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Brüggen MC, Traidl S, Mitamura Y, Walsh S, French LE, Gulati N, Phillips E, Maverakis E, Ingen-Housz-Oro S. Medical algorithm: Diagnosis and treatment of drug reaction with eosinophilia and systemic symptoms in adult patients. Allergy 2024; 79:2876-2880. [PMID: 38587051 DOI: 10.1111/all.16122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 03/15/2024] [Accepted: 03/31/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Marie-Charlotte Brüggen
- Faculty of Medicine, University Zurich, Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland
- ToxiTEN group of the ERN-skin
| | - Stephan Traidl
- Faculty of Medicine, University Zurich, Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - Yasutaka Mitamura
- Swiss Institute of Allergy and Asthma Research (SIAF) Davos, Davos, Switzerland
| | - Sarah Walsh
- ToxiTEN group of the ERN-skin
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Lars E French
- ToxiTEN group of the ERN-skin
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Nicholas Gulati
- The Kimberly and Eric J. Waldman Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elizabeth Phillips
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emanual Maverakis
- Department of Dermatology, University of California, Davis, California, USA
| | - Saskia Ingen-Housz-Oro
- ToxiTEN group of the ERN-skin
- Department of Dermatology, Henri Mondor Hospital, Univ Paris Est Créteil EpidermE, Créteil, Paris, France
- Reference center for severe drug reactions TOXIBUL, Créteil, France
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2
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Wedel CL. Demystifying drug reaction with eosinophilia and systemic symptoms (DRESS): a review of the literature and guidelines for management. Arch Dermatol Res 2024; 316:644. [PMID: 39325061 DOI: 10.1007/s00403-024-03389-z] [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: 01/02/2024] [Revised: 09/04/2024] [Accepted: 09/14/2024] [Indexed: 09/27/2024]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe, adverse drug reaction that is notoriously complex in both its presentation and treatment. Although early diagnosis and cessation of the causative agent are universally accepted as the initial interventions for DRESS, the subsequent management lacks a standardized approach. Historically, systemic steroids have been used as first-line treatment, but there is debate about the optimal dosing and route of administration, and evidence persists on the long-term complications associated with steroid use. Novel treatment approaches with targeted therapy, cyclosporine, intravenous immunoglobulin, and plasmapheresis have been gaining interest as alternative mono- and adjuvant therapies, but their use has yet to be supported by clinical trials. This narrative review provides a summary of the current knowledge of DRESS, with a focus on clinical management. The various mono- and adjuvant therapy options are discussed, with literature-supported suggestions for their optimal use in clinical practice. The risks for relapses, viral reactivation, and long-term complications are also considered. The PubMed and Medline databases were searched for articles on DRESS, published between January 1, 2008, and May 1, 2023. 334 articles met the inclusion criteria. Based on the literature, a DRESS management tool with step-by-step guidance is provided. Further suggestions for management are woven throughout this review, giving clinicians a toolbelt of resources with which to approach diagnosis, treatment, and follow-up.
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Affiliation(s)
- Chelsea L Wedel
- Faculty of Health Sciences, University of the Fraser Valley, Chilliwack, BC, Canada.
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3
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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 II diagnosis and management. J Am Acad Dermatol 2024; 90:911-926. [PMID: 37516356 DOI: 10.1016/j.jaad.2023.02.073] [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: 09/28/2022] [Revised: 02/11/2023] [Accepted: 02/17/2023] [Indexed: 07/31/2023]
Abstract
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.
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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 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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4
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Hung SI, Mockenhaupt M, Blumenthal KG, Abe R, Ueta M, Ingen-Housz-Oro S, Phillips EJ, Chung WH. Severe cutaneous adverse reactions. Nat Rev Dis Primers 2024; 10:30. [PMID: 38664435 DOI: 10.1038/s41572-024-00514-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 06/15/2024]
Abstract
Severe cutaneous adverse reactions (SCARs), which include Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (also known as drug-induced hypersensitivity syndrome), acute generalized exanthematous pustulosis, and generalized bullous fixed drug eruption, are life-threatening conditions. The pathogenesis of SCARs involves T cell receptors recognizing drug antigens presented by human leukocyte antigens, triggering the activation of distinct T cell subsets. These cells interact with keratinocytes and various immune cells, orchestrating cutaneous lesions and systemic manifestations. Genetic predisposition, impaired drug metabolism, viral reactivation or infections, and heterologous immunity influence SCAR development and clinical presentation. Specific genetic associations with distinct SCAR phenotypes have been identified, leading to the implementation of genetic screening before prescription in various countries to prevent SCARs. Whilst systemic corticosteroids and conventional immunomodulators have been the primary therapeutic agents, evolving strategies, including biologics and small molecules targeting tumour necrosis factor, different cytokines, or Janus kinase signalling pathways, signify a shift towards a precision management paradigm that considers individual clinical presentations.
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Affiliation(s)
- Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department and Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Mayumi Ueta
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saskia Ingen-Housz-Oro
- Dermatology Department, AP-HP, Henri Mondor Hospital, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Université Paris Est Créteil EpiDermE, Créteil, France
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei/Linkou branches, and Chang Gung University, Taoyuan, Taiwan.
- Department of Dermatology, Chang Gung Memorial Hospital, Xiamen branch, Xiamen, China.
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5
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Brüggen MC, Walsh S, Ameri MM, Anasiewicz N, Maverakis E, French LE, Ingen-Housz-Oro S. Management of Adult Patients With Drug Reaction With Eosinophilia and Systemic Symptoms: A Delphi-Based International Consensus. JAMA Dermatol 2024; 160:37-44. [PMID: 37966824 PMCID: PMC10652220 DOI: 10.1001/jamadermatol.2023.4450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/28/2023] [Indexed: 11/16/2023]
Abstract
Importance Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal drug hypersensitivity reaction. To our knowledge, there is no international consensus on its severity assessment and treatment. Objective To reach an international, Delphi-based multinational expert consensus on the diagnostic workup, severity assessment, and treatment of patients with DRESS. Design, Setting, and Participants The Delphi method was used to assess 100 statements related to baseline workup, evaluation of severity, acute phase, and postacute management of DRESS. Fifty-seven international experts in DRESS were invited, and 54 participated in the survey, which took place from July to September 2022. Main Outcomes/Measures The degree of agreement was calculated with the RAND-UCLA Appropriateness Method. Consensus was defined as a statement with a median appropriateness value of 7 or higher (appropriate) and a disagreement index of lower than 1. Results In the first Delphi round, consensus was reached on 82 statements. Thirteen statements were revised and assessed in a second round. A consensus was reached for 93 statements overall. The experts agreed on a set of basic diagnostic workup procedures as well as severity- and organ-specific further investigations. They reached a consensus on severity assessment (mild, moderate, and severe) based on the extent of liver, kidney, and blood involvement and the damage of other organs. The panel agreed on the main lines of DRESS management according to these severity grades. General recommendations were generated on the postacute phase follow-up of patients with DRESS and the allergological workup. Conclusions and Relevance This Delphi exercise represents, to our knowledge, the first international expert consensus on diagnostic workup, severity assessment, and management of DRESS. This should support clinicians in the diagnosis and management of DRESS and constitute the basis for development of future guidelines.
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Affiliation(s)
- Marie-Charlotte Brüggen
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
| | - Sarah Walsh
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
- Department of Dermatology, King’s College Hospital, London, England, United Kingdom
| | - M. Milad Ameri
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
| | - Natalie Anasiewicz
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Emanual Maverakis
- Department of Dermatology, University of California, Davis, Sacramento, California
| | - Lars E. French
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Saskia Ingen-Housz-Oro
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
- Department of Dermatology, Henri Mondor University Hospital, University of Paris-Est Créteil, Créteil, France
- Toxic Bullous Dermatoses TOXIBUL Reference Center, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France
- Univ Paris Est Créteil EpiDermE, Créteil, France
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6
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Marcombes C, Ingen-Housz-Oro S, Dezoteux F, Staumont-Sallé D, Milpied B, Tetart F, de Prost N, Fourati S, Ortonne N, Kasimir F, Prusty BK, Descamps V. Retrospective study on the association of human herpesvirus reactivation with severe DRESS: A description of blood and skin reactivations. J Eur Acad Dermatol Venereol 2023; 37:2550-2557. [PMID: 37591509 DOI: 10.1111/jdv.19425] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a severe adverse event (mortality of 10%). Its pathophysiology involves herpesviruses, particularly HHV-6, but the exact mechanisms are still poorly understood. OBJECTIVE To describe severe cases of DRESS and especially their association with herpesvirus reactivation. METHODS This study was a multicentre case series conducted between 2007 and 2021 at five University Hospital Centres in France. The study included patients who had severe DRESS, which was defined as death, transfer to the intensive care unit (ICU), or severe damage to internal organs. We excluded patients without blood PCR sample, without a drug formally attributed or with RegiSCAR score < 6. We collected data on severity, causative drug, associated visceral damage and results of viral blood PCRs. HHV-6 reactivation was studied in skin biopsies by detection of small non-coding transcripts (HHV-6 miR-aU14) and a late viral protein (GP82/105). RESULTS Fifty-two patients were included (29 female, median age 62, interquartile range (IQR) [37;72]). Eight patients (15%) died, 13 (27%) were admitted to ICU. Most patients (n = 34; 65%) had multisystem involvement: most frequent was liver (n = 46; 88%), then renal failure (n = 24; 46%). Forty patients (77%) had at least one blood viral reactivation among HHV-6, EBV or CMV, of which 21 (53%) had at least two. Median time of blood HHV-6 reactivation was 24 days (IQR [20;35]). HHV-6 reactivation was demonstrated in 15 out of 20 skin biopsies, with a median time of 11 days [9;17]. CONCLUSIONS We confirmed the high rate of HHV-6 reactivation in severe DRESS and demonstrated cutaneous HHV-6 reactivation using small non-coding transcripts (HHV-6 miR-aU14), which preceded viral PCR positivity in blood. These results suggest that HHV-6 reactivation during DRESS may start in skin. Furthermore, search for miR-aU14 in skin biopsy could become a useful diagnostic tool for early detection of HHV-6 reactivation.
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Affiliation(s)
- C Marcombes
- Department of Dermatology, AP-HP, Bichat Hospital, Paris, France
| | - S Ingen-Housz-Oro
- Department of Dermatology, AP-HP, Henri-Mondor Hospital, Créteil, France
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions TOXIBUL, Créteil, France
- Epiderme, Paris Est Créteil University, Créteil, France
- FISARD Study Group (French Investigators for Skin Adverse Reactions to Drugs) of the French Dermatology Society, Paris, France
| | - F Dezoteux
- FISARD Study Group (French Investigators for Skin Adverse Reactions to Drugs) of the French Dermatology Society, Paris, France
- Department of Dermatology, CHU Lille, Univ Lille, INSERM U1286, Lille Inflammation Translational Research Institute (INFINITE), Lille, France
| | - D Staumont-Sallé
- FISARD Study Group (French Investigators for Skin Adverse Reactions to Drugs) of the French Dermatology Society, Paris, France
- Department of Dermatology, CHU Lille, Univ Lille, INSERM U1286, Lille Inflammation Translational Research Institute (INFINITE), Lille, France
| | - B Milpied
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions TOXIBUL, Créteil, France
- FISARD Study Group (French Investigators for Skin Adverse Reactions to Drugs) of the French Dermatology Society, Paris, France
- Department of Dermatology, UHC Bordeaux, Bordeaux, France
| | - F Tetart
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions TOXIBUL, Créteil, France
- FISARD Study Group (French Investigators for Skin Adverse Reactions to Drugs) of the French Dermatology Society, Paris, France
- Department of Dermatology, UHC Rouen, Rouen, France
| | - N de Prost
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions TOXIBUL, Créteil, France
- Intensive Care Unit, AP-HP, Henri-Mondor Hospital, Créteil, France
| | - S Fourati
- Virology Department, AP-HP, Henri-Mondor Hospital, Créteil, France
| | - N Ortonne
- Department of Pathology, Henri-Mondor Hospital, Créteil, France
| | - F Kasimir
- Institute for Virology and Immunobiology, Julius-Maximilians-UniversitätWürzburg, Würzburg, Germany
| | - B K Prusty
- Institute for Virology and Immunobiology, Julius-Maximilians-UniversitätWürzburg, Würzburg, Germany
| | - V Descamps
- Department of Dermatology, AP-HP, Bichat Hospital, Paris, France
- FISARD Study Group (French Investigators for Skin Adverse Reactions to Drugs) of the French Dermatology Society, Paris, France
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7
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Martínez JD, Franco R, Sáenz LM, Alvarado AG, García JA, Delgado SM, Ionescu MA, Busilă C, Tatu AL. DRESS and Stevens-Johnson Syndrome Overlap Secondary to Allopurinol in a 50-Year-Old Man-A Diagnostic and Treatment Challenge: Case Report. Life (Basel) 2023; 13:2251. [PMID: 38137852 PMCID: PMC10744808 DOI: 10.3390/life13122251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/13/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
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.
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Affiliation(s)
- José Dario Martínez
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitario José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico;
| | - Rodolfo Franco
- Department of Human Pathology, Faculty of Medicine, Hospital Universitario José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico; (R.F.); (J.A.G.)
| | - Luis Manuel Sáenz
- Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico; (L.M.S.); (S.M.D.)
| | - Americo Guadalupe Alvarado
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitario José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico;
| | - José Antonio García
- Department of Human Pathology, Faculty of Medicine, Hospital Universitario José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico; (R.F.); (J.A.G.)
| | - Sergio Máximo Delgado
- Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico; (L.M.S.); (S.M.D.)
| | - Marius-Anton Ionescu
- Department of Dermatology, University Hospital Saint Louis, 63110 Paris, France;
| | - Camelia Busilă
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, 800008 Galati, Romania;
| | - Alin Laurentiu Tatu
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, 800008 Galati, Romania;
- Dermatology Department, “Sfanta Cuvioasa Paraschiva” Hospital of Infectious Diseases, 800179 Galati, Romania
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8
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Lian BS, Ha JH, Sultana R, Chan LCE, Choo KJL, Yeo YW, Lee HY. Systemic Versus Topical Corticosteroids in the Treatment of DRESS: A Retrospective Cohort Study Followed by a Meta-Analysis. Am J Clin Dermatol 2023:10.1007/s40257-023-00776-6. [PMID: 37133714 DOI: 10.1007/s40257-023-00776-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe systemic drug hypersensitivity syndrome with significant risks of mortality and long-term sequelae. Management is challenging; whilst systemic corticosteroids are generally regarded as standard of care, there is a suggestion that topical corticosteroids may be a safe alternative. OBJECTIVE We aimed to compare the clinical outcomes of patients with DRESS treated with systemic corticosteroids and topical corticosteroids in an academic medical center. METHODS The medical records of patients diagnosed with DRESS at the Singapore General Hospital between 2009 and 2017 were retrospectively reviewed. A secondary systematic review and meta-analysis were performed to further clarify the outcomes. RESULTS Out of 94 patients with DRESS, 41 (44%) were treated with topical corticosteroids and 53 (56%) were treated with systemic corticosteroids. Patients receiving systemic corticosteroids were more likely to develop infective complications (32.1 vs 12.2%, p = 0.02). One-month and 12-month mortality, length of hospital stay, flares of DRESS, and viral reactivation were similar between the two groups. In our meta-analysis (six studies, n = 292), there were no significant differences in mortality or length of stay between patients treated with systemic or topical corticosteroids. LIMITATIONS This study was a non-controlled retrospective cohort study and the allocation of treatment may have been influenced by the severity of disease. Results of the secondary meta-analysis are limited by the quality of included studies. CONCLUSIONS Topical corticosteroids may be a safe and efficacious alternative to systemic corticosteroids in the treatment of mild-to-moderate DRESS. CLINICAL TRIAL REGISTRATION PROSPERO registration CRD42021285691.
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Affiliation(s)
- Bertrand ShengYang Lian
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Judy H Ha
- Duke-NUS Medical School, Singapore, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, The Academia, Singapore, Singapore
| | - Linus Chong En Chan
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Karen Jui Lin Choo
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Yi Wei Yeo
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
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9
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Kridin K, Brüggen MC, Walsh S, Bensaid B, Ranki A, Oppel E, Meyersburg D, Chua SL, Seeli C, Sandberg H, French LE, Vorobyev A, Ingen-Housz-Oro S. Management and treatment outcome of DRESS patients in Europe: An international multicentre retrospective study of 141 cases. J Eur Acad Dermatol Venereol 2023; 37:753-762. [PMID: 36479739 DOI: 10.1111/jdv.18808] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal drug hypersensitivity reaction. OBJECTIVE To explore treatment approaches across Europe and their impact on the disease course, as well as prognostic factors and culprit drugs. METHODS In this retrospective European multicentric study, we included patients with probable or certain DRESS (RegiSCAR score ≥ 4) between January 2016 and December 2020. Independent associations between clinical parameters and the risk of intensive care unit admission and mortality at three months were assessed using a multivariable-adjusted logistic regression model. RESULTS A total of 141 patients from 8 tertiary centres were included. Morbilliform exanthem was the most frequent cutaneous manifestation (78.0%). The mean affected body surface area (BSA) was 67%, 42% of the patients presented with erythroderma, and 24.8% had mucosal involvement. Based on systemic involvement, 31.9% of the patients had a severe DRESS. Anticonvulsants (24.1%) and sulphonamides (22.0%) were the most frequent causative agents. In all, 73% of the patients were treated with systemic glucocorticoids, and 25.5% received topical corticosteroids as monotherapy. Few patients received antiviral drugs or anti-IL5. No patients received intravenous immunoglobulins. The overall mortality was 7.1%. Independent predictors of mortality were older age (≥57.0 years; fully adjusted OR, 9.80; 95% CI, 1.20-79.93; p = 0.033), kidney involvement (fully adjusted OR, 4.70; 95% CI, 1.00-24.12; p = 0.049), and admission in intensive care unit (fully adjusted OR, 8.12; 95% CI, 1.90-34.67; p = 0.005). Relapse of DRESS and delayed autoimmune sequelae occurred in 8.5% and 12.1% of patients, respectively. CONCLUSIONS This study underlines the need for diagnostic and prognostic scores/markers as well as for prospective clinical trials of drugs with the potential to reduce mortality and complications of DRESS.
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Affiliation(s)
- Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Marie-Charlotte Brüggen
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Medical Campus Davos, Davos, Switzerland.,ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin)
| | - Sarah Walsh
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, King's College Hospital, London, UK
| | - Benoit Bensaid
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France.,Department of Dermatology, Edouard Herriot Hospital, Lyon, France
| | - Annamari Ranki
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, Allergology and Venereology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Helsinki, Finland
| | - Eva Oppel
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany
| | - Damian Meyersburg
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology and Allergology, University Hospital Salzburg of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ser-Ling Chua
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Corsin Seeli
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Heidi Sandberg
- Department of Dermatology, Allergology and Venereology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Helsinki, Finland
| | - Lars E French
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany.,Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Artem Vorobyev
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Saskia Ingen-Housz-Oro
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France.,Department of Dermatology, AP-HP, Henri Mondor Hospital, Créteil, France.,Univ Paris Est Créteil EpiDermE, Créteil, France
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10
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Kwon HJ, Yoon JH. Comparison of cyclosporine and systemic corticosteroid for treating drug reaction with eosinophilia and systemic symptoms syndrome: A retrospective 20-year single-centre study in South Korea. Australas J Dermatol 2023; 64:50-57. [PMID: 36695042 DOI: 10.1111/ajd.13982] [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: 08/17/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND/OBJECTIVES Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a potentially life-threatening hypersensitive disorder. Cyclosporine has been indicated for adverse cutaneous drug eruptions. However, studies evaluating its clinical effectiveness in DRESS syndrome have been rare. This study aimed to evaluate the clinical efficacy of cyclosporine in DRESS syndrome compared to that of systemic corticosteroids. METHODS In the cyclosporine group, oral cyclosporine was administered twice a day for a total of 2-3 mg/kg/day for 1 week, and subsequently reduced to 1-1.5 mg/kg/day for extended treatment. In the corticosteroid group, intravenous or oral methylprednisolone was administered at 1-1.5 mg/kg/day for 1 week, with variable tapering plans. Laboratory changes before and after treatment, hospitalized days, treatment periods, and time to normalization from clinical manifestations in each group were statistically evaluated. Adverse effects of these regimens were observed during the entire treatment period. RESULTS Eighty patients were enrolled in this retrospective study. The cyclosporine and corticosteroid group had 27 and 53 patients, respectively. Total leucocyte and eosinophil counts, liver enzymes, and C-reactive proteins were significantly decreased after treatment in both groups. There were no statistically significant differences observed in hospitalized days, treatment period, and time to normalization from clinical manifestations between the two groups. The corticosteroid group experienced relatively more adverse effects than the cyclosporine group. CONCLUSIONS Cyclosporine was discovered to be clinically effective in DRESS syndrome and this study suggests that cyclosporine could be a feasible primary therapeutic option for DRESS syndrome.
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Affiliation(s)
- Hyeok-Jin Kwon
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Korea
| | - Jung-Ho Yoon
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Korea
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11
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Stirton H, Shear NH, Dodiuk-Gad RP. Drug Reaction with Eosinophilia and Systemic Symptoms (DReSS)/Drug-Induced Hypersensitivity Syndrome (DiHS)-Readdressing the DReSS. Biomedicines 2022; 10:999. [PMID: 35625735 PMCID: PMC9138571 DOI: 10.3390/biomedicines10050999] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 12/17/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DReSS), also known as drug-induced hypersensitivity syndrome (DiHS), is a severe, systemic, T cell mediated drug reaction with combinations of cutaneous, hematologic, and internal organ involvement. Pathogenesis of DReSS is multi-factorial, involving drug-exposure, genetic predisposition through specific human leukocyte antigen (HLA) alleles and metabolism defects, viral reactivation, and immune dysregulation. Clinical features of this condition are delayed, stepwise, and heterogenous, making this syndrome challenging to recognize and diagnose. Two sets of validated diagnostic criteria exist that can be employed to diagnose DReSS/DiHS. Methods to improve early recognition of DReSS and predict disease severity has been a recent area of research focus. In vitro and in vivo tests can be employed to confirm the diagnosis and help identify culprit drugs. The mainstay treatment of DReSS is prompt withdrawal of the culprit drug, supportive treatment, and immunosuppression depending on the severity of disease. We present a comprehensive review on the most recent research and literature on DReSS, with emphasis on pathogenesis, clinical features, diagnosis, confirmatory testing modalities, and treatment. Additionally, this summary aims to highlight the differing viewpoints on this severe disease and broaden our perspective on the condition known as DReSS.
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Affiliation(s)
- Hannah Stirton
- Section of Dermatology, Department of Medicine, University of Manitoba, Winnipeg, MB R2M 3Y8, Canada;
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Neil H. Shear
- Temerty Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Roni P. Dodiuk-Gad
- Temerty Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada;
- Emek Medical Centre, Afula 1855701, Israel
- Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa 3525433, Israel
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