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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: 6] [Impact Index Per Article: 6.0] [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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Wang ZZ, Zeng R, Wu ZW, Wang C, Jiang HQ, Wang HS. Overview and Current Advances in Dapsone Hypersensitivity Syndrome. Curr Allergy Asthma Rep 2023; 23:635-645. [PMID: 37804376 DOI: 10.1007/s11882-023-01109-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE OF REVIEW As a sulfone antibacterial agent, dapsone has been widely used to treat leprosy. Moreover, dapsone is also used in many immune diseases such as herpetic dermatitis because of its anti-inflammatory and immunomodulatory effects. However, dapsone can cause several adverse effects, the most serious being dapsone hypersensitivity syndrome. Dapsone hypersensitivity syndrome is characterized by a triad of eruptions, fever, and organ involvement, which limits the application of dapsone to some extent. RECENT FINDINGS In this article, we review current research about the interaction model between HLA-B*13:01, dapsone, and specific TCR in dapsone-induced drug hypersensitivity. In addition to the proposed mechanisms, we also discussed clinical features, treatment progress, prevalence, and prevention of dapsone hypersensitivity syndrome. These studies reveal the pathogenesis, clinical features, and prevalence from the perspectives of genetic susceptibility and innate and adaptive immunity in dapsone hypersensitivity syndrome, thereby guiding clinicians on how to diagnose, prevent, and treat dapsone hypersensitivity syndrome.
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Affiliation(s)
- Zhen-Zhen Wang
- Hospital of Skin Diseases and Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, St. 12 Jiangwangmiao, Nanjing, Jiangsu, China
| | - Rui Zeng
- Hospital of Skin Diseases and Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, St. 12 Jiangwangmiao, Nanjing, Jiangsu, China
| | - Zi-Wei Wu
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Chen Wang
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hai-Qin Jiang
- Hospital of Skin Diseases and Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, St. 12 Jiangwangmiao, Nanjing, Jiangsu, China.
| | - Hong-Sheng Wang
- Hospital of Skin Diseases and Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, St. 12 Jiangwangmiao, Nanjing, Jiangsu, China.
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China.
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[Dapsone in the treatment of pemphigus foliaceus: A clinical series of 23 cases and a literature review]. Ann Dermatol Venereol 2020; 147:873-876. [PMID: 32826082 DOI: 10.1016/j.annder.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 02/08/2020] [Accepted: 07/23/2020] [Indexed: 11/20/2022]
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Watanabe H, Watanabe Y, Tashiro Y, Mushiroda T, Ozeki T, Hashizume H, Sueki H, Yamamoto T, Utsunomiya-Tate N, Gouda H, Kusakabe Y. A docking model of dapsone bound to HLA-B*13:01 explains the risk of dapsone hypersensitivity syndrome. J Dermatol Sci 2017; 88:320-329. [PMID: 28870516 DOI: 10.1016/j.jdermsci.2017.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/04/2017] [Accepted: 08/08/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Dapsone (4,4'-diaminodiphenylsulfone) has been widely used for the treatment of infections such as leprosy. Dapsone hypersensitivity syndrome (DHS) is a major side effect, developing in 0.5-3.6% of patients treated with dapsone, and its mortality rate is ∼10%. Recently, human leukocyte antigen (HLA)-B*13:01 was identified as a marker of susceptibility to DHS. OBJECTIVES To investigate why HLA-B*13:01 is responsible for DHS from a structural point of view. METHODS First, we used homology modeling to derive the three-dimensional structures of HLA-B*13:01 (associated with DHS) and HLA-B*13:02 (not so associated despite strong sequence identity [99%] with HLA-B*13:01). Next, we used molecular docking, molecular dynamic simulations, and the molecular mechanics Poisson-Boltzman surface area method, to investigate the interactions of dapsone with HLA-B*13:01 and 13:02. RESULTS We found a crucial structural difference between HLA-B*13:01 and 13:02 in the F-pocket of the antigen-binding site. As Trp95 in the α-domain of HLA-B*13:02 is replaced with the less bulky Ile95 in HLA-B*13:01, we found an additional well-defined sub-pocket within the antigen-binding site of HLA-B*13:01. All three representative docking poses of dapsone against the antigen-binding site of HLA-B*13:01 used this unique sub-pocket, indicating its suitability for binding dapsone. However, HLA-B*13:02 does not seem to possess a binding pocket suitable for binding dapsone. Finally, a binding free energy calculation combined with a molecular dynamics simulation and the molecular mechanics Poisson-Boltzman surface area method indicated that the binding affinity of dapsone for HLA-B*13:01 would be much greater than that for HLA-B*13:02. CONCLUSIONS Our computational results suggest that dapsone would fit within the structure of the antigen-recognition site of HLA-B*13:01. This may change the self-peptides that bind to HLA-B*13:01, explaining why HLA-B*13:01 is a marker of DHS susceptibility.
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Affiliation(s)
- Hideaki Watanabe
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan.
| | - Yurie Watanabe
- Department of Analytical and Physical Chemistry, Showa University School of Pharmacy, Tokyo, Japan
| | - Yasuya Tashiro
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan
| | | | - Takeshi Ozeki
- RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Hideo Hashizume
- Department of Dermatology, Shimada Municipal Hospital, Shizuoka, Japan
| | - Hirohiko Sueki
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan
| | - Toshinori Yamamoto
- Showa University Medical Foundation, Showa University School of Pharmacy, Tokyo, Japan
| | - Naoko Utsunomiya-Tate
- Laboratory of Chemistry, Faculty of Pharma Sciences, Teikyo University, Tokyo, Japan
| | - Hiroaki Gouda
- Department of Analytical and Physical Chemistry, Showa University School of Pharmacy, Tokyo, Japan.
| | - Yoshio Kusakabe
- Department of Analytical and Physical Chemistry, Showa University School of Pharmacy, Tokyo, Japan; Laboratory of Chemistry, Faculty of Pharma Sciences, Teikyo University, Tokyo, Japan
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Novel interferon-γ enzyme-linked immunoSpot assay using activated cells for identifying hypersensitivity-inducing drug culprits. J Dermatol Sci 2017; 86:222-229. [DOI: 10.1016/j.jdermsci.2017.03.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/27/2017] [Accepted: 03/08/2017] [Indexed: 11/24/2022]
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Sun Q, Sha W, Gui XW, Xiao YJ, Zeng WH, Sun WW, Xiao HP, Ye WY. Drug-induced lymphocyte stimulation test in the prediction of drug-induced hypersensitivity to antituberculosis drugs. Diagn Microbiol Infect Dis 2015; 82:172-6. [PMID: 25863530 DOI: 10.1016/j.diagmicrobio.2015.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 03/03/2015] [Accepted: 03/08/2015] [Indexed: 01/10/2023]
Abstract
Antituberculosis (TB) chemotherapeutic drugs may cause a variety of adverse drug reactions (ADRs). To assess the potential of drug-induced lymphocyte stimulation test (DLST) in screening ADRs in patients treated with anti-TB drugs, we performed DLST in 272 TB patients (176 cases with ADRs and 96 controls without ADRs) treated with anti-TB drugs isoniazid (INH), rifampicin (RFP), ethambutol (EMB), and pyrazinamide (PZA). The ADRs were diagnosed by drug provocation test based on clinical and laboratory examinations. The sensitivities of DLST in the diagnosis of INH-, RFP-, EMB-, or PZA-induced ADRs were 57.8%, 37.1%, 42.4%, and 23.1%, respectively, with the corresponding specificities being 93.4%, 94.0%, 97.5%, and 98.8%. DLST has high specificity and limited sensitivity in the diagnosis of anti-TB drug-induced ADRs. In combination with clinical observation and drug use history, DLST could have a predictive validity of ADRs, especially when a positive result is obtained.
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Affiliation(s)
- Qin Sun
- Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Wei Sha
- Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China.
| | - Xu-Wei Gui
- Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Yang-Jiong Xiao
- Shanghai Institute of Immunology, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Wei-Hong Zeng
- Shanghai Institute of Immunology, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Wen-Wen Sun
- Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - He-Ping Xiao
- Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Wei-Yi Ye
- Shanghai Institute of Immunology, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
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Oliveira-Batista DP, Janini MER, Fernandes NC, Santos N. Laboratory Diagnosis of Herpesvirus Infections in Patients with Pemphigus Vulgaris Lesions. Intervirology 2013; 56:231-6. [DOI: 10.1159/000349889] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 02/11/2013] [Indexed: 11/19/2022] Open
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Hanafusa T, Azukizawa H, Matsumura S, Katayama I. The predominant drug-specific T-cell population may switch from cytotoxic T cells to regulatory T cells during the course of anticonvulsant-induced hypersensitivity. J Dermatol Sci 2012; 65:213-9. [DOI: 10.1016/j.jdermsci.2011.12.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 11/22/2011] [Accepted: 12/02/2011] [Indexed: 01/20/2023]
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Development of a human herpesvirus 6 species-specific immunoblotting assay. J Clin Microbiol 2012; 50:1245-51. [PMID: 22278837 DOI: 10.1128/jcm.05834-11] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In order to assess the full spectrum of human herpesvirus 6A (HHV-6A)- and HHV-6B-associated diseases, we sought to develop an HHV-6 species-specific serological assay based on immunoblot analysis. The immunodominant proteins encoded by open reading frame U11, p100 for HHV-6A (strain U1102) and 101K for HHV-6B (strain Z29), were selected to generate virus species-specific antigens. Recombinant p100 and 101K were produced in a prokaryotic expression system. The expression of these proteins was confirmed by using anti-His tag and 101K-specific monoclonal antibodies. HHV-6 species-specific antibodies were detected by immunoblotting in patient sera. Eighty-seven serum samples obtained from various subjects were utilized to determine the reliability of the method for clinical use. Ten of twelve exanthem subitum convalescent-phase sera reacted exclusively with 101K, whereas none of twelve acute-phase sera reacted with either protein. Two of three sera collected from HHV-6A-infected patients reacted with p100 and 101K. Although all five acute and convalescent-phase sera obtained from transplant recipients reacted exclusively with 101K, two of six convalescent-phase sera obtained from patients with drug-induced hypersensitivity syndrome reacted with both p100 and 101K. Of 38 sera obtained from healthy adults, 31 were positive for 101K antibody, while 4 reacted with both proteins. However, PCR analysis of peripheral blood mononuclear cells and saliva from these subjects did not detect HHV-6A DNA. In conclusion, this novel serological assay based on immunoblot analysis using recombinant HHV-6A p100 and HHV-6B 101K allowed us to discriminate between HHV-6A- and HHV-6B-specific antibodies.
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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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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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Gürcan HM, Ahmed AR. Efficacy of dapsone in the treatment of pemphigus and pemphigoid: analysis of current data. Am J Clin Dermatol 2009; 10:383-96. [PMID: 19824739 DOI: 10.2165/11310740-000000000-00000] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Dapsone is a chemotherapeutic agent primarily used in treating leprosy, Pneumocystis jiroveci (previously carinii) pneumonia, and malaria. It is also used as an adjuvant in the treatment of pemphigus and pemphigoid. To assess the role of dapsone in the treatment of pemphigus and pemphigoid, a retrospective review of reports in the English-language literature was conducted. Information on the number of patients treated, their average age, prior therapies, indications for use, protocol (dose and interval) used, concomitant therapies, reported adverse effects, and clinical outcomes were analyzed. There were 35 case reports/series published describing the use of dapsone in a total of 427 patients. Data on 55 pemphigus patients were obtained from several case reports and some case series and one randomized controlled trial. Of these, 32 patients with pemphigus vulgaris and 14 patients with pemphigus foliaceus responded to dapsone. Data from 13 case series, each including at least five patients, accounted for 372 patients with pemphigoid. The overall response rates to dapsone, when given either alone or in combination with corticosteroids or immunosuppressive agents, were 84% in mucous membrane pemphigoid, and 81% in bullous pemphigoid. Hemolysis was the most common adverse effect observed. Dapsone is a promising and useful agent in patients with autoimmune mucocutaneous blistering diseases, especially in mucous membrane pemphigoid. It can be used as a corticosteroid-sparing agent. Therefore, its combined use with oral corticosteroids may be useful in pemphigus vulgaris and bullous pemphigoid. Adverse effects of dapsone are dose dependent and usually reversible. Hemolysis and concomitant anemia secondary to hemolysis are expected in most patients. In the opinion of the authors, dapsone is underutilized in the treatment of autoimmune mucocutaneous blistering diseases.
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Affiliation(s)
- Hakan M Gürcan
- Center for Blistering Diseases, New England Baptist Hospital, Boston, Massachusetts 02120, USA
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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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Severe cutaneous adverse drug reactions: a review on epidemiology, etiology, clinical manifestation and pathogenesis. Chin Med J (Engl) 2008. [DOI: 10.1097/00029330-200804020-00019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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