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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 I. Epidemiology, pathogenesis, clinicopathological features, and prognosis. J Am Acad Dermatol 2024; 90:885-908. [PMID: 37516359 DOI: 10.1016/j.jaad.2023.02.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/26/2023] [Indexed: 07/31/2023]
Abstract
Drug-induced hypersensitivity syndrome (DiHS), also known as drug reaction with eosinophilia and systemic symptoms (DRESS), is a severe cutaneous adverse reaction (SCAR) characterized by an exanthem, fever, and hematologic and visceral organ involvement. Anticonvulsants, antibiotics, and allopurinol are the most common triggers. The pathogenesis involves a complex interplay between drugs, viruses, and the immune system primarily mediated by T-cells. DiHS/DRESS typically presents with a morbilliform eruption 2-6 weeks after drug exposure, and is associated with significant morbidity, mortality, and risk of relapse. Long-term sequelae primarily relate to organ dysfunction and autoimmune diseases. Part I of this continuing medical education activity on DiHS/DRESS provides an update on epidemiology, novel insights into pathogenesis, and a description of clinicopathological features and prognosis.
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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 Dermatology, Yale School of Medicine, New Haven, Connecticut; 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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Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Focus on the Pathophysiological and Diagnostic Role of Viruses. Microorganisms 2023; 11:microorganisms11020346. [PMID: 36838310 PMCID: PMC9966117 DOI: 10.3390/microorganisms11020346] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a heterogeneous, multiorgan and potentially life-threatening drug-hypersensitivity reaction (DHR) that occurs several days or weeks after drug initiation or discontinuation. DHRs constitute an emerging issue for public health, due to population aging, growing multi-organ morbidity, and subsequent enhanced drug prescriptions. DRESS has more consistently been associated with anticonvulsants, allopurinol and antibiotics, such as sulphonamides and vancomycin, although new drugs are increasingly reported as culprit agents. Reactivation of latent infectious agents such as viruses (especially Herpesviridae) plays a key role in prompting and sustaining aberrant T-cell and eosinophil responses to drugs and pathogens, ultimately causing organ damage. However, the boundaries of the impact of viral agents in the pathophysiology of DRESS are still ill-defined. Along with growing awareness of the multifaceted aspects of immune perturbation caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the ongoing SARS-CoV-2-related disease (COVID-19) pandemic, novel interest has been sparked towards DRESS and the potential interactions among antiviral and anti-drug inflammatory responses. In this review, we summarised the most recent evidence on pathophysiological mechanisms, diagnostic approaches, and clinical management of DRESS with the aim of increasing awareness on this syndrome and possibly suggesting clues for future research in this field.
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van der Ree MH, van Dussen L, Rosenberg N, Stolwijk N, van den Berg S, van der Wel V, Jacobs BAW, Wilde AAM, Hollak CEM, Postema PG. Effectiveness and safety of mexiletine in patients at risk for (recurrent) ventricular arrhythmias: a systematic review. Europace 2022; 24:1809-1823. [PMID: 36036670 DOI: 10.1093/europace/euac087] [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: 03/15/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022] Open
Abstract
While mexiletine has been used for over 40 years for prevention of (recurrent) ventricular arrhythmias and for myotonia, patient access has recently been critically endangered. Here we aim to demonstrate the effectiveness and safety of mexiletine in the treatment of patients with (recurrent) ventricular arrhythmias, emphasizing the absolute necessity of its accessibility. Studies were included in this systematic review (PROSPERO, CRD42020213434) if the efficacy or safety of mexiletine in any dose was evaluated in patients at risk for (recurrent) ventricular arrhythmias with or without comparison with alternative treatments (e.g. placebo). A systematic search was performed in Ovid MEDLINE, Embase, and in the clinical trial registry databases ClinicalTrials.gov and ICTRP. Risk of bias were assessed and tailored to the different study designs. Large heterogeneity in study designs and outcome measures prompted a narrative synthesis approach. In total, 221 studies were included reporting on 8970 patients treated with mexiletine. Age ranged from 0 to 88 years. A decrease in ventricular arrhythmias of >50% was observed in 72% of the studies for pre-mature ventricular complexes, 64% for ventricular tachycardia, and 33% for ventricular fibrillation. Electrocardiographic effects of mexiletine were small; only in a subset of patients with primary arrhythmia syndromes, a relative (desired) QTc decrease was reproducibly observed. As for adverse events, gastrointestinal complaints were most frequently observed (33% of the patients). In this systematic review, we present all the currently available knowledge of mexiletine in patients at risk for (recurrent) ventricular arrhythmias and show that mexiletine is both effective and safe.
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Affiliation(s)
- Martijn H van der Ree
- Department of Clinical Cardiology, Heart Center, Amsterdam UMC-University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
| | - Laura van Dussen
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Noa Rosenberg
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Nina Stolwijk
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Sibren van den Berg
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent van der Wel
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Bart A W Jacobs
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
- Department of Pharmacy, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Clinical Cardiology, Heart Center, Amsterdam UMC-University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
| | - Carla E M Hollak
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter G Postema
- Department of Clinical Cardiology, Heart Center, Amsterdam UMC-University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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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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Komaroff AL, Pellett PE, Jacobson S. Human Herpesviruses 6A and 6B in Brain Diseases: Association versus Causation. Clin Microbiol Rev 2020; 34:e00143-20. [PMID: 33177186 PMCID: PMC7667666 DOI: 10.1128/cmr.00143-20] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Human herpesvirus 6A (HHV-6A) and human herpesvirus 6B (HHV-6B), collectively termed HHV-6A/B, are neurotropic viruses that permanently infect most humans from an early age. Although most people infected with these viruses appear to suffer no ill effects, the viruses are a well-established cause of encephalitis in immunocompromised patients. In this review, we summarize the evidence that the viruses may also be one trigger for febrile seizures (including febrile status epilepticus) in immunocompetent infants and children, mesial temporal lobe epilepsy, multiple sclerosis (MS), and, possibly, Alzheimer's disease. We propose criteria for linking ubiquitous infectious agents capable of producing lifelong infection to any neurologic disease, and then we examine to what extent these criteria have been met for these viruses and these diseases.
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Affiliation(s)
- Anthony L Komaroff
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philip E Pellett
- Department of Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Steven Jacobson
- Virology/Immunology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
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Portaro S, Biasini F, Bramanti P, Naro A, Calabrò RS. Chronic inflammatory demyelinating polyradiculoneuropathy relapse after mexiletine withdrawal in a patient with concomitant myotonia congenita: A case report on a potential treatment option. Medicine (Baltimore) 2020; 99:e21117. [PMID: 32664137 PMCID: PMC7360317 DOI: 10.1097/md.0000000000021117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION we report on the first case of a woman affected by chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and recessive myotonia congenita (MC), treated with mexiletine. We aimed at describing the possible role of mexiletine in CIDP management. PATIENT CONCERNS A 44-year-old female affected by CIDP and MC, gained beneficial effects for CIDP symptoms (muscle weakness, cramps, and fatigue) and relapses, after mexiletine intake (200 mg twice a day). The patient presented with detrimental effects after mexiletine drop out, with a worsening of CIDP symptoms. INTERVENTIONS The patient reported a nearly complete remission of muscle stiffness and weakness up to 3 years since mexiletine intake. Then, she developed an allergic reaction with glottis edema, maybe related to mexiletine intake, as per emergency room doctors' evaluation, who suggested withdrawing the drug. OUTCOMES The patient significantly worsened after the medication drop out concerning both CIDP and MC symptoms. CONCLUSION This is the first report on the association of CIDP and MC in the same patient. Such diseases may share some clinical symptoms related to a persistent sodium currents increase, which maybe due either to the over-expression of sodium channels following axonal damage due to demyelination or to the chloride channel genes mutations. This is the possible reason why mexiletine maybe promising to treat CIDP symptoms.
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Síndrome de DRESS. Semergen 2020; 46:214-215. [DOI: 10.1016/j.semerg.2019.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/22/2019] [Accepted: 08/01/2019] [Indexed: 11/19/2022]
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Seree-aphinan C, Assanangkornchai N, Nilmoje T. Prolonged Extracorporeal Membrane Oxygenation Support In a Patient with Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome-associated Fulminant Myocarditis – A Case Report and Literature Review. Heart Int 2020; 14:112-117. [DOI: 10.17925/hi.2020.14.2.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/09/2020] [Indexed: 11/24/2022] Open
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Morinaga Y, Abe I, Minamikawa T, Ueda Y, Nii K, Sakamoto K, Inoue R, Mitsutake T, Hanada H, Tsugawa J, Kurihara K, Higashi T. A case of drug-induced hypersensitivity syndrome induced by salazosulfapyridine combined with SIADH caused by interstitial pneumonia. Drug Discov Ther 2019; 13:232-238. [PMID: 31534076 DOI: 10.5582/ddt.2019.01045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present a case of a patient with drug-induced hypersensitivity syndrome (DIHS) caused by salazosulfapyridine combined with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) caused by interstitial pneumonia (IP). A 67-year-old man with a past history of rheumatism (RA) presented with right hemiparalysis and aphasia as the chief complaints. A diagnosis of left embolic cerebral infarction following trial therapy for RA based on computed tomography findings was made, and external decompression was performed. Salazosulfapyridine was newly started on day 7. Dabigatran was started on day 37. On day 41, the patient developed fever. On day 42, edema and erythema appeared on his face, and erythema and rash appeared on his trunk and extremities, with gradual transition to erythroderma. The drug eruption was initially attributed to the dabigatran. Various symptoms of organ dysfunction (enteritis, myocarditis, interstitial pneumonia, hepatic disorder, stomatitis, and others) then appeared and persisted; hence, a diagnosis of DIHS associated with human herpes virus 6 and cytomegalovirus infection induced by salazosulfapyridine was suggested, and the oral administration of salazosulfapyridine was discontinued on day 53. Hyponatremia was observed in association with exacerbation of IP. Due to low serum osmotic pressure and prompt improvement of the serum sodium level by fluid restriction, the SIADH was attributed to IP. In this case, steroid pulse therapy followed by gradual decrease therapy prevented worsening of the condition.
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Affiliation(s)
- Yusuke Morinaga
- Department of Neurosurgery, Fukuoka University Chikushi Hospital
| | - Ichiro Abe
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital
| | | | - Yusuke Ueda
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital
| | - Kouhei Nii
- Department of Neurosurgery, Fukuoka University Chikushi Hospital
| | - Kimiya Sakamoto
- Department of Neurosurgery, Fukuoka University Chikushi Hospital
| | - Ritsurou Inoue
- Department of Neurosurgery, Fukuoka University Chikushi Hospital
| | | | - Hayatsura Hanada
- Department of Neurosurgery, Fukuoka University Chikushi Hospital
| | - Jun Tsugawa
- Department of Neurology, Fukuoka University Chikushi Hospital.,Stroke Center, Fukuoka University Chikushi Hospital
| | - Kanako Kurihara
- Department of Neurology, Fukuoka University Chikushi Hospital.,Stroke Center, Fukuoka University Chikushi Hospital
| | - Toshio Higashi
- Department of Neurosurgery, Fukuoka University Chikushi Hospital.,Stroke Center, Fukuoka University Chikushi Hospital
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Shiohara T, Mizukawa Y. Drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS): An update in 2019. Allergol Int 2019; 68:301-308. [PMID: 31000444 DOI: 10.1016/j.alit.2019.03.006] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Indexed: 12/14/2022] Open
Abstract
The aim of this review was to provide an updated overview of drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS). Several new insights have been made, particularly with regards to the diagnosis, pathogenesis and care of some important complications and sequelae. The indication of herpesvirus reactivations in diagnosis in the assessment of disease severity is now better specified. Nevertheless, because fatal complications and autoimmune sequelae have been under-recognized, there is a clear need to identify effective parameters for assessing disease severity and predicting prognosis of the disease in the early phase. In this regard, we have established a scoring system that can be used to monitor severity, predict prognosis and stratify the risk of developing severe complications including fatal cytomegalovirus (CMV) disease. Regulatory T cells are likely to be central to the mechanism and would represent potential targets for therapeutic approaches that can ameliorate inflammatory responses occurring at the acute phase while preventing the subsequent development of harmful outcomes, such as CMV disease and autoimmune diseases.
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Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms severity score: A useful tool for assessing disease severity and predicting fatal cytomegalovirus disease. J Am Acad Dermatol 2019; 80:670-678.e2. [DOI: 10.1016/j.jaad.2018.08.052] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 08/26/2018] [Accepted: 08/30/2018] [Indexed: 12/16/2022]
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Komura K, Hasegawa M, Hamaguchi Y, Yukami T, Nagai M, Yachie A, Sato S, Takehara K. Drug-Induced Hypersensitivity Syndrome Associated with Human Herpesvirus 6 and Cytomegalovirus Reactivation. J Dermatol 2014; 32:976-81. [PMID: 16471461 DOI: 10.1111/j.1346-8138.2005.tb00885.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2005] [Accepted: 06/28/2005] [Indexed: 10/25/2022]
Abstract
We describe a patient with drug-induced hypersensitivity syndrome (DIHS) associated with human herpesvirus 6 (HHV-6) and cytomegalovirus (CMV) infection induced by sulfasalazine. Two weeks after starting sulfasalazine to treat a rectal ulcer, the patient developed disseminated macular erythema accompanied by fever, liver injury, and lymphadenopathy. Seroconversion of antibodies to HHV-6 was observed. Systemic steroid treatment was not effective against the eruptions. Five months after the onset, he presented with an acute febrile disease. The detection of CMV antigen on peripheral blood leukocytes and positive staining for CMV on cutaneous endothelium indicated active CMV infection. Furthermore, he developed a bacteremia of methicillin resistant Staphylococcus aureus. An association the CMV reactivation with DIHS was suggested, although there remains the possibility that the systemic steroid treatment precipitated CMV reactivation. Recently, HHV-6 has been documented to have immunomodulating effects and to be associated with CMV reactivation. Therefore, we should pay attention to the possibility of CMV reactivation in patients with DIHS in whom the immunomodulating virus of HHV-6 has been reactivated.
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Affiliation(s)
- Kazuhiro Komura
- Department of Dermatology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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Morito H, Ogawa K, Kobayashi N, Fukumoto T, Asada H. Drug-induced hypersensitivity syndrome followed by persistent arthritis. J Dermatol 2011; 39:178-9. [PMID: 21767291 DOI: 10.1111/j.1346-8138.2011.01236.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
The Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) is a severe adverse drug-induced reaction. Diagnosing DRESS is challenging due to the diversity of cutaneous eruption and organs involved. We used the RegiSCAR scoring system that grades DRESS cases as "no," "possible," "probable," or "definite" to classify cases reported in the literature. We also analyzed the clinical course and treatments of the cases. A total of 44 drugs were associated with the 172 cases reported between January 1997 and May 2009 in PubMed and MEDLINE. The most frequently reported drug was carbamazepine, and the vast majority of cases were classified as "probable/definite" DRESS cases. Hypereosinophilia, liver involvement, fever, and lymphadenopathy were significantly associated with "probable/definite" DRESS cases, whereas skin rash was described in almost all of the cases, including "possible cases." Culprit drug withdrawal and corticosteroids constituted the mainstay of DRESS treatment. The outcome was death in 9 cases. However, no predictive factors for serious cases were found. This better knowledge of DRESS may contribute to improve the diagnosis and management of this syndrome in clinical practice.
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Bergmann JF. DRESS syndrome : à propos d’une revue de la littérature publiée dans Thérapie. Therapie 2011. [DOI: 10.2515/therapie/2011020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Özcan D, Seçkin D, Bilezikçi B, Arslan H. The role of human herpesvirus-6, Epstein-Barr virus and cytomegalovirus infections in the etiopathogenesis of different types of cutaneous drug reactions. Int J Dermatol 2010; 49:1250-4. [DOI: 10.1111/j.1365-4632.2010.04531.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ablashi DV, Devin CL, Yoshikawa T, Lautenschlager I, Luppi M, Kühl U, Komaroff AL. Review Part 3: Human herpesvirus-6 in multiple non-neurological diseases. J Med Virol 2010; 82:1903-10. [DOI: 10.1002/jmv.21860] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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19
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Sano S, Ueno H, Yamagami K, Yakushiji Y, Isaka Y, Kawasaki I, Takemura M, Inoue T, Hosoi M. Isolated ileal perforation due to cytomegalovirus reactivation during management of terbinafine hypersensitivity. World J Gastroenterol 2010; 16:3339-42. [PMID: 20614493 PMCID: PMC2900729 DOI: 10.3748/wjg.v16.i26.3339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We report a case of 71-year-old man who developed a hypersensitivity syndrome associated with terbinafine. He was placed on terbinafine (250 mg/d) for the treatment of tinea pedis due to diabetes mellitus. Following the treatment with terbinafine, he developed drug-induced hypersensitivity syndrome (DIHS). Systemic corticosteroid led to transient improvement of his clinical manifestations. Three months after disease onset, he presented with panperitonitis due to ileal perforation, and underwent an emergency operation. The affected ileum was resected and ileostomy was performed in the terminal ileum. Cytomegalovirus (CMV)-specific IgG antibodies were significantly increased, high-titer CMV antigenemia was detected, and pathological examination of the resected ileum confirmed CMV infection. Based on these observations, we strongly recommend that physicians monitor reactivation of the family of herpesvirus other than herpesvirus 6, to manage DIHS properly.
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Kano Y, Ishida T, Hirahara K, Shiohara T. Visceral involvements and long-term sequelae in drug-induced hypersensitivity syndrome. Med Clin North Am 2010; 94:743-59, xi. [PMID: 20609861 DOI: 10.1016/j.mcna.2010.03.004] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Drug-induced hypersensitivity syndrome (DIHS) is a severe systemic reaction with several herpesvirus reactivations. Multiple organ failures appear during the course of the disease. The severity of DIHS is determined by the degree of visceral involvement. Autoimmune diseases also develop several months to years after the apparent clinical resolution of DIHS.
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Affiliation(s)
- Yoko Kano
- Department of Dermatology, Kyorin University School of Medicine, 6-20-2 Shinkawa Mitaka, Tokyo 181-8611, Japan.
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Lee SP, Kim SH, Kim TH, Sohn JW, Shin DH, Park SS, Yoon HJ. A case of mexiletine-induced hypersensitivity syndrome presenting as eosinophilic pneumonia. J Korean Med Sci 2010; 25:148-51. [PMID: 20052362 PMCID: PMC2800002 DOI: 10.3346/jkms.2010.25.1.148] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Accepted: 07/14/2008] [Indexed: 11/20/2022] Open
Abstract
An 82-yr-old man was presented with fever and cough accompanied by generalized erythematous rash. He had taken mexiletine for 5 months, as he had been diagnosed with dilated cardiomyopathy and ventricular arrhythmia. Laboratory studies showed peripheral blood eosinophilia and elevated liver transaminase levels. Chest radiographs showed multiple nodular consolidations in both lungs. Biopsies of the lung and skin lesions revealed eosinophilic infiltration. After a thorough review of his medication history, mexiletine was suspected as the etiologic agent. After discontinuing the mexiletine and starting oral prednisolone, the patient improved, and the skin and lung lesions disappeared. Subsequently, mexiletine was confirmed as the causative agent based on a positive patch test. Drug-induced hypersensitivity syndrome is a severe adverse reaction to drugs and results from treatment with anticonvulsants, allopurinol, sulfonamides, and many other drugs. Several cases of mexiletine-induced hypersensitivity syndrome have been reported in older Japanese males with manifestation of fever, rash, peripheral blood eosinophilia, liver dysfunction without other organ involvement. Here, we report a case of mexiletine-induced hypersensitivity syndrome which presented as eosinophilic pneumonia in a Korean male.
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Affiliation(s)
- Sang-Pyo Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Tae Hyung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jang Won Sohn
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dong Ho Shin
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sung Soo Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Ho Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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22
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Kano Y, Shiohara T. The variable clinical picture of drug-induced hypersensitivity syndrome/drug rash with eosinophilia and systemic symptoms in relation to the eliciting drug. Immunol Allergy Clin North Am 2009; 29:481-501. [PMID: 19563993 DOI: 10.1016/j.iac.2009.04.007] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Drug-induced hypersensitivity syndrome (DIHS)/drug rash with eosinophilia and systemic symptoms (DRESS) is a life-threatening adverse reaction characterized by skin rashes, fever, leukocytosis with eosinophilia or atypical lymphocytosis, lymph node enlargement, and liver or renal dysfunction. The syndrome develops 2 to 6 weeks after initiation of administration of a specific drug. It has been demonstrated that various herpesvirus reactivations, in addition to human herpesvirus 6, contribute to internal organ involvement and the relapse of symptoms observed long after discontinuation of the causative drugs. A better understanding of the interplay in the development of DIHS/DRESS has implications for safer and more efficient treatment of this syndrome.
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Affiliation(s)
- Yoko Kano
- Department of Dermatology, Kyorin University School of Medicine, 6-20-2 Shinkawa Mitaka, Tokyo 181-8611, Japan.
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23
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Abstract
Drug-induced hypersensitivity syndrome (DIHS) is an adverse reaction with clinical signs of fever, rash, and internal organ involvement. The culprit drugs of DIHS are limited to several drugs such as carbamazepine, phenytoin, phenobarbital, zonisamide, allopurinol, salazosulfapyridine, diaphenylsulphone, and mexiletine. The association of HHV-6 reactivation with DIHS has been known. Flaring of symptoms such as fever and hepatitis is closely related to HHV-6 reactivation. A combination of immunologic reaction to a drug and HHV-6 reactivation results in the severe course of DIHS.
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Affiliation(s)
- Mikiko Tohyama
- Department of Dermatology, Ehime University Graduate School of Medicine.
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Tohyama M, Hashimoto K, Yasukawa M, Kimura H, Horikawa T, Nakajima K, Urano Y, Matsumoto K, Iijima M, Shear NH. Association of human herpesvirus 6 reactivation with the flaring and severity of drug-induced hypersensitivity syndrome. Br J Dermatol 2007; 157:934-40. [PMID: 17854362 DOI: 10.1111/j.1365-2133.2007.08167.x] [Citation(s) in RCA: 242] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Drug-induced hypersensitivity syndrome (DIHS) is an adverse reaction with clinical signs of fever, rash and internal organ involvement. In the vast majority of patients in Japan, the causative drugs for DIHS are limited to the following eight: carbamazepine, phenytoin, phenobarbital, zonisamide, mexiletine, dapsone, salazosulfapyridine and allopurinol. The association of human herpesvirus (HHV)-6 reactivation with DIHS has been reported by various groups. OBJECTIVES To confirm the relationship between the flaring and severity of DIHS and HHV-6 reactivation. METHODS We evaluated 100 patients with drug rash and systemic symptom(s) caused by the drugs associated with DIHS. HHV-6 reactivation was examined by serological antibody assay and quantitative real-time polymerase chain reaction assay of serial serum samples. RESULTS Anti-HHV-6 IgG titres increased in 62 of 100 patients, 14-28 days after the onset of symptoms. These patients suffered from severe organ involvement and a prolonged course compared with 38 patients showing no reactivation of HHV-6. Significant amounts of HHV-6 DNA were detected in serum samples from 18 of the 62 patients. Flaring of symptoms such as fever and hepatitis was closely related to HHV-6 reactivation in these 18 patients. It should be emphasized that all five patients with fatal outcome and 10 patients with renal failure were in the HHV-6 reactivation group. CONCLUSIONS A combination of immunological reaction to a drug and HHV-6 reactivation results in the severe course of DIHS. The demonstration of HHV-6 reactivation is a useful marker of diagnosis as well as prognosis in DIHS.
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Affiliation(s)
- M Tohyama
- Department of Dermatology, Ehime University School of Medicine, Toon-city, Ehime 791-0295, Japan.
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25
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Seishima M, Yamanaka S, Fujisawa T, Tohyama M, Hashimoto K. Reactivation of human herpesvirus (HHV) family members other than HHV-6 in drug-induced hypersensitivity syndrome. Br J Dermatol 2006; 155:344-9. [PMID: 16882173 DOI: 10.1111/j.1365-2133.2006.07332.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Drug-induced hypersensitivity syndrome (DIHS) is characterized by a severe multiorgan hypersensitivity reaction that usually appears after a 3-6-week exposure to certain drugs, including anticonvulsants. There are some reports showing that serum IgG levels often decrease at the early stage of DIHS. Reactivation of human herpesvirus (HHV)-6 has been reported in patients with DIHS, and some other DIHS patients showed reactivation of cytomegalovirus (CMV) or Epstein-Barr virus (EBV). OBJECTIVES To determine whether reactivation of HHV-6, HHV-7, CMV and/or EBV occurs in patients with DIHS. METHODS Titres of IgG and IgM antibodies to HHV-6 and HHV-7 were determined using an indirect immunofluorescence antibody assay on admission and at various times after admission. Anti-CMV IgG and IgM antibody titres and anti-EBV capsid antigen IgG, IgA, IgM, and EBV nuclear antigen and EBV early antigen IgG titres were determined by enzyme immunoassay. Polymerase chain reaction (PCR) procedures for HHV-6, HHV-7, CMV and EBV DNAs were performed using serum samples. IgG antibody titres to HHV-6, HHV-7, CMV and EBV were increased after the onset in seven, six, seven and two of seven patients, respectively. IgG antibody titres to HHV-6 and HHV-7 were elevated simultaneously 21-38 days after the onset. RESULTS IgG antibody titres to CMV and EBV were elevated 10-21 days after the elevation of HHV-6 and HHV-7 antibody titres. PCR showed that HHV-6, HHV-7, CMV and EBV DNAs became positive in six, five, seven and two of seven patients, respectively. HHV-6 and HHV-7 DNAs were detected 21-35 days after the onset, and CMV DNA was detected 10-21 days after detection of HHV-6 and HHV-7 DNAs. CONCLUSION The present study suggests that in addition to HHV-6 reactivation, reactivation of HHV-7, CMV and/or EBV may also occur following drug eruption in some patients with DIHS.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Viral/blood
- Cytomegalovirus/immunology
- Cytomegalovirus/isolation & purification
- Cytomegalovirus/physiology
- DNA, Viral/blood
- Drug Eruptions/virology
- Drug Hypersensitivity/virology
- Female
- Herpesviridae/immunology
- Herpesviridae/isolation & purification
- Herpesviridae/physiology
- Herpesviridae Infections/complications
- Herpesviridae Infections/virology
- Herpesvirus 4, Human/immunology
- Herpesvirus 4, Human/isolation & purification
- Herpesvirus 4, Human/physiology
- Herpesvirus 6, Human/immunology
- Herpesvirus 6, Human/isolation & purification
- Herpesvirus 6, Human/physiology
- Herpesvirus 7, Human/immunology
- Herpesvirus 7, Human/isolation & purification
- Herpesvirus 7, Human/physiology
- Humans
- Male
- Middle Aged
- Virus Activation
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Affiliation(s)
- M Seishima
- Department of Dermatology, Ogaki Municipal Hospital, Minaminokawa-cho 4-86, Ogaki City 503-8502, Japan.
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Pichler WJ, Beeler A, Keller M, Lerch M, Posadas S, Schmid D, Spanou Z, Zawodniak A, Gerber B. Pharmacological interaction of drugs with immune receptors: the p-i concept. Allergol Int 2006; 55:17-25. [PMID: 17075282 DOI: 10.2332/allergolint.55.17] [Citation(s) in RCA: 170] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2005] [Indexed: 12/17/2022] Open
Abstract
Drug-induced hypersensitivity reactions have been explained by the hapten concept, according to which a small chemical compound is too small to be recognized by the immune system. Only after covalently binding to an endogenous protein the immune system reacts to this so called hapten-carrier complex, as the larger molecule (protein) is modified, and thus immunogenic for B and T cells. Consequently, a B and T cell immune response might develop to the drug with very heterogeneous clinical manifestations. In recent years, however, evidence has become stronger that not all drugs need to bind covalently to the MHC-peptide complex in order to trigger an immune response. Rather, some drugs may bind directly and reversibly to immune receptors like the major histocompatibility complex (MHC) or the T cell receptor (TCR), thereby stimulating the cells similar to a pharmacological activation of other receptors. This concept has been termed pharmacological interaction with immune receptors the (p-i) concept. While the exact mechanism is still a matter of debate, non-covalent drug presentation clearly leads to the activation of drug-specific T cells as documented for various drugs (lidocaine, sulfamethoxazole (SMX), lamotrigine, carbamazepine, p-phenylendiamine, etc.). In some patients with drug hypersensitivity, such a response may occur within hours even upon the first exposure to the drug. Thus, the reaction to the drug may not be due to a classical, primary response, but rather be mediated by stimulating existing, pre-activated, peptide-specific T cells that are cross specific for the drug. In this way, certain drugs may circumvent the checkpoints for immune activation imposed by the classical antigen processing and presentation mechanisms, which may help to explain the peculiar nature of many drug hypersensitivity reactions.
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Affiliation(s)
- Werner J Pichler
- Division of Allergology, Clinic for Rheumatology and Clinical Immunology/Allergology, Inselspitel, Berne, Switzerland.
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27
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2005. [DOI: 10.1002/pds.1033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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