Allopurinol-Induced Drug Reaction With Eosinophilia and Systemic Symptoms: A Case Report

Renal Manifestations of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome: A Systematic Review of 71 Cases

Unlike other adverse drug reactions, visceral organ involvement is a prominent feature of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and correlates with mortality. The aim of this study was to systematically review cases published in PubMed-indexed, peer-reviewed journals in which patients had renal injury during the episode of DRESS syndrome (DS). We found 71 cases, of which 67 were adults and 56% were males. Female sex was associated with higher mortality. Chronic kidney disease (CKD) was present in 14% of patients who developed acute kidney injury (AKI) during DS. In 21% of cases, the kidneys were the only visceral organ involved, while 54% of patients had both liver and kidney involvement. Eosinophilia was absent in 24% of patients. The most common classes of medication associated with renal injury in DS were antibiotics in 34%, xanthine oxidase inhibitors in 15%, and anticonvulsants in 11%. Among antibiotics, vancomycin was the most common culprit in 68% of patients. AKI was the most common renal manifestation reported in 96% of cases, while isolated proteinuria or hematuria was present in only 4% of cases. In cases with AKI, 88% had isolated increase in creatinine and decrease in glomerular filtration (GFR), 27% had AKI concomitantly with proteinuria, 18% had oliguria, and 13% had concomitant AKI with hematuria. Anuria was the rarest manifestation, occurring in only 4% of patients with DS. Temporary renal replacement therapy was needed in 30% of cases, and all but one patient fully recovered renal function. Mortality of DS in this cohort was 13%, which is higher than previously reported. Medication class, latency period, or pre-existing CKD were not found to be associated with higher mortality. More research, particularly prospective studies, is needed to better recognize the risks associated with renal injury in patients with DS. The development of disease-specific biomarkers would also be useful so DS with renal involvement can be easier distinguished from other eosinophilic diseases that might affect the kidney.

How to Recognize and Manage Challenging DRESS Cases: Two Case Reports and A Review of the Literature

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon systemic adverse drug reaction. Furthermore, it is a unique syndrome encompassing various manifestations of fever, facial edema, eosinophilia, atypical lymphocytosis, and organ dysfunction. Since there are no large prospective studies concerning DRESS syndrome, current treatment modalities for DRESS have been mainly determined based on various case reports and expert opinions. Corticosteroids are the mainstay of therapy after the cessation of the culprit drug. Although most cases recover within a couple of months, some may persist and even progress despite 1 mg/kg/day of prednisolone or its equivalent. We herein present two cases of severe DRESS syndrome. Both cases presented with organ dysfunction and remained unresponsive to initial treatment with 1 mg/kg/day of intravenous methylprednisolone. Therefore, plasmapheresis or pulse steroid therapy (250 mg/day methylprednisolone for three days) was used. In the follow-up period, patients' clinical conditions improved dramatically without recurrence. We aimed to share our experience in recognizing and managing severe DRESS cases in this manuscript. Furthermore, we reviewed the literature in comparison with the present cases. In conclusion, plasmapheresis or pulse steroid therapy (250 mg/day of methylprednisolone for three days) can be used to treat difficult DRESS cases where organ failure is about to happen.