the importance of considering DIHS in differential diagnoses and the complexities of managing it alongside co-infections in rural healthcare settings.

Severe cutaneous adverse reactions

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.

Heparin-induced DRESS syndrome in a paediatric patient and successful anaesthetic management in cardiovascular bypass surgery: case report

BACKGROUND

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome is a severe adverse drug reaction marked by delayed hypersensitivity reactions causing skin and systemic complications. DRESS diagnosis is challenging due to the variety of clinical presentations and symptom overlap with other conditions. The perioperative period in these patients requires precise pharmacological strategies to prevent complications associated with this syndrome. The treatment of DRESS induced by unfractionated heparin during cardiopulmonary bypass (CPB) surgery presents some challenges that must be considered when selecting an anticoagulant to avoid side effects. In this case, bivalirudin, a direct thrombin inhibitor, is indicated as an alternative to heparin in patients undergoing CPB. However, in contrast to heparin/protamine, there is no direct reversal agent for bivalirudin.

CASE PRESENTATION

We report the case of an 11-year-old male diagnosed with native aortic valve endocarditis and thrombosis in his left lower extremity. During valvular replacement surgery, systemic unfractionated heparin was administered. Postoperatively, the patient developed fever, eosinophilia and pruritic rash. Warm shock and elevated alanine transaminase (ALT) and aspartate transaminase (AST) levels followed, leading to the diagnosis of DRESS syndrome. Treatment with methylprednisolone resulted in complete resolution of symptoms. Seven years later, the patient was readmitted due to insufficient anticoagulation and a thrombus in the prosthetic aortic valve, presenting a recurrent DRESS episode due to the administration of unfractionated heparin, which was later replaced with low-molecular-weight heparin during hospitalization. Treatment with corticosteroids and antihistamines was initiated, resulting in the resolution of this episode. Ultimately, the patient required the Ross procedure. During this intervention the anticoagulation strategy was modified, unfractionated heparin was replaced with bivalirudin during the procedure and fondaparinux was administered during the postoperative period. This resulted in stable transaminases levels and no eosinophilia.

CONCLUSION

The severity of DRESS Syndrome underscores the importance of early recognition, heightened monitoring, and a comprehensive approach tailored to each patient's needs. This particular case highlights the significance of this approach and may have a substantial clinical impact since it provides alternatives to heparin, such as bivalirudin and fondaparinux, in the anticoagulation strategy of CPB for patients who have a hypersensibility reaction to this medication; thus, enhancing clinical outcomes by minimizing risks linked to adverse drug reactions.

Knowledge mapping and global trends of drug hypersensitivity from 2013 to 2023: A bibliometric analysis

BACKGROUND

Drug hypersensitivity is a major global public health issue with a significant increase in prevalence in populations. Here, we provide a deep insight into the frontier hotspot and future direction in the field of drug hypersensitivity.

METHODS

A knowledge map is portrayed based on publications related to drug hypersensitivity from Web of Science Core Collection using CiteSpace. Co-occurrence relationships of countries, institutes, authors, journals, references, and keywords are constructed. According to the co-occurrence relationships, hotspots and future trends are overviewed.

RESULTS

The United States ranked first in the world and China with the second highest publications was the only developing country. Torres, Mayorga, and Blanca were highly productive authors. Harvard University was the institution with the most research publications. Keywords co-occurrence analysis suggested applications in emerging causes, potential mechanisms, and clinical diagnosis as the research hotspots and development frontiers.

CONCLUSION

Research on drug hypersensitivity is in a rapid development stage and an emerging trend in reports of anaphylaxis to polyethylene glycols is identified. Developing algorithms for understanding the standardization process of culprit drugs, clinical manifestations, and diagnostic methods will be the focus of future direction. In addition, a better understanding of the mechanisms to culprit drugs with immunological precise phenotypic definitions and high-throughput platforms is needed.

Clinical observation and analysis of rash caused by lacosamide in children with epilepsy

PURPOSE

To draw clinical attention to rashes caused by lacosamide.

METHODS

This retrospective analysis included patients admitted to the Department of Pediatrics, Second Affiliated Hospital of Xi'an Jiaotong University between January 2021 and September 2023. We focused on patients who developed rashes after lacosamide treatment and analyzed all patients who exhibited rashes after lacosamide treatment to analyze the risk factors.

RESULTS

In total, 190 patients received lacosamide, of whom four developed allergies (2.1 %). Three patients had severe rashes, and two patients had high fever. All of these adverse events improved after the withdrawal of lacosamide. Of the 13 patients reported to date, including the four patients in this study, eight used various antiseizure medicines, including seven patients who used four or more antiseizure medicines. Four patients underwent testing for HLA-B*1502, and two patients were positive. Patients developed rashes within 1-10 days after treatment initiation, and the duration of the rash ranged 2-37 days.

CONCLUSIONS

Lacosamide-induced rash was detected in 2.1 % of patients in our cohort. Rashes are potentially serious, and prompt evaluation is required. Rashes are more likely to occur when multiple antiseizure medicines are used simultaneously, typically within 10 days of treatment initiation.

Herpesvirus activated NF-κB-mediated antigen processing and presentation to aggravate trichloroethylene-induced hypersensitivity dermatitis

Trichloroethylene-induced hypersensitivity dermatitis (TIHD) is a delayed hypersensitivity response that is affected by genetic and environmental factors. Occupational exposure to trichloroethylene (TCE) enhances antigen presentation, leading to hypersensitivity in workers with the HLA-B* 13:01 allele. Several studies have observed the activation of herpesviruses, such as EpsteinBarr virus (EBV), in TIHD patients. However, the underlying mechanisms remain unclear. Toll-like receptors (TLRs) play a pivotal role in the pathogenesis of herpesvirus infection. This study aimed to explore whether TLRs serve as a shared mechanism for both herpesvirus and allergenic chemicals. In this study, HLA-B* 13:01-transfected Hmy2. A C1R cell model was constructed, and cells were treated with TCOH and EBV to explore the possible mechanisms. We established a mouse model of dermatitis and used a TLR4 agonist to verify the effect of herpesvirus on TIHD. The results showed that EBV and TCOH synergistically enhance antigen processing and presentation via the TLR2/NF-κB axis. Furthermore, TLR4 agonist further aggravated skin lesions and liver damage in TCE-sensitized mice through TLR4/NF-κB axis-mediated antigen processing and presentation. Together, this study indicates that viral infection further aggravates the inflammatory response in TIHD based on environment-gene interactions.

Drug-Induced Hypersensitivity Syndrome Accompanied With Acute Renal Failure With Hemodialysis: A Case Report and Literature Review

Drug-induced hypersensitivity syndrome (DIHS) is a severe type of cutaneous adverse event involving systemic organ failures. In some cases of DIHS, acute renal failure takes place, and it becomes necessary to perform hemodialysis. However, the clinical outcome of renal failure in the course of treatment of DIHS remains unclear. Herein, we report a case of DIHS complicated with acute renal failure, which requires hemodialysis. Furthermore, we also review the DIHS cases accompanied by acute renal failure with hemodialysis in the English case report literature.

Management of Adult Patients With Drug Reaction With Eosinophilia and Systemic Symptoms: A Delphi-Based International Consensus

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.

Immunological Mechanisms in Cutaneous Adverse Drug Reactions

Adverse drug reactions (ADRs) are an inherent aspect of drug use. While approximately 80% of ADRs are predictable, immune system-mediated ADRs, often unpredictable, are a noteworthy subset. Skin-related ADRs, in particular, are frequently unpredictable. However, the wide spectrum of skin manifestations poses a formidable diagnostic challenge. Comprehending the pathomechanisms underlying ADRs is essential for accurate diagnosis and effective management. The skin, being an active immune organ, plays a pivotal role in ADRs, although the precise cutaneous immunological mechanisms remain elusive. Fortunately, clinical manifestations of skin-related ADRs, irrespective of their severity, are frequently rooted in immunological processes. A comprehensive grasp of ADR morphology can aid in diagnosis. With the continuous development of new pharmaceuticals, it is noteworthy that certain drugs including immune checkpoint inhibitors have gained notoriety for their association with ADRs. This paper offers an overview of immunological mechanisms involved in cutaneous ADRs with a focus on clinical features and frequently implicated drugs.

Characteristics of DRESS Syndrome in the Elderly: A Comparative Study of 55 Patients

Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare drug reaction characterized by a skin rash, eosinophilia, and organ involvement. Objective: Our purpose is to focus on the clinical and epidemiological characteristics of DRESS in the elderly and to identify the incriminated drugs. Methods: This is a retrospective study including patients, hospitalized for DRESS with a RegiSCAR ≥4. The population was divided into 2 groups according to age: 65 years or older (G1) and <65 years (G2). The statistical study was performed using the comparative and multivariate analysis. Results: We included 55 patients (30.9% G1 and 69.1% G2). Skin manifestations were comparable in both groups. Lymphadenopathy was less common in G1 with a statistically significant difference (P = 0.012). Renal impairment was more frequent in the elderly with a statistically significant result (P = 0.005). DRESS in the elderly group was significantly associated with the occurrence of sepsis (P = 0.008). Allopurinol was the most common culprit associated with DRESS in G1 (P = 0.001). Relapses and recurrences were comparable in both groups (P = 0.71). Conclusions: DRESS in the elderly is associated with a high risk of complications, mainly kidney involvement and sepsis. Allopurinol is the most incriminated drug.

Development of a multivariate predictive model for dapsone adverse drug events in people with leprosy under standard WHO multidrug therapy

BACKGROUND

The occurrence of adverse drug events (ADEs) during dapsone (DDS) treatment in patients with leprosy can constitute a significant barrier to the successful completion of the standardized therapeutic regimen for this disease. Well-known DDS-ADEs are hemolytic anemia, methemoglobinemia, hepatotoxicity, agranulocytosis, and hypersensitivity reactions. Identifying risk factors for ADEs before starting World Health Organization recommended standard multidrug therapy (WHO/MDT) can guide therapeutic planning for the patient. The objective of this study was to develop a predictive model for DDS-ADEs in patients with leprosy receiving standard WHO/MDT.

METHODOLOGY

This is a case-control study that involved the review of medical records of adult (≥18 years) patients registered at a Leprosy Reference Center in Rio de Janeiro, Brazil. The cohort included individuals that received standard WHO/MDT between January 2000 to December 2021. A prediction nomogram was developed by means of multivariable logistic regression (LR) using variables. The Hosmer-Lemeshow test was used to determine the model fit. Odds ratios (ORs) and their respective 95% confidence intervals (CIs) were estimated. The predictive ability of the LRM was assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

A total of 329 medical records were assessed, comprising 120 cases and 209 controls. Based on the final LRM analysis, female sex (OR = 3.61; 95% CI: 2.03-6.59), multibacillary classification (OR = 2.5; 95% CI: 1.39-4.66), and higher education level (completed primary education) (OR = 1.97; 95% CI: 1.14-3.47) were considered factors to predict ADEs that caused standard WHO/MDT discontinuation. The prediction model developed had an AUC of 0.7208, that is 72% capable of predicting DDS-ADEs.

CONCLUSION

We propose a clinical model that could become a helpful tool for physicians in predicting ADEs in DDS-treated leprosy patients.

Multidisciplinary approach to diagnosis and management of fever of unknown origin: A case report

INTRODUCTION

Fever of unknown origin (FUO) poses a diagnostic challenge, often requiring a systematic evaluation to uncover its elusive cause. This case study delves into the presentation of a 42-year-old Chinese male with persistent fever, muscle pain, and a perplexing rash.

PATIENT CONCERNS

The patient's symptoms included a prolonged fever, chills, muscle pain, and throat discomfort, with a history of pulmonary tuberculosis. Initial diagnoses of upper respiratory infection and unspecified infection were followed by antibiotic treatments, yet the fever persisted, accompanied by an exacerbating rash.

DIAGNOSIS

Extensive diagnostic investigations, including laboratory tests, imaging studies, and skin dermoscopy, provided valuable insights. The patient exhibited elevated inflammatory markers, hepatosplenomegaly, lymphadenopathy, and lung nodules. Differential diagnoses included adult-onset Still disease and drug-induced hypersensitivity syndrome.

INTERVENTIONS

The patient received a series of antibiotic treatments, which initially had limited success. Upon considering an autoimmune etiology, corticosteroids were introduced, followed by cyclosporine. The patient exhibited a positive response to this immunosuppressive therapy.

OUTCOMES

Treatment adjustments were made, and the patient responded positively to a combination of corticosteroids and cyclosporine. His fever subsided, and laboratory markers normalized. One month after discharge, the patient showed continued improvement.

CONCLUSION

FUO cases often demand a multidisciplinary approach, considering rare and uncommon diseases. This case underscores the importance of thorough evaluation, collaboration between specialties, and vigilant monitoring of treatment responses. The patient's unique presentation emphasizes the need to consider drug-induced reactions, even when symptoms deviate from typical disease patterns, highlighting the complexities in diagnosing and managing FUO.

Retrospective study on the association of human herpesvirus reactivation with severe DRESS: A description of blood and skin reactivations

BACKGROUND

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a severe adverse event (mortality of 10%). Its pathophysiology involves herpesviruses, particularly HHV-6, but the exact mechanisms are still poorly understood.

OBJECTIVE

To describe severe cases of DRESS and especially their association with herpesvirus reactivation.

METHODS

This study was a multicentre case series conducted between 2007 and 2021 at five University Hospital Centres in France. The study included patients who had severe DRESS, which was defined as death, transfer to the intensive care unit (ICU), or severe damage to internal organs. We excluded patients without blood PCR sample, without a drug formally attributed or with RegiSCAR score < 6. We collected data on severity, causative drug, associated visceral damage and results of viral blood PCRs. HHV-6 reactivation was studied in skin biopsies by detection of small non-coding transcripts (HHV-6 miR-aU14) and a late viral protein (GP82/105).

RESULTS

Fifty-two patients were included (29 female, median age 62, interquartile range (IQR) [37;72]). Eight patients (15%) died, 13 (27%) were admitted to ICU. Most patients (n = 34; 65%) had multisystem involvement: most frequent was liver (n = 46; 88%), then renal failure (n = 24; 46%). Forty patients (77%) had at least one blood viral reactivation among HHV-6, EBV or CMV, of which 21 (53%) had at least two. Median time of blood HHV-6 reactivation was 24 days (IQR [20;35]). HHV-6 reactivation was demonstrated in 15 out of 20 skin biopsies, with a median time of 11 days [9;17].

CONCLUSIONS

We confirmed the high rate of HHV-6 reactivation in severe DRESS and demonstrated cutaneous HHV-6 reactivation using small non-coding transcripts (HHV-6 miR-aU14), which preceded viral PCR positivity in blood. These results suggest that HHV-6 reactivation during DRESS may start in skin. Furthermore, search for miR-aU14 in skin biopsy could become a useful diagnostic tool for early detection of HHV-6 reactivation.

A case of drug-induced hypersensitivity syndrome complicated with fulminant type 1 diabetes and type 2 myocardial infarction

Drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) is a type of drug eruption that causes multiorgan disorders after the administration of certain drugs such as anticonvulsants. Herein, we report the case of a 66-year-old man with DiHS/DRESS complicated by fulminant type 1 diabetes (FT1D), shock, and cardiac involvement who was treated conservatively without systemic corticosteroid administration. He had taken carbamazepine for trigeminal neuralgia for 7 weeks until he noticed eruptions on his trunk. Two days after admission, he developed diabetic ketoacidosis, resulting in hypovolemic shock. The patient was diagnosed with FT1D, and insulin was administered. Additionally, the patient had a fever over 38°C, elevated white blood cells (>20 000/μL), liver dysfunction, atypical lymphocytes, and lymphadenopathy, but no evidence of viral reactivation. The lymphocyte transformation test for carbamazepine was positive, and human leukocyte antigen typing revealed the A31:01 haplotype, a risk factor for carbamazepine-induced cutaneous adverse drug reactions. Collectively, a diagnosis of atypical DiHS and a definitive case of DRESS was made. Moreover, myocardial dysfunction wall motion was observed. A close examination revealed mild coronary artery stenosis, leading to a diagnosis of type 2 myocardial infarction due to relative ischemia. The patient was carefully monitored without systemic corticosteroid administration because both clinical findings and laboratory data peaked on the same day. The patient's eruption and general condition improved, and he was discharged 4 weeks later. While most cases of DiHS/DRESS with cardiac involvement present with myocarditis, the possibility of ischemic heart disease should be considered in patients with cardiac involvement under shock.

Case Report of Probable DRESS Syndrome Associated with Ribociclib

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but known and potentially severe side effect of drugs. The recent development of cyclin-dependent kinase 4/6 (CDK4/6) inhibitors, such as ribociclib, has considerably improved the management of hormone receptor positive (HR+) and HER2 negative (HER2-) advanced breast cancer. Here, we present the case of an 83-year-old patient who developed a probable DRESS syndrome induced by ribociclib, presenting with fever, eosinophilia, rash, and hepatic cytolysis. The RegiSCAR score was 4. The symptomatology evolved favorably with topical and systemic corticosteroids, without any sequel. Another CDK4/6 inhibitor, palbociclib, was introduced later without any cross-toxicity and with an excellent therapeutic response for more than 3 years.

Tolerated Re-Challenge of Immunotherapy in a Patient with ICI Associated Myocarditis: A Case Report and Literature Review

Many different types of cancer can be treated with immunotherapy drugs called immune checkpoint inhibitors (ICIs). These drugs have altered the landscape of cancer treatment options since they function by triggering a stronger immune response to malignancy. As expected, ICIs' modification of immune regulatory controls leads to a wide range of organ/gland-specific immune-related side effects. These adverse effects are uncommonly deadly and typically improve by discontinuing treatment or administering corticosteroid drugs. As a result of a number of factors-including a lack of specificity in the clinical presentation, the possibility of overlap with other cardiovascular and general medical illnesses, difficulties in diagnosis, and a general lack of awareness-the true incidence of ICI-associated myocarditis is likely underestimated. Currently, protocols for the surveillance, diagnosis, or treatment of this condition are unclear. Several questions remain unanswered, such as how to best screen for this rare toxin, what tests should be run on patients who are suspected of having it, how to treat myocarditis once it has developed, and who is at most risk. In this article, we provide a case study of ICI-associated myocarditis and explain its key characteristics and treatment options.