Overlapping DRESS and Stevens-Johnson Syndrome: Case Report and Review of the Literature

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review of Current Management and Innovative Therapies

There is no consensus regarding the treatment of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Supportive care remains the preferred approach internationally, while the efficacy of topical/systemic therapies is subject to controversy. We reviewed published guidelines and recommendations on SJS/TEN management and assessed supportive care involving topical and systemic therapies in a series of SJS patients. We included several specialty departments from different countries to determine the consensus in the management of SJS/TEN. We also included SJS patients and provided supportive care including silver nitrate at 0.5% sprayed on denuded areas, in conjunction with a single dose of subcutaneous etanercept. Based on our literature review and experience, we propose a management algorithm for SJS/TEN. Our review confirmed the importance of supportive care, including specific topical and systemic treatments, for SJS/TEN. Systemic corticotherapy, cyclosporine A, intravenous immunoglobulin, tumor necrosis factor-alpha (TNF-α) blockers, or combinations are subject to controversies. In our pilot series of seven adult patients with SJS, we obtained good clinical results within 1 week, with mucosal and skin clearance at Week 2, along with a good safety profile. This was achieved by spraying topical silver nitrate at a concentration of 0.5% on denuded areas, following a single dose of etanercept. This consensus led to the recommendation of a combination of supportive care along with several possible topical and systemic therapies for SJS/TEN. Corticosteroids, immunoglobulins, cyclosporine A, and TNF-alpha blockers were used in our centers alone or in combination, with good results associated with 0.5% topical silver nitrate. In our series of SJS patients, silver nitrate at 0.5% associated with etanercept showed a good response.

Overlapping of DRESS and Stevens-Johnson syndrome due to first-line antituberculosis drugs: a case report

The overlap of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) and Stevens-Johnson syndrome (SJS) caused by antituberculosis drugs represents an extremely rare event. This situation can manifest between 2 and 8 weeks after the first exposure to the medication. The overlap of these conditions can lead to atypical clinical manifestations, thus complicating the early diagnosis and the implementation of early treatment. This report describes the case of a patient who developed the DRESS/SJS overlap 35 days after starting antituberculosis treatment. The patient experienced severe skin and systemic involvement, a situation that required her admission and monitoring in the intensive care unit. From our experience with this case, we conclude the importance of an accurate and timely diagnosis using validated scoring systems such as RegiSCAR to confirm the clinical diagnosis of DRESS/SJS and ALDEN to assess the likelihood of drug causality. Timely intervention with corticosteroids plays a key role in moderating the exaggerated immune response, helping to alleviate dermatological symptoms and prevent long-term organ damage. In addition, the availability of safe therapeutic alternatives for tuberculosis treatment allows for more effective and safer management in these patients.

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.

DRESSed for distress: a case of allopurinol-induced DRESS syndrome

DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) syndrome is a severe systemic drug reaction characterized by a latent period of several weeks following the initiation of drug therapy. Among the most well-known causative agents is allopurinol, commonly prescribed for managing asymptomatic gout. Allopurinol-induced DRESS syndrome is associated with high mortality rates and significant long-term sequelae. This report details the case of an elderly female patient who presented with an extensive rash covering her trunk and extremities which was concurrent with her use of allopurinol. The condition progressed to renal impairment but showed significant improvement upon cessation of the drug and administration of high-dose corticosteroids. This case aims to shed light on one of the most underrecognized types of systemic drug reactions, hoping to raise awareness about this rare yet serious complication of one of the most widely prescribed drugs.

Stevens-Johnson syndrome with overlapping features of DRESS syndrome: A report of two cases

Stevens-Johnson syndrome and drug reaction with eosinophilia and systemic symptoms are severe cutaneous adverse reactions to drugs that are generally considered distinct entities. In addition to identifying the offending medication, distinguishing between these diagnoses is important, as they have differing treatment regimens and prognoses. Distinction between severe cutaneous adverse reactions, particularly in the early stages of disease, can be difficult, and overlapping conditions have been reported in the literature. We present two cases of severe cutaneous adverse reaction, one following initiation of carbamazepine and the other lamotrigine, with extensive mucosal involvement and epidermal detachment, initially diagnosed as Stevens-Johnson syndrome. Despite the use of cyclosporine and repeated doses of etanercept, both cases evolved to have significant edema of the face and extremities, palmar and plantar involvement, and rapid response to systemic corticosteroids, which is more in-keeping with drug reaction with eosinophilia and systemic symptoms. We aim to help clinicians gain awareness of Stevens-Johnson syndrome/drug reaction with eosinophilia and systemic symptoms overlap which may aid diagnosis and guide treatment.

Toxic Epidermal Necrolysis Superimposed on Severe Drug Rash With Eosinophilia and Systemic Symptoms Complicated by Fatal Hemophagocytic Lymphohistiocytosis: A Case Report

Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse reaction (SCAR) characterized by an extensive skin rash associated with visceral organ involvement, fever, eosinophilia, atypical lymphocytosis, and lymphadenopathy. Toxic epidermal necrolysis (TEN) is a more severe, distinct adverse cutaneous reaction that causes extensive necrosis and detachment of the epidermis, involving over 30% of the body surface area (BSA). Hemophagocytic lymphohistiocytosis (HLH), a form of excessive immune activation, is known to be associated with SCARs such as DRESS. We present a peculiar case of overlap between different SCARs to reiterate their gravity, a severe form of DRESS triggered by the use of allopurinol overlapping with the aggressive TEN possibly from interaction with vancomycin administered for severe sepsis, which was complicated by a fatal case of HLH.

DRESS and Stevens-Johnson Syndrome Overlap Secondary to Allopurinol in a 50-Year-Old Man-A Diagnostic and Treatment Challenge: Case Report

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a drug reaction commonly related to eosinophilia, from uncertain epidemiology, and without consensus for diagnosis and treatment globally. It presents a great challenge in its management and is characterized by fever, lymphadenopathy, skin rash, and multisystemic involvement. An aggressive and difficult-to-manage clinical case is presented in a 50-year-old man with chronic kidney disease due to diabetes mellitus type 2 and systemic arterial hypertension, who developed an unusual variant similar to DRESS and Stevens-Johnson syndrome (SJS) overlap secondary to allopurinol, with skin manifestations without eosinophilia, but fulfilling clinical and laboratory criteria for DRESS and SJS syndrome.

Etanercept leads to a rapid recovery of a Dabrafenib-/Trametinib-associated toxic epidermal necrolysis-like severe skin reaction

Targeted therapy with BRAF- and MEK-Inhibitors (BRAFi, MEKi) provides an excellent therapeutic option for patients with malignant melanomas with a BRAF-Mutation. Mild cutaneous adverse events have been common under the BRAF- and MEK-Inhibitor therapy, on the contrary, severe cutaneous adverse reactions to drugs (SCARs) are rarely reported. We present the case of a 59- year-old female patient who after the resection of cutaneous in-transit metastases of a malignant melanoma received one adjuvant cycle of Nivolumab followed by a switch of the therapy to an oral BRAFi/MEKi therapy. 3-4 Weeks after the therapy switch she developed high fever, chills, progredient general weakness, headaches, abdominal complaints, generalised rash as well as thrombocytopaenia, eosinophilia, elevated liver enzymes, declining kidney, and pulmonary function as well as a maculopapular exanthema. She was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS) and quickly started recovery after initiation of a high steroid substitution. Under steroid dose reduction, the exanthema worsened and toxic epidermal necrolysis (TEN) was histologically diagnosed. After a series of unsuccessful therapeutic approaches (high dose steroid, human immunoglobulins and ciclosporin) the patient received a single dose of the TNF-alpha inhibitor etanercept, which led to a quick recovery. This case demonstrates that DRESS and TEN can present a spectrum of possibly transitioning SCARs providing a diagnostic and therapeutic challenge. Nevertheless, in a such complicated therapeutic setting, etanercept may be lifesaving even after multiple previous unsuccessful therapies. This effective approach provides evidence SCARs due to BRAF/MEK targeted therapy may be driven by TNF-alpha.

Stevens-Johnson syndrome and toxic epidermal necrolysis in a referral center in Taiwan

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially fatal adverse drug reactions. The characteristics of these diseases are changing with the use of novel drugs, posing new challenges to doctors. We aimed to review recent SJS/TEN cases in order to assist general practitioners with timely diagnosis and correct management.

METHODS

We conducted a retrospective chart review of SJS/TEN patients in a referral center in Taiwan from 2009 to 2019. We included 24 patients' charts and analyzed demographic data, medication histories, clinical courses, human leukocyte antigen (HLA) alleles, and long-term complications.

RESULTS

The average age was 63.4 years, and the average toxic epidermal necrolysis-specific severity of illness score was 1.9. The most common culprit drug was carbamazepine (33.3%), followed by antibiotics (12.5%) and nonsteroidal anti-inflammatory drugs (8.3%). Two cases were caused by immune checkpoint inhibitors, and one of them had a long latency of 210 days. Three out of the four patients carrying HLA-B*15:02 had carbamazepine-induced SJS/TEN. All patients were treated with systemic corticosteroids in the acute stage of the diseases. The length of in-hospital stay did not correlate with the average daily dose of corticosteroids. The overall mortality rate was 4.2%, and the disease-specific mortality rate was 0%.

CONCLUSIONS

The most common culprit drug was carbamazepine, which had strong association with HLA-B*15:02. There was no statistically significant correlation between in-hospital stay and the average daily dose of corticosteroids. Immune checkpoint inhibitor-related SJS/TEN may have an extended latent period.

Epidemiology and Risk Factors for Severe Delayed Drug Hypersensitivity Reactions

Severe delayed drug hypersensitivity reactions comprise different clinical entities and can involve different immune-mediated mechanisms. Common examples are severe cutaneous adverse reactions and druginduced internal organ injuries. The incidence of such reactions is overall low but seems to be on the rise reaching numbers as high as 9 per million individuals-years in the case of SJS/TEN and DRESS. Such conditions carry an important associated morbidity, and mortality can attain 40% in SJS/TEN patients, making these hypersensitivity reactions important targets when implementing preventive measures. Several risk factors have been identified for reaction severity; some are transverse, such as older age and underlying chronic diseases. The recent advances in pharmacogenetics allowed the identification of specific populations with higher risk and permitted strategic avoidance of certain drugs being HLA-B*57:01 screening in patients initiating abacavir the best successful example. In this work, we reviewed the epidemiology of SCARs and liver/kidney/lung drug-induced immune-mediated reactions. We focus on particular aspects such as prevalence and incidence, drugs involved, mortality and risk factors.

Human leukocyte antigen-associated severe cutaneous adverse drug reactions: from bedside to bench and beyond

Despite their being uncommon, severe cutaneous adverse drug reactions (SCARs) result in a very great burden of disease. These reactions not only carry with them a high mortality (10%-50%) and high morbidity (60%) with severe ocular complications, alopecia, oral and dental complications and development of autoimmune diseases, but also create a substantial economic burden for patients' families and society. SCARs are, therefore, an important medical problem needing a solution in many countries, especially in Asia. The clinical spectrum of SCARs comprises Stevens-Johnson syndrome, toxic epidermal necrolysis, DRESS (drug rash with eosinophilia and systemic symptoms) (also known as drug hypersensitivity syndrome or drug-induced hypersensitivity syndrome) and acute generalised exanthematous pustulosis. Recent crucial advances in determining genetic susceptibility and understanding how T cells recognise certain medications or their metabolites via the major histocompatibility complex and the effects of cofactors, have led to the implementation of cost-effective screening programs enabling prevention in a number of countries, and to further understanding of the patho-mechanisms involved in SCARs and their significance. In this review, we document comprehensively the journey of SCARs from bedside to bench and outline future perspectives in SCARs research.