RegiSCAR DRESS (drug reaction with eosinophilia and systemic symptoms) validation scoring system and Japanese consensus group criteria for atypical drug-induced hypersensitivity syndrome (DiHS): A comparative analysis

Accelerated Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome in Response to TMP-SMX: A Case Report

BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare and severe hypersensitivity reaction triggered by medications, characterized by fever, rash, eosinophilia, and multi-organ involvement. While DRESS shares features with Stevens-Johnson syndrome (SJS) and fixed-drug eruption, distinguishing factors such as organ involvement, absence of mucosal lesions, and extended latency periods complicate its diagnosis. This case report aims to highlight an unusual presentation of DRESS to contribute to the growing understanding of its diagnostic and management challenges. CASE REPORT We present the case of a 25-year-old woman with DRESS attributed to trimethoprim-sulfamethoxazole (TMP-SMX) for acute pyelonephritis. Symptoms, including fever, diffuse maculopapular rash, facial edema, and lymphadenopathy, began within 6 days of drug exposure, deviating significantly from the typical 2- to 8-week latency period. Differential diagnoses, such as Stevens-Johnson syndrome and fixed-drug eruption, delayed the recognition of DRESS. A calculated RegiSCAR score of 5 indicated a probable case. Management included discontinuation of TMP-SMX, initiation of systemic corticosteroids, and supportive care. The patient experienced rapid symptom resolution without relapse, demonstrating a favorable outcome despite atypical features. CONCLUSIONS This case underscores the diagnostic complexities of DRESS, particularly in distinguishing it from other severe cutaneous drug reactions and managing atypical presentations with multiple drug exposures. It emphasizes the importance of early identification, timely cessation of the offending agent, and individualized treatment strategies. Further investigation into the role of concurrent antibiotic use in accelerating DRESS onset and exacerbating severity is warranted to enhance clinical understanding and improve patient outcomes.

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.

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.

Leflunomide-induced drug reaction eosinophilia systemic symptoms and haemophagocytic lymphohistiocytosis overlap syndrome with rheumatoid arthritis

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and haemophagocytic lymphohistiocytosis (HLH) are rare but severe immune-mediated diseases with overlapping clinical manifestations. We present a case of a woman in her late 40s with rheumatoid arthritis who developed DRESS/HLH overlap syndrome after starting hydroxychloroquine and leflunomide therapy. Despite corticosteroid treatment, her condition worsened, necessitating etoposide therapy. The persistent pancytopenia required supportive measures, including transfusions of blood products and administration of growth factors. Tofacitinib was successfully used as a steroid-sparing agent and resulted in the resolution of symptoms without relapse during a 2 month follow-up. This case emphasises the diagnostic and therapeutic challenges posed by the co-occurrence of DRESS and HLH and highlights the importance of tailoring treatment strategies to achieve good outcomes.

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.

[Delayed hypersensitivity reactions to drugs: Group Report of the Drug Allergy Committee of the Mexican College of Clinical Immunology and Allergy (CMICA).]

BACKGROUND

Adverse drug reactions are defined as unexpected reactions, either derived from the pharmacokinetics of the treatment (Type A) or as a host immune response (Type B), resulting in harmful or undesirable manifestations in the patient following the administration of pharmacological therapy. Type B reactions are less defined and are considered a result of hypersensitivity to pharmacological treatment, categorized as immediate (within 1 to 6 hours after exposure) and delayed or non-immediate (occurring 6 hours after exposure).

OBJECTIVE

A review to describe the immunological mechanisms of delayed hypersensitivity reactions to drugs.

METHODS

A search of major medical databases on delayed hypersensitivity reactions to drugs was conducted. The review was limited to articles published in the period between 2013 and 2023, taking into consideration articles written in English and Spanish.

RESULTS

The terms defining delayed hypersensitivity reactions to drugs, their classification, clinical manifestations, diagnosis, treatment algorithms, and prognosis.

CONCLUSIONS

Adverse drug reactions represent a challenge for the specialist physician, with a complex pathophysiology. A prompt diagnosis and treatment focused on the drug phenotype and its immunological expression are required to provide a multidisciplinary approach.

A prospective observational study validating the CET score as a screening tool in suspected DRESS syndrome

BACKGROUND

Drug reaction with eosinophilia and systemic symptoms (DRESS) is an idiosyncratic severe cutaneous adverse reaction that may be potentially life-threatening. Recently, a simple scoring system for the early screening of DRESS patients was derived by combining hsCRP levels, the eosinophil count, and the total body surface area (CET score). The objectives of this study were validating the CET score, and calculating its lead time advantage and cost-benefits compared to RegiSCAR scoring.

METHODS

This is a prospective observational case-control study, where 110 consecutive patients diagnosed with drug-induced maculopapular exanthema (MPE) were recruited during the 18 months of the study period. Patients were classified as cases (DRESS) and controls (MPE) using RegiSCAR score cut-off 2 (possible DRESS). They were also simultaneously screened using the CET score, based on which patients were classified as positive or negative. They were subsequently followed up on Day 15 for a second comparison and assessment of lead time and at 3 and 6 weeks to evaluate clinical response.

RESULTS

Seventy cases and 40 controls were recruited. At a cut-off of >2.12, the CET score had a sensitivity of 94.3%, a specificity of 60%, a positive predictive value (PPV) of 80.5%, and a negative predictive value (PPV) of 85.7%. The median delay in diagnosing DRESS using RegiSCAR was around 14.5 hours. There was a median cost benefit of 12.1 USD in favor of the CET score.

CONCLUSIONS

The CET score had good diagnostic performance in screening DRESS patients with a lead time of 14.5 hours and fewer costs incurred.

Case report: Drug reaction with eosinophilia and systemic symptoms (DRESS) induced by ceftazidime in a connective tissue disease (CTD) patient

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare and severe cutaneous adverse drug reactions (SCARs) with high mortality. Antibiotics are the most frequent causative agents related to DRESS. However, it is rarely reported in cephalosporins, especially for ceftazidime. Here, we reported a case of ceftazidime-induced DRESS with HLA genotypic polymorphism as a risk factor. A 58-year-old woman with connective tissue disease was intravenously infused with ceftazidime for the treatment of pneumonia and intestinal infection, followed by the presence of fever, rash, and hematologic and hepatic laboratory abnormalities. DRESS was diagnosed and the positive polymorphism in HLA-B*15:02 was found. Our case illustrated the necessity to clarify the patho-mechanism and the use of pretreatment HLA analysis to prevent ceftazidime-related DRESS may be a valuable option soon.

Evaluation of Anticonvulsant-Induced Leukocytosis: A Review of Evidence for Carbamazepine, Lamotrigine, and Phenobarbital

Objective: The objective was to determine the incidence of leukocytosis associated with carbamazepine, lamotrigine, and phenobarbital. Data sources: A comprehensive literature review was conducted with the assistance of a medical reference librarian on PubMed, MEDLINE, Embase, and Google Scholar through June 2023 using the following search terminology: "leukocytosis/chemically induced"[MeSH Terms] AND ("Anticonvulsants"[MeSH Terms] OR ("Anticonvulsants"[Pharmacological Action] OR "Anticonvulsants"[MeSH Terms] OR "Anticonvulsants"[All Fields] OR "anticonvulsant"[All Fields] OR "anticonvulsion"[All Fields] OR "anticonvulsive"[All Fields] OR "anticonvulsives"[All Fields]) OR ("Anticonvulsants"[Pharmacological Action] OR "Anticonvulsants"[MeSH Terms] OR "Anticonvulsants"[All Fields] OR "antiepileptic"[All Fields] OR "antiepileptics"[All Fields])). Study selection and data extraction: Thirteen reports were included from 64 potential results of our literature review following the application of inclusion and exclusion criteria: 7 of the reports involved carbamazepine, 4 of the reports involved lamotrigine, and 2 of the reports involved phenobarbital. Data synthesis: Drug-induced leukocytosis is commonly a diagnosis of exclusion and is a phenomenon that has numerous ramifications to patients and clinicians at the bedside, including mandating a full infectious evaluation, the identification of confounding variables, and the eventual discontinuation of the offending agent. Despite several medications and medication classes possessing this adverse drug effect, an evaluation of the specific clinical presentation and management strategies for drug-induced leukocytosis associated with anticonvulsant medications has not been elucidated in the literature. Conclusions: Clinicians should be judicious when evaluating leukocytosis in patients on potentially precipitating medications, including carbamazepine, lamotrigine, and phenobarbital.

Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part II diagnosis and management

Drug-induced hypersensitivity syndrome, also known as drug reaction with eosinophilia and systemic symptoms, is a severe cutaneous adverse reaction characterized by an exanthem, fever, and hematologic and visceral organ involvement. The differential diagnosis includes other cutaneous adverse reactions, infections, inflammatory and autoimmune diseases, and neoplastic disorders. Three sets of diagnostic criteria have been proposed; however, consensus is lacking. The cornerstone of management is immediate discontinuation of the suspected drug culprit. Systemic corticosteroids remain first-line therapy, but the literature on steroid-sparing agents is expanding. Longitudinal evaluation for sequelae is recommended. Adjunctive tests for risk stratification and drug culprit identification remain under investigation. Part II of this continuing medical education activity begins by exploring the differential diagnosis and diagnosis of drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms and concludes with an evidence-based overview of evaluation and treatment.

ALDRESS: A Retrospective Pilot Study to Develop a Pharmacological Causality Algorithm for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

Background: The drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome represents a severe form of drug hypersensitivity reaction characterized by significant morbidity, mortality, and long-term sequelae, coupled with limited therapeutic avenues. Accurate identification of the causative drug(s) is paramount for acute management, exploration of safe therapeutic alternatives, and prevention of future occurrences. However, the absence of a standardized diagnostic test and a specific causality algorithm tailored to DRESS poses a significant challenge in its clinical management. Methods: We conducted a retrospective case-control study involving 37 DRESS patients to validate a novel causality algorithm, the ALDRESS, designed explicitly for this syndrome, comparing it against the current standard algorithm, SEFV. Results: The ALDRESS algorithm showcased superior performance, exhibiting an 85.7% sensitivity and 93% specificity with comparable negative predictive values (80.6% vs. 97%). Notably, the ALDRESS algorithm yielded a substantially higher positive predictive value (75%) compared to SEFV (51.40%), achieving an overall accuracy rate of 92%. Conclusions: Our findings underscore the efficacy of the ALDRESS algorithm in accurately attributing causality to drugs implicated in DRESS syndrome. However, further validation studies involving larger, diverse cohorts are warranted to consolidate its clinical utility and broaden its applicability. This study lays the groundwork for a refined causality assessment tool, promising advancements in the diagnosis and management of DRESS syndrome.

Evaluation of the frequency and characteristics of drug hypersensitivity reactions in hospitalized children: Real life-cohort study

Introduction

There are limited data regarding the characteristics and management of drug hypersensitivity reactions (DHR) in hospitalized children. This study aims to determine the prevalence, clinical features, and management of DHRs in pediatric inpatients.

Methods

Children who had pediatric allergy consultation for suspected DHR during hospitalization in Ankara Bilkent City Hospital between August 1, 2020, and July 30, 2021, were included. Patient and reaction characteristics, culprit drugs, and management strategies were recorded. When possible, diagnostic tests (skin or provocation tests) were performed after discharge.

Results

Among the 14,090 hospitalized children, 165 (72% male, median age: 106 months) underwent consultation for 192 suspected DHRs with 246 drugs. Cutaneous eruptions were the most common (94.3%). There was anaphylaxis in 40 patients and severe cutaneous adverse drug reaction in 4 patients (drug rash with eosinophilia and systemic symptoms in 3, acute generalized exanthematous pustulosis in 1). Antimicrobials were the leading cause (78.4%, n = 193/246). In 48 reactions, 60 (24%) culprit drugs could be readministered with close follow-up or desensitization (n = 12). In total, 186 suspected drugs were discontinued, and 115 were replaced with alternative drugs. After discharge, 38 provocation tests (2 positives) and 36 skin tests (1 positive prick test, 1 positive intradermal test, and 1 positive patch test) were performed.

Discussion/conclusions

The incidence of suspected DHR among pediatric inpatients was approximately 1.1%. Skin symptoms were the most common manifestation. Twenty-four percent of suspected drugs could be continued during hospitalization. Patients with DHR during hospitalization should be evaluated with a drug allergy work-up unless there are contraindications to testing.

Key factors predicting the in-hospital mortality of patients with severe cutaneous adverse reactions in Thailand

BACKGROUND

At present, no predictive models are available to determine the probability of in-hospital mortality rates (HMRs) in all phenotypes of severe cutaneous adverse reactions (SCARs).

OBJECTIVES

Our study explored whether simple clinical and laboratory assessments could help predict the HMRs in any phenotypes of SCAR patients.

METHODS

Factors influencing HMRs in 195 adults diagnosed with different SCAR phenotypes were identified, and their optimal cut-offs were determined by Youden's index. Predictive equations for HMRs for all SCAR patients and Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) patients were determined using the exact logistic regression models.

RESULTS

Acute generalized exanthematous pustulosis (AGEP) patients were significantly older, with a short time from drug exposure to reaction, and higher neutrophil count compared to SJS/TEN and drug reaction with eosinophilia and systemic symptoms (DRESS, p < 0.001). Peripheral blood eosinophilia, atypical lymphocytosis and elevated liver transaminase enzymes were significantly higher in DRESS. SJS/TEN phenotype, age ≥ 71.5 years, neutrophil-to-lymphocyte ratio ≥ 4.08 (high NLR) and systemic infection were factors predicting in-hospital mortality in all SCAR subjects. The ALLSCAR model developed from these factors demonstrated high-diagnostic accuracy for predicting HMRs in all SCAR phenotypes (area under the receiver-operator curve (AUC) = 0.95). The risk of in-hospital death was significantly increased in SCAR patients with high NLR after adjusting for systemic infection. The model derived from high NLR, systemic infection and age yielded higher accuracy than SCORTEN (AUC = 0.77) for predicting the HMRs in SJS/TEN patients (AUC = 0.97).

CONCLUSIONS

Being older, having systemic infection, having a high NLR and SJS/TEN phenotype increases ALLSCAR scores, which in turn increases the risk of in-hospital mortality. These basic clinical and laboratory parameters can easily be obtained in any hospital setting. Despite its simple approach, further validation of the model is warranted.

A posteriori diagnosis of DRESS syndrome induced by diazoxide in a patient with an insulinoma: a case report and review of the literature

The Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome can be potentially life-threatening. The diagnosis is sometimes difficult since the clinical manifestations may be incomplete or non-specific. Insulinoma is a rare functioning neuroendocrine tumor (NET) of the pancreas. Medical therapy may be needed when surgery is contraindicated, delayed or refused. Diazoxide is widely used to control hypoglycemia in patients with insulinoma. We report a clinical case of an insulinoma in a 85-year-old patient treated with diazoxide with a fatal outcome due to a delayed diagnosis of a DRESS syndrome. This is the first case of DRESS syndrome reported after using diazoxide for insulinoma treatment in our knowledge.

Drug Reaction With Eosinophilia and Systemic Symptoms-Associated Perimyocarditis After Initiation of Anti-tuberculosis Therapy: A Case Report

A 34-year-old female who was recently placed on anti-tuberculosis medication with rifampin, isoniazid, pyrazinamide, and levofloxacin therapy for suspected tuberculosis reinfection presented with subjective fevers, rash, and generalized fatigue. Labs showed signs of end-organ damage with eosinophilia and leukocytosis. One day later, the patient became hypotensive with a worsening fever, and an electrocardiogram showed new diffuse ST segment elevations with an elevated troponin. An echocardiogram revealed a reduction in ejection fraction with diffuse hypokinesis, and cardiac magnetic resonance imaging (MRI) showed circumferential myocardial edema with subepicardial and pericardial inflammation. Prompt diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome using the European Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) criteria and discontinuation of therapy was initiated. Due to the hemodynamic instability of the patient, the patient was started on systemic corticosteroids and cyclosporine, with the improvement of her symptoms and rash. A skin biopsy was performed, which revealed perivascular lymphocytic dermatitis, consistent with DRESS syndrome. As the patient's ejection fraction improved spontaneously with corticosteroids, the patient was discharged with oral corticosteroids, and a repeat echocardiogram showed full recovery of ejection fraction. Perimyocarditis is a rare complication of DRESS syndrome that is associated with degranulation and the release of cytotoxic agents into myocardial cells. Early discontinuation of offending agents and initiation of corticosteroids are essential to rapid recovery of ejection fraction and improved clinical outcomes. Multimodality imaging, including MRI, should be used to confirm perimyocardial involvement and guide the necessity for mechanical support or transplant. Further research should be on the mortality of DRESS syndrome with and without myocardial involvement, with an increased emphasis on cardiac evaluation in DRESS syndrome.

Drug-Induced Reaction With Eosinophilia and Systemic Symptoms: A Review

Drug-induced reaction with eosinophilia and systemic symptoms (DRESS) is a part of severe cutaneous adverse reactions (SCAR), often a life-threatening condition. DRESS is an uncommon reaction; however, it is more prevalent than Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and is left undiagnosed due to its atypical clinical presentation. So far, no standard criteria or investigational tool assists in early and accurate diagnosis. The administration of systemic corticosteroids remains the widely used first line of management. However, new studies have revealed other potential treatment armamentariums. Because of the potential life-threatening outcome, every physician who deals with acute cases should be familiar with the clinical presentation and be able to start the necessary measurements. Recent studies revealed important information in the pathogenesis and management of the disorder were summarized in this review.