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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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Chaabane A, Romdhane HB, Fadhel NB, Fredj NB, Ammar H, Boughattas N, Chadly Z, Aouam K. DRESS characteristics according to the causative medication. Eur J Clin Pharmacol 2022; 78:1503-1510. [PMID: 35726027 DOI: 10.1007/s00228-022-03353-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND To date, no study has identified a clear relationship between drug and a specific clinical presentation of DRESS. OBJECTIVES To investigate the particularities of DRESS and analyze the variation of DRESS pattern according to culprit drugs. METHODS We analyzed cases of DRESS notified to the Department of Clinical Pharmacology at the University Hospital of Monastir over a 15-year period. The statistical study was performed using the comparative and multivariate analysis. RESULTS DRESS was mostly induced by anticonvulsive agents (27%) followed by allopurinol (26.3%) and antibiotics (24%): For anticonvulsive agents, the occurrence of lymphadenopathy was higher, renal involvement was rare and mild, and positive skin tests were more frequent. The allopurinol group was associated with the patient's older age and a lower incidence of lymphadenopathy and kidney injury. For antibiotics, eosinophilia rate was lower, time to recovery was shorter, and RegiSCAR score was low. The multivariate analysis showed a link of allopurinol with severe renal impairment, antibiotics with short latency period and low RegiSCAR score, and anticonvulsants with high propensity of positive skin test. CONCLUSION We report the largest African and south Mediterranean cohort of DRESS and evaluated the usefulness of skin tests in identifying the culprit drug. The prominent finding was that latency period and renal involvement may independently differ according to culprit drugs.
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Affiliation(s)
- A Chaabane
- Service de Pharmacologie Clinique, CHU/Faculté de Médecine, Université de Monastir, Rue 1er Juin 1955, 5019, Monastir, Tunisia
| | - H Ben Romdhane
- Service de Pharmacologie Clinique, CHU/Faculté de Médecine, Université de Monastir, Rue 1er Juin 1955, 5019, Monastir, Tunisia
| | - N Ben Fadhel
- Service de Pharmacologie Clinique, CHU/Faculté de Médecine, Université de Monastir, Rue 1er Juin 1955, 5019, Monastir, Tunisia
| | - N Ben Fredj
- Service de Pharmacologie Clinique, CHU/Faculté de Médecine, Université de Monastir, Rue 1er Juin 1955, 5019, Monastir, Tunisia
| | - H Ammar
- Service de Pharmacologie Clinique, CHU/Faculté de Médecine, Université de Monastir, Rue 1er Juin 1955, 5019, Monastir, Tunisia
| | - N Boughattas
- Service de Pharmacologie Clinique, CHU/Faculté de Médecine, Université de Monastir, Rue 1er Juin 1955, 5019, Monastir, Tunisia
| | - Z Chadly
- Service de Pharmacologie Clinique, CHU/Faculté de Médecine, Université de Monastir, Rue 1er Juin 1955, 5019, Monastir, Tunisia
| | - K Aouam
- Service de Pharmacologie Clinique, CHU/Faculté de Médecine, Université de Monastir, Rue 1er Juin 1955, 5019, Monastir, Tunisia.
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Delgado MG, Casu S, Montani M, Brunner F, Semmo N, Berzigotti AB, Dufour JF. Hepatic manifestations of drug reaction with eosinophilia and systemic symptoms syndrome. EXPLORATION OF MEDICINE 2021. [DOI: 10.37349/emed.2021.00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a potentially life-threatening drug reaction, which can affect multiple organs. Patients with DRESS syndrome and hepatic manifestations may present alterations ranging from mild hepatitis to acute liver failure. The diagnosis might be difficult, and the management of these patients is challenging. This report analyzes a series of five cases reporting the clinical presentation, which ranged from acute hepatitis to liver failure, and discussed their treatment.
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Affiliation(s)
- Maria Gabriela Delgado
- Hepatology, University Clinic of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, 3010 Bern, Switzerland
| | - Stefania Casu
- ASST Santi Paolo e Carlo, Hepatology and Gastroenterology Unit, 20153 Milano, Italy
| | - Matteo Montani
- Institute of Pathology, Inselspital, University Hospital Bern, 3008 Bern, Switzerland
| | - Felix Brunner
- Clinic of Gastroenterolgy and Hepatology, Bürgerspital Solothurn, 4500 Solothurn, Switzerland
| | - Nasser Semmo
- Hepatology, University Clinic of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, 3010 Bern, Switzerland
| | - Annalisa Berzigotti Berzigotti
- Hepatology, University Clinic of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, 3010 Bern, Switzerland 5Hepatology, Department of Biomedical Research, University of Bern, 3008 Bern, Switzerland
| | - Jean François Dufour
- Hepatology, University Clinic of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, 3010 Bern, Switzerland 5Hepatology, Department of Biomedical Research, University of Bern, 3008 Bern, Switzerland
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Devarbhavi H, Raj S. Drug-induced liver injury with skin reactions: Drugs and host risk factors, clinical phenotypes and prognosis. Liver Int 2019; 39:802-811. [PMID: 30515930 DOI: 10.1111/liv.14004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/30/2018] [Accepted: 11/07/2018] [Indexed: 02/13/2023]
Abstract
While dermatologic manifestations of adverse drug reactions are frequent, drug-induced liver injury is rare. Numerous drugs are implicated in either Drug-Induced Liver Injury or Drug-Induced Skin Injury. However, concomitant Drug-Induced Liver Injury and Drug-Induced Skin Injury are uncommon, not well characterized and appear to be caused by a limited number of drugs. These are often associated with immuno-allergic or hypersensitivity features such as fever, skin rash, blisters or peeling of skin, eosinophilia, lymphadenopathy and mucositis. Liver injury can range from asymptomatic elevation of liver biochemical tests to severe hepatitis and acute liver failure needing liver transplantation. Severe cutaneous adverse reaction, particularly drug reaction with eosinophilia and systemic symptoms is commonly associated with internal organ involvement, the liver being the most frequently involved in approximately 90% of the cases. In Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis, abnormalities in liver biochemistry tests are common but severe liver disease is rare. There is a strong association of Human Leukocyte Antigen genotype with both drug reaction with eosinophilia and systemic symptoms and Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. It is likely that the delayed immune-mediated reaction triggering skin reaction is also responsible for hepatitis. Drug-specific lymphocytes are found in the organs involved and also in circulating blood, which along with the cytokines and chemokines play a role in pathogenesis. Anti-epileptic drugs, allopurinol, sulfonamides, antibiotics and nevirapine are the top five causes of concomitant liver and skin injury. This review will focus on drug and host factors causing concomitant Drug-Induced Skin Injury and Drug-Induced Liver Injury and discuss the characteristics of liver involvement in patients with severe cutaneous adverse reaction.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Sujata Raj
- Department of Dermatology, St. John's Medical College Hospital, Bangalore, India
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Sim DW, Yu JE, Jeong J, Jung JW, Kang HR, Kang DY, Ye YM, Jee YK, Kim S, Park JW, Kang MG, Kim SH, Park HK, Yang MS, Hur GY, Lee JK, Choi JH, Kwon YE, Koh YI. Variation of clinical manifestations according to culprit drugs in DRESS syndrome. Pharmacoepidemiol Drug Saf 2019; 28:840-848. [PMID: 31044478 DOI: 10.1002/pds.4774] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/31/2019] [Accepted: 02/21/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but serious condition that systematically damages various internal organs through T-cell-mediated immunological drug reactions. We aimed to investigate whether clinical manifestations of DRESS syndrome differ according to culprit drugs. METHODS We retrospectively analyzed data from 123 patients with probable/definite DRESS syndrome based on the RegiSCAR criteria (January 2011 to July 2016). The data were obtained from the Korean Severe Cutaneous Adverse Reaction Registry. Causality was assessed using the World Health Organization-Uppsala Monitoring Centre criteria. The culprit drugs were categorized as allopurinol, carbamazepine, anti-tuberculosis drug, vancomycin, cephalosporins, dapsone, and nonsteroidal anti-inflammatory drugs. RESULTS Differences were observed among culprit drugs regarding the frequencies of hepatitis (P < 0.01), renal dysfunction (P < 0.0001), lymphadenopathy (P < 0.01), and atypical lymphocyte (P < 0.01). Latency period differed among culprit drugs (P < 0.0001), being shorter in vancomycin and cephalosporin. In terms of clinical severity, admission duration (P < 0.01) and treatment duration (P < 0.05) differed among culprit drugs, being longer in vancomycin and anti-tuberculosis drugs, respectively. CONCLUSIONS Based on the findings, clinical manifestations, including latency period and clinical severity, may differ according to culprit drugs in DRESS syndrome.
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Affiliation(s)
- Da Woon Sim
- Division of Allergy, Asthma and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.,Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Eun Yu
- Division of Allergy, Asthma and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jiung Jeong
- Division of Allergy, Asthma and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hye-Ryun Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
| | - Dong Yoon Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
| | - Young Min Ye
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Young-Koo Jee
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Sujeong Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jung-Won Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Gyu Kang
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Sae Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Gyu-Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jeong-Hee Choi
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Yong Eun Kwon
- Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Young-Il Koh
- Division of Allergy, Asthma and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Intarasupht J, Kanchanomai A, Leelasattakul W, Chantrarat T, Nakakes A, Tiyanon W. Prevalence, risk factors, and mortality outcome in the drug reaction with eosinophilia and systemic symptoms patients with cardiac involvement. Int J Dermatol 2018; 57:1187-1191. [DOI: 10.1111/ijd.14174] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/20/2018] [Accepted: 07/16/2018] [Indexed: 12/17/2022]
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De A, Rajagopalan M, Sarda A, Das S, Biswas P. Drug Reaction with Eosinophilia and Systemic Symptoms: An Update and Review of Recent Literature. Indian J Dermatol 2018. [PMID: 29527023 PMCID: PMC5838752 DOI: 10.4103/ijd.ijd_582_17] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, is also known as drug induced hypersensitivity syndrome and by various other names. It is now recognised as one of the severe cutaneous adverse reaction (SCAR) and can be potentially life-threatening. Historically, it was most frequently linked with phenytoin and was initially described as phenytoin hypersensitivity syndrome. However, it was later found to be caused by various other medications. Anticonvulsants and sulfonamides are the most common offender. Characteristically DRESS has a latent period of 2 to 6 weeks. The pathophysiology remains incompletely understood but involves reactivation of viruses and activation of lymphocyte. It is manifested most commonly with a morbilliform cutaneous eruption with fever and lymphadenopathy. The severity of this syndrome is related to the systemic involvement, which can result in multi-organ failure. Most important step in the management of DRESS is early diagnosis and immediate cessation of the suspected offending drug. Patients of DRESS syndrome should be managed in an intensive care set up for appropriate supportive care and infection control. Topical corticosteroids can give symptomatic relief, but systemic therapy with steroid and other immunosuppressant is usually required.
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Affiliation(s)
- Abhishek De
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | | | - Aarti Sarda
- Department of Dermatology, Wizderm Speciality Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Sudip Das
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Projna Biswas
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
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