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Singh S, Vinay K, Bishnoi A, Parsad D, Kumaran MS. A prospective observational study validating the CET score as a screening tool in suspected DRESS syndrome. Int J Dermatol 2024; 63:1178-1184. [PMID: 38415838 DOI: 10.1111/ijd.17080] [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] [Received: 11/10/2023] [Revised: 01/14/2024] [Accepted: 01/29/2024] [Indexed: 02/29/2024]
Abstract
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.
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Affiliation(s)
- Sukhdeep Singh
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Keshavamurthy Vinay
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anuradha Bishnoi
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Davinder Parsad
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Muthu Sendhil Kumaran
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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de Filippis R, Kane JM, Arzenton E, Moretti U, Raschi E, Trifirò G, Barbui C, De Fazio P, Gastaldon C, Schoretsanitis G. Antipsychotic-Related DRESS Syndrome: Analysis of Individual Case Safety Reports of the WHO Pharmacovigilance Database. Drug Saf 2024; 47:745-757. [PMID: 38722481 PMCID: PMC11286650 DOI: 10.1007/s40264-024-01431-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is gaining attention in pharmacovigilance, but its association with antipsychotics, other than clozapine, is still unclear. METHODS We conducted a case/non-case study with disproportionality analysis based on the World Health Organization (WHO) global spontaneous reporting database, VigiBase®. We analyzed individual case safety reports of DRESS syndrome related to antipsychotics compared to (1) all other medications in VigiBase®, (2) carbamazepine (a known positive control), and (3) within classes (typical/atypical) of antipsychotics. We calculated reporting odds ratio (ROR) and Bayesian information component (IC), with 95% confidence intervals (CIs). Disproportionate reporting was prioritized based on clinical importance, according to predefined criteria. Additionally, we compared characteristics of patients reporting with serious/non-serious reactions. RESULTS A total of 1534 reports describing DRESS syndrome for 19 antipsychotics were identified. The ROR for antipsychotics as a class as compared to all other medications was 1.0 (95% CI 0.9-1.1). We found disproportionate reporting for clozapine (ROR 2.3, 95% CI 2.1-2.5; IC 1.2, 95% CI 1.1-1.3), cyamemazine (ROR 2.3, 95% CI 1.5-3.5; IC 1.2, 95% CI 0.5-1.7), and chlorpromazine (ROR 1.5, 95% CI 1.1-2.1; IC 0.6, 95% CI 0.1-1.0). We found 35.7% of cases with co-reported anticonvulsants, and 25% with multiple concurrent antipsychotics in serious compared to 8.6% in non-serious cases (p = 0.03). Fatal cases were 164 (10.7%). CONCLUSIONS Apart from the expected association with clozapine, chlorpromazine and cyamemazine (sharing an aromatic heteropolycyclic molecular structure) emerged with a higher-than-expected reporting of DRESS. Better knowledge of the antipsychotic-related DRESS syndrome should increase clinicians' awareness leading to safer prescribing of antipsychotics.
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Affiliation(s)
- Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, 88100, Catanzaro, Italy.
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Elena Arzenton
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Ugo Moretti
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Gianluca Trifirò
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, 88100, Catanzaro, Italy
| | - Chiara Gastaldon
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
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Machona MS, Muloiwa R, Porter M, Peter J, Lehloenya RJ. Advanced human immunodeficiency virus (HIV) does not affect ability to utilize lymphadenopathy in assessment of drug reaction with eosinophilia and systemic symptoms syndrome in HIV and tuberculosis: Prospective comparative study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100276. [PMID: 38946893 PMCID: PMC11214507 DOI: 10.1016/j.jacig.2024.100276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 07/02/2024]
Abstract
Background RegiSCAR validation criteria for drug reaction with eosinophilia and systemic symptoms (DRESS) includes lymphadenopathy, a frequent feature of both tuberculosis (TB) and human immunodeficiency virus (HIV). TB is the most common HIV-associated coinfection. Advanced HIV is associated with lymph node (LN) fibrosis. It is not clear if this negatively affects case validation in HIV-associated DRESS. To answer this question, we designed a prospective descriptive study to assess lymphadenopathy in various combinations of comorbid HIV, TB, and DRESS. Objectives We sought to describe the prevalence of DRESS-associated lymphadenopathy and characterize LN quality, size, and distribution in a high HIV-TB burden setting over time. Methods We prospectively and systematically examined LN in 25 consecutive acute DRESS cases hospitalized at a South African tertiary-care center and 10 hospitalized non-DRESS HIV-TB coinfected controls. Results Fourteen (56%) of 25 patients were HIV infected, with a median (interquartile range) CD4 count of 254 (66-478) cells/mm³, and 7 of 14 were coinfected with TB. Using RegiSCAR criteria, 12 (46%) of 25 were definite DRESS cases, 8 (31%) of 25 probable, and 5 (23%) of 25 possible. Possible cases were excluded in the analysis. Fifteen (75%) of 20 subjects had LN in ≥2 anatomic sites, including all 7 patients with HIV-TB coinfection. In contrast, 1 (20%) of 5 hospitalized non-DRESS HIV-TB coinfected controls had LN. Cervical LN, in 15 (88%) of 17, was most common, followed by axillary (76%) and inguinal (59%). Cervical LN ranged between 1 and 2 cm in size. Among the 8 (32%) of 25 subjects with follow-up data, LN had regressed in all within 6 weeks of stopping the offending drug and initiating TB treatment. There was no correlation with CD4 cell count and LN. Conclusion Lymphadenopathy is a common feature of acute DRESS, even among HIV-TB-coinfected patients with advanced immunosuppression.
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Affiliation(s)
- Musonda Sharon Machona
- Department of Medicine, Division of Dermatology, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Mireille Porter
- Department of Medicine, Division of Allergy and Clinical Immunology, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Jonny Peter
- Department of Medicine, Division of Allergy and Clinical Immunology, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Rannakoe J. Lehloenya
- Department of Medicine, Division of Dermatology, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
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Alphonce B, Komanya F, Magitta NF, Deodatus S, Sindato E. Amoxicillin-induced DRESS syndrome without eosinophilia. Clin Case Rep 2024; 12:e9333. [PMID: 39161667 PMCID: PMC11331589 DOI: 10.1002/ccr3.9333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 07/22/2024] [Accepted: 08/01/2024] [Indexed: 08/21/2024] Open
Abstract
Despite the name, eosinophilia is not essential for diagnosing drug reaction with eosinophilia and systemic symptoms (DRESS syndrome). Early recognition and stopping the offending drug are vital to managing this condition, as it can otherwise lead to high mortality rates.
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Affiliation(s)
- Baraka Alphonce
- Department of Internal MedicineBenjamin Mkapa HospitalDodomaTanzania
| | - Francisca Komanya
- Department of Internal MedicineBenjamin Mkapa HospitalDodomaTanzania
| | - Ng'weina F. Magitta
- Department of Internal MedicineUniversity of DodomaDodomaTanzania
- Department of Biochemistry & Clinical Pharmacology, Mbeya College of Health & Allied SciencesUniversity of Dar es SalaamMbeyaTanzania
| | - Shani Deodatus
- Department of DermatologyBenjamin Mkapa HospitalDodomaTanzania
| | - Emmanuel Sindato
- Department of Internal MedicineUniversity of DodomaDodomaTanzania
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Li W, Yu Y, Li M, Fang Q, Jin X, Lin H, Xu J. Identification of novel signal of proton pump inhibitor-associated drug reaction with eosinophilia and systemic symptoms: a disproportionality analysis. Int J Clin Pharm 2024:10.1007/s11096-024-01778-y. [PMID: 39042351 DOI: 10.1007/s11096-024-01778-y] [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: 01/22/2024] [Accepted: 07/07/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are commonly prescribed for treating upper gastrointestinal hemorrhage, eradicating Helicobacter pylori, and stress ulcer prophylaxis, among other digestive system diseases. Recent case reports provided limited evidence of a correlation between PPIs and drug reactions with eosinophilia and systemic symptoms (DRESS). However, there is currently no established association between PPIs and DRESS. AIM This research aimed to identify the associations between PPIs and DRESS using the US Food and Drug Administration Adverse Events Reporting System (FAERS) database. METHOD A retrospective investigation of DRESS associated with six PPIs used FAERS data from Q1 2004 to Q3 2023. Data mining algorithms were used to identify adverse events in the FAERS database that met the following criteria: (1) proportional reporting ratio (PRR) ≥ 2; (2) reporting odds ratio (ROR) > 1; (3) 95% confidence interval (CI) of ROR > 1; (4) Chi-square (χ2) ≥ 4 and case count ≥ 3. RESULTS There were 495 reports of PPI-related DRESS, including pantoprazole (174, 35.2%), omeprazole (103, 20.8%), lansoprazole (103, 20.8%), esomeprazole (101, 20.4%), rabeprazole (8, 1.6%), and dexlansoprazole (6, 1.2%). The results indicated a significant association of three PPIs (pantoprazole, omeprazole, and lansoprazole) with DRESS. The sensitivity analysis demonstrated that only pantoprazole remained significantly associated with DRESS after 10 concomitant drugs had been removed (ROR: 3.00, PRR: 2.99, and information component [IC]: 1.57). CONCLUSION This study identified the signals suggesting a potential association between DRESS and six PPIs. However, more investigation of epidemiological data is required to validate of these conclusions.
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Affiliation(s)
- Wanshu Li
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Yanan Yu
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Minghui Li
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Qing Fang
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Xin Jin
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Hangjuan Lin
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Jun Xu
- Department of Nursing, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China.
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Lu Y, Zhou L, Zou Y, Wei H, Zhou Y, Guo X, Li Q, Ye Y, Zhang L. Antibiotic-induced severe cutaneous adverse reactions: a single-center retrospective study over ten years. Front Immunol 2024; 15:1415830. [PMID: 39091503 PMCID: PMC11291224 DOI: 10.3389/fimmu.2024.1415830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 06/24/2024] [Indexed: 08/04/2024] Open
Abstract
Objective Severe cutaneous adverse reactions (SCARs) are rare but life-threatening, with antibiotics being the main cause. This retrospective study from a single center was designed to analyze the culprit drugs, clinical features and treatment outcomes of antibiotic-induced SCARs. Methods We analyzed cases of antibiotic-induced SCARs in a tertiary hospital in China between January 2013 and January 2024, including Steven-Johnson syndrome (SJS) or Stevens-Johnson syndrome-toxic epidermal necrolysis (SJS-TEN) overlap, toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP). Descriptive analysis of the demographic characteristics, clinical manifestations, treatment and prognosis were carried out. Results Among 354 cases of SCARs, 63 validated antibiotic-related cases were included. Cephalosporins (31.7%), penicillins (25.4%), and quinolones (19.0%) were the most common triggers for SCARs. Overall, liver (50.8%), lungs (31.7%), and kidneys (23.8%) were the most frequently affected organ in SCARs cases. Eight patients (28.6%) in the SJS/SJS-TEN overlap group and 8 patients (80.0%) in the TEN group received combination therapy of corticosteroids and IVIG. Patients with SCARs caused by penicillins or cephalosporins could receive alternative treatments such as lincomamides, quinolones, and tetracyclines. The mortality rate in the TEN group was the highest at 20.0%, followed by the SJS/SJS-TEN overlap group (7.1%), and no deaths were observed in the DRESS and AGEP groups. Conclusion The identification of the culprit antibiotics and the application of alternative antibiotic therapies are crucial for the management of antibiotic-induced SCARs. If complicated underlying conditions and complications like advanced age, cancer and pneumonia coexist with SCARs, patients might be more at risk for mortality.
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Affiliation(s)
- Yun Lu
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Lu Zhou
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Ya Zou
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Hua Wei
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Yan Zhou
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Xirui Guo
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Qinchuan Li
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Yongqin Ye
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Liwen Zhang
- Department of Dermatovenereology, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
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Aleksandrova N, De Rop J, Camu F, Hubloue I, Devue K. A diagnostic dilemma: distinguishing a sulfasalazine induced DRESS hypersensitivity syndrome from a CD30 + lymphoma in a young patient. Int J Emerg Med 2024; 17:94. [PMID: 39026234 PMCID: PMC11256461 DOI: 10.1186/s12245-024-00665-7] [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: 02/09/2024] [Accepted: 07/04/2024] [Indexed: 07/20/2024] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe hypersensitivity reaction characterized by cutaneous rash, lymphadenopathy, fever, eosinophilia, leukocytosis, and life-threatening organ dysfunctions. We describe the case of a 26 year old patient admitted to the Emergency Department for DRESS syndrome after sulfasalazine treatment for rheumatoid arthritis in the right knee. Whole body computer tomography showed multiple neck, chest, and abdominal lymphadenopathy with splenomegaly, massive ascites and severe hepatic cytolysis. Serology results for Epstein-Barr Virus (EBV), influenza, measles, rubella, hepatitis A and B were negative. The histologic analysis of skin, lymph node and bone marrow biopsies could not indicate a classical Hodgkin's Disease or iatrogenic immunodeficiency/EBV-associated lymphoproliferative disorder (LPD), Hodgkin type. The relatively small caliber of the CD30 + immunoreactive blastoid cells in the lymph nodes suggested reactive immunoblasts rather than Hodgkin cells. The morphologic aspects of the lymph node biopsies with predominance of T-cells were compatible with the diagnosis of a sulfasalazine-induced DRESS syndrome as the patient had a high RegiSCAR score for DRESS. [DRESS Syndrome Foundation: Diagnosis and Treatment. (2023)] The patient's complex clinical course, marked by two hospital admissions, highlights the challenges in diagnosing and managing DRESS. This case underscores the need for individualized care, close patient monitoring, and further research to better understand DRESS's underlying mechanisms and optimal therapeutic strategies.
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Affiliation(s)
| | - Jonas De Rop
- Department of Endocrinology, ASZ Aalst, Aalst, Belgium
- Department of Endocrinology, UZ Brussel, Jette, Belgium
| | - Frederic Camu
- Department of Emergency Medicine, ASZ Aalst, Aalst, Belgium
| | - Ives Hubloue
- Department of Emergency Medicine, UZ Brussel, Jette, Belgium
| | - Katleen Devue
- Department of Emergency Medicine, ASZ Aalst, Aalst, Belgium.
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Ajon ARS, Camara PTA. Drug Rash With Eosinophilia and Systemic Symptoms (DRESS) Due to Multiple Anti-Epileptic Drug Hypersensitivity. Cureus 2024; 16:e65417. [PMID: 39184707 PMCID: PMC11344962 DOI: 10.7759/cureus.65417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 08/27/2024] Open
Abstract
Drug rash with eosinophilia and systemic symptoms (DRESS) is a rare type of hypersensitivity reaction with an incidence in the general population of one case per 10,000, which may lead to life-threatening complications with a mortality rate of 3.8% to 10%. This condition has been characterized by the following symptoms: skin rash, febrile episodes, lymph node enlargement, and involvement of internal organs, specifically the liver. Common medications associated with these reactions are aromatic anticonvulsants and antibiotics. In this paper, we report a case of a 41-year-old female presenting with head-turning to the right and stiffening of the right upper and lower extremities, with subsequent involvement of the left upper and lower extremities secondary to a left frontal lobe glioma. She had a hypersensitivity reaction to five anticonvulsant medications and was treated with prednisone pulse therapy. This case showed that DRESS syndrome may also manifest with newer non-aromatic anticonvulsants such as levetiracetam and that steroid pulse therapy is effective in resolving the elevated blood parameters as well as skin lesions of patients with DRESS syndrome. The patient's epilepsy responded well to gabapentin without any recurrence of seizure episodes or hypersensitivity reactions.
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Affiliation(s)
- Alyssa Roseni S Ajon
- Department of Adult Neurology, Center for Neurological Sciences, Quirino Memorial Medical Center, Quezon City, PHL
| | - Pia Teresa A Camara
- Department of Adult Neurology, Center for Neurological Sciences, Quirino Memorial Medical Center, Quezon City, PHL
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Domański I, Kozieł A, Kuderska N, Wójcik P, Dudzik Ł, Dudzik T. Hyperuricemia - consequences of not initiating therapy. Benefits and drawbacks of treatment. Reumatologia 2024; 62:207-213. [PMID: 39055725 PMCID: PMC11267652 DOI: 10.5114/reum/189998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 06/12/2024] [Indexed: 07/27/2024] Open
Abstract
Hyperuricemia, characterized by elevated levels of uric acid in the body, is associated with several health risks, including gout, urolithiasis and cardiovascular disease. Although treatment options are available, they can lead to hypersensitivity reactions, particularly with allopurinol therapy. This paper provides a comprehensive review of the consequences of hyperuricemia, the need for treatment and the potential adverse effects of allopurinol, illustrated by a case study. The study highlights the importance of careful consideration before initiating therapy, particularly in patients with comorbidities and concomitant medication. It emphasizes the need for vigilant monitoring and individualized treatment approaches to reduce adverse effects. In addition, genetic factors, particularly HLA-B*5801, play an important role in determining susceptibility to allopurinol hypersensitivity reactions. This paper highlights the importance of informed decision making in the management of hyperuricemia to optimize patient outcomes while minimizing the risks associated with treatment.
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Affiliation(s)
- Igor Domański
- Lower Silesian Oncology, Pulmonology and Hematology Center, Wroclaw, Poland
- Family Medicine Practice, Wroclaw, Poland
| | - Aleksandra Kozieł
- Lower Silesian Oncology, Pulmonology and Hematology Center, Wroclaw, Poland
| | | | - Paulina Wójcik
- J. Gromkowski Specialist Regional Hospital, Wroclaw, Poland
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Watanabe A, Nakamoto Y, Aita T, Naganuma T, Takahashi S, Kiko Y, Nakagawa H, Hamaguchi S. Fatal Myocarditis in Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Without Mortality-Related Risk Factors: A Case Report and Literature Review. Cureus 2024; 16:e63541. [PMID: 39086788 PMCID: PMC11289355 DOI: 10.7759/cureus.63541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 08/02/2024] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe drug reaction characterized by skin rash, organ involvement, lymph node swelling, eosinophilia, and atypical lymphocytosis, with myocarditis being a rare but potentially fatal complication. It has been reported that in patients with cardiac involvement due to DRESS, older age and shorter periods between offending drug exposure and symptom onset are associated with mortality. We report a case of fatal DRESS-associated myocarditis in a young woman, occurring one month after drug exposure, despite intensive immunosuppressive therapy. This case report highlights the risk of mortality from DRESS-associated myocarditis even in patients lacking known risk factors.
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Affiliation(s)
- Aya Watanabe
- Department of General Internal Medicine, Fukushima Medical University, Fukushima, JPN
| | - Yohei Nakamoto
- Department of General Internal Medicine, Fukushima Medical University, Fukushima, JPN
| | - Tetsuro Aita
- Department of General Internal Medicine, Fukushima Medical University, Fukushima, JPN
| | - Toru Naganuma
- Department of General Internal Medicine, Futaba Emergency and General Medicine Support Center, Fukushima Medical University, Fukushima, JPN
| | - Sei Takahashi
- Department of General Internal Medicine, Futaba Emergency and General Medicine Support Center, Fukushima Medical University, Fukushima, JPN
| | - Yuichiro Kiko
- Department of Diagnostic Pathology, Fukushima Medical University, Fukushima, JPN
| | - Hiroaki Nakagawa
- Department of General Internal Medicine, Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, JPN
| | - Sugihiro Hamaguchi
- Department of General Internal Medicine, Fukushima Medical University, Fukushima, JPN
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Palakornkitti P, Rattananukrom T. Drug Reaction with Eosinophilia and Systemic Symptoms Induced by Diosmin and Hesperidin: A Case Report. Clin Cosmet Investig Dermatol 2024; 17:1127-1132. [PMID: 38770090 PMCID: PMC11104364 DOI: 10.2147/ccid.s464672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/25/2024] [Indexed: 05/22/2024]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse reaction which exhibits a diverse range of presentations. We described a 48-year-old man diagnosed with acute generalized exanthematous pustulosis (AGEP)-like DRESS following the administration of diosmin and hesperidin. To our knowledge, diosmin and hesperidin-induced DRESS are exceptionally rare. This aims to raise awareness of potential severe cutaneous side effects in patients taking these agents.
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Affiliation(s)
- Pasita Palakornkitti
- Division of Dermatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Teerapong Rattananukrom
- Division of Dermatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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12
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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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13
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Peña-Blanco L, Gutiérrez-Soriano L, Montes FR, Barragán-Méndez A, Beltrán-Villegas S, López-Reyes JJ, Villa-Hincapié CA, Umaña JP. Heparin-induced DRESS syndrome in a paediatric patient and successful anaesthetic management in cardiovascular bypass surgery: case report. J Cardiothorac Surg 2024; 19:242. [PMID: 38632589 PMCID: PMC11022424 DOI: 10.1186/s13019-024-02722-x] [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: 11/23/2023] [Accepted: 03/29/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome is a severe adverse drug reaction marked by delayed hypersensitivity reactions causing skin and systemic complications. DRESS diagnosis is challenging due to the variety of clinical presentations and symptom overlap with other conditions. The perioperative period in these patients requires precise pharmacological strategies to prevent complications associated with this syndrome. The treatment of DRESS induced by unfractionated heparin during cardiopulmonary bypass (CPB) surgery presents some challenges that must be considered when selecting an anticoagulant to avoid side effects. In this case, bivalirudin, a direct thrombin inhibitor, is indicated as an alternative to heparin in patients undergoing CPB. However, in contrast to heparin/protamine, there is no direct reversal agent for bivalirudin. CASE PRESENTATION We report the case of an 11-year-old male diagnosed with native aortic valve endocarditis and thrombosis in his left lower extremity. During valvular replacement surgery, systemic unfractionated heparin was administered. Postoperatively, the patient developed fever, eosinophilia and pruritic rash. Warm shock and elevated alanine transaminase (ALT) and aspartate transaminase (AST) levels followed, leading to the diagnosis of DRESS syndrome. Treatment with methylprednisolone resulted in complete resolution of symptoms. Seven years later, the patient was readmitted due to insufficient anticoagulation and a thrombus in the prosthetic aortic valve, presenting a recurrent DRESS episode due to the administration of unfractionated heparin, which was later replaced with low-molecular-weight heparin during hospitalization. Treatment with corticosteroids and antihistamines was initiated, resulting in the resolution of this episode. Ultimately, the patient required the Ross procedure. During this intervention the anticoagulation strategy was modified, unfractionated heparin was replaced with bivalirudin during the procedure and fondaparinux was administered during the postoperative period. This resulted in stable transaminases levels and no eosinophilia. CONCLUSION The severity of DRESS Syndrome underscores the importance of early recognition, heightened monitoring, and a comprehensive approach tailored to each patient's needs. This particular case highlights the significance of this approach and may have a substantial clinical impact since it provides alternatives to heparin, such as bivalirudin and fondaparinux, in the anticoagulation strategy of CPB for patients who have a hypersensibility reaction to this medication; thus, enhancing clinical outcomes by minimizing risks linked to adverse drug reactions.
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Affiliation(s)
- Laura Peña-Blanco
- Anesthesiology Department, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia.
| | - Laura Gutiérrez-Soriano
- Anesthesiology Department, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Félix Ramón Montes
- Anesthesiology Department, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Andrea Barragán-Méndez
- Anesthesiology Department, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
| | - Susana Beltrán-Villegas
- Anesthesiology Department, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
| | - Juan José López-Reyes
- Anesthesiology Department, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
| | - Carlos A Villa-Hincapié
- Department of Cardiovascular Surgery, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Juan Pablo Umaña
- Department of Cardiovascular Surgery, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
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14
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Velasco-Amador JP, Prados-Carmona Á, Navarro-Triviño FJ. Wenn es kein Angioödem ist, was dann? Diagnostisches Vorgehen bei Gesichtsödemen. J Dtsch Dermatol Ges 2024; 22:501-512. [PMID: 38574029 DOI: 10.1111/ddg.15336_g] [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: 06/14/2023] [Accepted: 11/16/2023] [Indexed: 04/06/2024]
Abstract
ZusammenfassungGesichtsödeme sind ein relativ häufiges Symptom bei Patienten allergologischer und dermatologischer Kliniken. Die Differentialdiagnose ist breit gefächert und die endgültige Diagnose kann manchmal eine Herausforderung für den Kliniker sein. Das faziale Angioödem selbst umfasst verschiedene Ätiopathologien (histaminerg, bradykinininduziert und weitere), die von anderen Ursachen des Gesichtsödems differenziert werden sollten, etwa allergischer Kontaktdermatitis, granulomatösen Erkrankungen, inflammatorischen Ursachen, Infektionen, Neoplasmen oder paraneoplastischen Syndromen, Autoimmunerkrankungen und anderen Entitäten, die hier als „Sonstige“ bezeichnet werden. Um die richtigen Untersuchungen anzuordnen und eine gezielte Therapie zu verordnen, ist ein angemessener diagnostischer Ansatz ausschlaggebend. Diese Übersicht konzentriert sich auf Entitäten, die mit Gesichtsödem einhergehen, und fasst ihre klinischen Charakteristika zusammen.
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Affiliation(s)
| | | | - Francisco José Navarro-Triviño
- Departamento de Eczema de Contacto e Inmunoalergia, Servicio de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario San Cecilio, Granada, Spanien
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15
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Rotulo GA, Campanello C, Battaglini M, Bassi M, Pastorino C, Angeletti A, Brisca G, Signa S, Caorsi R, Ghiggeri GM. A Rare Pediatric Case of Allopurinol-Induced Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Successfully Treated With Intravenous Immunoglobulins. J Pediatr Pharmacol Ther 2024; 29:195-199. [PMID: 38596415 PMCID: PMC11001218 DOI: 10.5863/1551-6776-29.2.195] [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: 02/25/2022] [Accepted: 11/28/2022] [Indexed: 04/11/2024]
Abstract
Allopurinol-induced drug reaction syndrome with eosinophilia and systemic symptoms (A-DRESS) is a well-described condition in adults, whereas it is uncommon among children. We describe a case of A-DRESS in a 16-year-old male with steroid-dependent nephrotic syndrome. He presented a life-threatening clinical course with persisting fever, skin rash, eosinophilia, lymphadenopathy, distributive shock, and herpesvirus 6 detection. The withdrawal of allopurinol and a combination of intravenous immunoglobulins (IVIGs) and systemic corticosteroids led to the patient's recovery without sequelae. Drug reaction with eosinophilia and systemic symptoms (DRESS) in pediatrics is rare and can present in a severe form. Early diagnosis and timely treatment are critical for prognostic purposes. This report suggests the potentially crucial role of IVIG in the treatment of patients with A-DRESS.
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Affiliation(s)
- Gioacchino Andrea Rotulo
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (GAR, CC, M Battaglini, M Bassi, SS), University of Genoa, Genoa, Italy
- Clinical and Research Unit of Clinical Immunology and Vaccinology (GAR), IRCCS Bambino Gesù Children Hospital, Rome, Italy
| | - Claudia Campanello
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (GAR, CC, M Battaglini, M Bassi, SS), University of Genoa, Genoa, Italy
| | - Marcella Battaglini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (GAR, CC, M Battaglini, M Bassi, SS), University of Genoa, Genoa, Italy
| | - Marta Bassi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (GAR, CC, M Battaglini, M Bassi, SS), University of Genoa, Genoa, Italy
| | - Carlotta Pastorino
- Dermatology Unit (CP), Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Andrea Angeletti
- Division of Nephrology, Dialysis, and Transplantation (AA, GMG), Giannina Gaslini Children’s Hospital, Genoa, Italy
| | - Giacomo Brisca
- Subintensive Care Unit (GB), IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sara Signa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (GAR, CC, M Battaglini, M Bassi, SS), University of Genoa, Genoa, Italy
- Autoinflammatory Diseases and Immunodeficiencies Center (SS, RC), IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Roberta Caorsi
- Autoinflammatory Diseases and Immunodeficiencies Center (SS, RC), IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, and Transplantation (AA, GMG), Giannina Gaslini Children’s Hospital, Genoa, Italy
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16
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Velasco-Amador JP, Prados-Carmona Á, Navarro-Triviño FJ. If not angioedema, what is it? Diagnostic approach to facial edema. J Dtsch Dermatol Ges 2024; 22:501-512. [PMID: 38483055 DOI: 10.1111/ddg.15336] [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: 06/14/2023] [Accepted: 11/16/2023] [Indexed: 04/05/2024]
Abstract
Facial edema is a relatively frequent clinical presentation encountered in patients seen in allergology and dermatology clinics. The differential diagnosis is broad, and sometimes the definitive diagnosis can be a challenge for the clinician. Facial angioedema itself encompasses different etiopathologies (histaminergic, bradykinergic, etc.) that must be distinguished from other causes of facial edema, such as allergic contact dermatitis, granulomatous conditions, inflammatory causes, infections, neoplasms or paraneoplastic syndromes, autoimmune diseases, among other entities hereby referred as miscellanea. A proper diagnostic approach is essential to order the appropriate tests, as well as to prescribe a targeted treatment. This review focuses on entities that present with facial edema and summarize their characteristic clinical features.
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Affiliation(s)
| | | | - Francisco José Navarro-Triviño
- Departamento de Eczema de Contacto e Inmunoalergia, Servicio de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario San Cecilio, Granada, Spain
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17
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Chatproedprai S, Tiasiri N, Chantawarangkul K, Wananukul S. Pediatric drug reaction with eosinophilia and systemic symptoms: A 12-year retrospective study in a tertiary center. J Dermatol 2024; 51:509-517. [PMID: 38214543 DOI: 10.1111/1346-8138.17098] [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: 09/07/2023] [Revised: 12/08/2023] [Accepted: 12/18/2023] [Indexed: 01/13/2024]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and severe adverse drug reaction involving multiple organs. Data on DRESS syndrome among children are currently limited. The purpose of this study was to determine the clinical features, causative drugs, systemic organ involvement, laboratory findings, disease severity score, and treatment outcomes in pediatric DRESS patients. The medical records of all pediatric DRESS patients, based on the RegiSCAR diagnostic criteria and admitted to King Chulalongkorn Memorial Hospital, Bangkok, Thailand from January 2010 to December 2021, were reviewed. Twenty-two cases were identified (males 54.5%) with a median age of 9.5 years. Anticonvulsants (54.5%) and antibiotics (27.3%) were the leading culprit drugs. Skin rash was reported in all cases, followed closely by liver involvement (95.5%). Eosinophilia and atypical lymphocytosis were identified in 54.5% and 31.8% of cases, respectively. The median latency period was 17.5 days. Liver enzyme elevation was detected at an average onset of 20.0 days and hepatocellular type was the most common pattern of liver injury. Nineteen patients (86.4%) were treated with systemic corticosteroids with prednisolone being the most prescribed medication. One case developed Graves' disease after DRESS and multiple relapses of DRESS. One case (4.5%) died due to refractory status epilepticus that was unrelated to DRESS. Anticonvulsants were the major cause of DRESS in pediatric patients. High suspicion for DRESS is crucial in patients receiving these drugs and presenting with fever, rash, and internal organ involvement.
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Affiliation(s)
- Susheera Chatproedprai
- Division of Pediatric Dermatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial hospital, Bangkok, Thailand
| | - Nisha Tiasiri
- Division of Pediatric Dermatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial hospital, Bangkok, Thailand
| | - Karaked Chantawarangkul
- Division of Pediatric Dermatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial hospital, Bangkok, Thailand
| | - Siriwan Wananukul
- Division of Pediatric Dermatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial hospital, Bangkok, Thailand
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18
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Abusuliman M, Amreia M, Rehman S, Chaudhary AJ, Abosheaishaa H, Jamali T, Hanafi A. Fatal Itching and Failing Liver: A Case Report and Literature Review of Rare, Atypical DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) Syndrome. Cureus 2024; 16:e55355. [PMID: 38559511 PMCID: PMC10981999 DOI: 10.7759/cureus.55355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) syndrome is a rare, life-threatening, hypersensitivity reaction. The prolonged course and non-specific symptoms of the condition make diagnosis challenging. We present a case of DRESS syndrome that was misdiagnosed as urticaria. Investigations revealed deranged liver and kidney functions and abnormal blood count. The presented case emphasizes the need to have a high suspicion for DRESS syndrome in patients who present with jaundice, generalized rash, acute renal failure, and acute liver failure.
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Affiliation(s)
| | - Mahmoud Amreia
- Internal Medicine, Rochester Regional Health, Rochester, USA
| | - Sheema Rehman
- Internal Medicine, Henry Ford Health System, Detroit, USA
| | | | - Hazem Abosheaishaa
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York City, USA
- Internal Medicine/Gastroenterology, Cairo University, Cairo, EGY
| | - Taher Jamali
- Gastroenterology, Henry Ford Health System, Detroit, USA
| | - Amir Hanafi
- Internal Medicine, Rochester Regional Health, Rochester, USA
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19
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Yildirim Arslan S, Sahbudak Bal Z, Guner Ozenen G, Bilen NM, Avcu G, Erci E, Kurugol Z, Gunay H, Tamsel İ, Ozkinay F. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome secondary to antimicrobial therapy in pediatric bone and joint infections. World Allergy Organ J 2024; 17:100850. [PMID: 38370132 PMCID: PMC10869939 DOI: 10.1016/j.waojou.2023.100850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 11/13/2023] [Accepted: 11/18/2023] [Indexed: 02/20/2024] Open
Abstract
Background Bone and joint infections are common in children, particularly those under 10 years of age. While antimicrobial therapy can often successfully treat these infections, surgical drainage may also be necessary. It is important to note that prolonged courses of treatment have been associated with adverse events and drug reactions. Among these, drug reactions with eosinophilia and systemic symptoms (DRESS) syndrome is particularly severe and potentially life-threatening. We aimed to evaluate the cases of DRESS syndrome that develop during the treatment of bone and joint infections. Methods A retrospective study was conducted at a tertiary-level university hospital between 2015 and 2022 to determine the incidence and outcomes of definite DRESS Syndrome in children under 18 years of age with bone and joint infections. Results Of 73 patients with bone and joint infections, 16 (21.9 %) children developed antimicrobial therapy-induced DRESS syndrome. Eight (50 %) of these children were boys; the mean age of the patients was 9.76 ± 5.5 years. DRESS syndrome occurred in 16 children, including 13 children with osteomyelitis, 1 child with osteomyelitis and septic arthritis, and 2 children with septic arthritis and sacroiliitis. The mean duration of intravenous antibiotic therapy was 40.6 ± 16.6 days; the mean hospital stay was 48.7 ± 23.7 days; the mean time for the development of DRESS syndrome after starting antibiotics was 19.6 ± 7.68 days. New onset fever (68.8 %) and rash (43.8 %) were the most common symptoms of DRESS Syndrome. Cefotaxime and vancomycin were drugs responsible for DRESS syndrome in 8 (50 %) of 16. The causative antibiotics were switched to another class of antibiotic, most commonly preferred was ciprofloxacin (n:5; 31.3 %). For children with persistent symptoms, steroids were used in 5 (31.25) patients. Conclusions Clinicians should be aware of DRESS syndrome in children who develop fever and rash under long-term antibiotics and should check hematological and biochemical parameters to predict the severity of DRESS syndrome. In patients with persistent symptoms, steroids may be used to control the symptoms.
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Affiliation(s)
- Sema Yildirim Arslan
- Medical School of Ege University, Division of Infectious Disease, Department of Pediatrics, Izmir, Turkey
| | - Zumrut Sahbudak Bal
- Medical School of Ege University, Division of Infectious Disease, Department of Pediatrics, Izmir, Turkey
| | - Gizem Guner Ozenen
- Medical School of Ege University, Division of Infectious Disease, Department of Pediatrics, Izmir, Turkey
| | - Nimet Melis Bilen
- Medical School of Ege University, Division of Infectious Disease, Department of Pediatrics, Izmir, Turkey
| | - Gulhadiye Avcu
- Medical School of Ege University, Division of Infectious Disease, Department of Pediatrics, Izmir, Turkey
| | - Ece Erci
- Medical School of Ege University, Division of Infectious Disease, Department of Pediatrics, Izmir, Turkey
| | - Zafer Kurugol
- Medical School of Ege University, Division of Infectious Disease, Department of Pediatrics, Izmir, Turkey
| | - Huseyin Gunay
- Medical School of Ege University, Department of Orthopaedics and Traumatology, Izmir, Turkey
| | - İpek Tamsel
- Medical School of Ege University, Department of Radiology, Izmir, Turkey
| | - Ferda Ozkinay
- Medical School of Ege University, Division of Infectious Disease, Department of Pediatrics, Izmir, Turkey
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20
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Zhou C, Li J, Zhou F, Huang L, Liu X, Li H. Fatal Case of Pneumocystis Jirovecii Pneumonia (PJP) During Treatment for Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) Syndrome. Infect Drug Resist 2024; 17:153-159. [PMID: 38250337 PMCID: PMC10799616 DOI: 10.2147/idr.s447694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an acute, rare and potentially fatal drug reaction. To date, limited studies have reported secondary Pneumocystis jirovecii pneumonia (PJP) infection during the treatment of DRESS syndrome. A 53-year-old man was admitted to the hospital due to a persistent fever lasting for 5 days. He had a medical history of hypertension, psoriasis, urticaria, and had recently been treated with carbamazepine for nerve spasm two weeks ago. After admission, the patient presented with a high fever accompanied by chills, abdominal pain, bilateral upper limb muscle pain, and generalized lymph nodes enlargement. Laboratory tests revealed elevated eosinophils and atypical lymphocytes. Subsequently, the patient developed multiple internal organ complications, including oliguria, elevated serum creatinine, liver enzymes, and cardiac troponin I. Based on diagnostic criteria, the patient was diagnosed with DRESS syndrome. To manage the DRESS syndrome, the patient was successively or simultaneously prescribed methylprednisolone, cyclosporin and intravenous immunoglobulin, resulting in an improvement of the condition. However, during the treatment, the patient was infected with Pneumocystis jirovecii. Despite targeted therapy with trimethoprim/sulfamethoxazole, primaquine and clindamycin successively, no remission was observed. Chest CT scans exhibited multiple exudations in both lungs, indicative of interstitial pneumonia. Unfortunately, the patient's oxygenation progressively declined, leading to his untimely demise. This rare case further highlights the need for clinicians to be aware of the risk of Pneumocystis jirovecii infection in DRESS syndrome patients treated with long-term and high-dose glucocorticoid therapy.
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Affiliation(s)
- Chaoe Zhou
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Jun Li
- Department of Respiratory and Critical Care Medicine, Beijing Tsinghua Changgung Hospital, Beijing, People’s Republic of China
| | - Fude Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People’s Republic of China
| | - Lei Huang
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, People’s Republic of China
| | - Xinmin Liu
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Haichao Li
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, People’s Republic of China
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21
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Ziaka M, Liakoni E, Mani-Weber U, Exadaktylos A. Probable drug-induced systemic reaction without blood eosinophilia and rash- utility of eosinophilic cationic protein for diagnosis. Int J Immunopathol Pharmacol 2024; 38:3946320241271712. [PMID: 39214525 PMCID: PMC11366103 DOI: 10.1177/03946320241271712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 06/30/2024] [Indexed: 09/04/2024] Open
Affiliation(s)
- Mairi Ziaka
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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22
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Shea M, Weese K, Dhossche J. Leukemoid reaction in minocycline-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: A brief report. Pediatr Dermatol 2024; 41:141-142. [PMID: 37496096 DOI: 10.1111/pde.15392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/24/2023] [Indexed: 07/28/2023]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an idiosyncratic drug reaction hallmarked by cutaneous eruption, fever, lymphadenopathy, multiorgan involvement, and hematological abnormalities, most often eosinophilia and atypical lymphocytosis. Leukemoid reactions have rarely been described in DRESS syndrome and here we describe a 16-year-old male who was admitted to the hospital with DRESS syndrome due to minocycline, who had a severe leukocytosis up to 52.08 K/μL. He improved with cessation of minocycline and initiation of systemic steroids. We report this case to add to the literature on hematological abnormalities in pediatric DRESS syndrome.
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Affiliation(s)
- Moira Shea
- Oregon Health & Science University, Portland, Oregon, USA
| | | | - Julie Dhossche
- Oregon Health & Science University, Portland, Oregon, USA
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23
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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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24
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Çakmak ME. Drug Reaction with Eosinophilia and Systemic Symptom Syndrome Due to Everolimus: A Case Report. Ann Dermatol 2023; 35:S187-S190. [PMID: 38061700 PMCID: PMC10727864 DOI: 10.5021/ad.21.186] [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: 08/26/2021] [Revised: 10/14/2021] [Accepted: 11/26/2021] [Indexed: 12/20/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptom (DRESS) is a life-threatening drug hypersensitivity reaction that is characterized by skin rash, hematological abnormalities (eosinophilia, atypical lymphocytosis), lymphadenopathy, and internal organ involvement (liver, kidneys, and lung). Many drugs may cause DRESS syndrome, the most frequently reported of which are antiepileptics and allopurinol. In this case report, a patient who developed DRESS syndrome due to everolimus was presented herein.
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Affiliation(s)
- Mehmet Erdem Çakmak
- Department of Allergy and Clinical Immunology, Başakşehir Çam ve Sakura City Hospital, Istanbul, Turkey.
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25
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Schroeder JW, Napoli C, Caputo V, Bonoldi E, Rongioletti F. Unraveling the complexities of drug reaction with eosinophilia and systemic symptoms (DRESS): Insights into clinical, laboratory, and histopathologic features of a case series from an Italian tertiary center. Clin Dermatol 2023; 41:721-728. [PMID: 37730074 DOI: 10.1016/j.clindermatol.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe and potentially life-threatening drug hypersensitivity reaction. The diagnosis and management of DRESS are complicated due to its heterogeneous clinical and pathologic presentations, delayed onset of signs and symptoms, and unpredictable outcome. This retrospective study aimed to analyze cases of DRESS from a single Italian referring tertiary hospital center (Grande Ospedale Metropolitano Niguarda, Milan, Italy) with a focus on clinical features, causative drugs, histopathologic findings, and treatment. We have included 18 of 32 patients with a probable or definite diagnosis of DRESS. The study observed a slight predominance of women, with antimicrobials and allopurinol identified as the main causative drugs. Clinical manifestations varied, with a monomorphic maculopapular eruption being the most common, whereas facial edema and mucosal involvement were less frequently observed. Multiple organs were commonly affected, with liver and kidney involvement being prominent. Cardiac involvement was associated with the severity of eosinophilia. Laboratory evaluations showed elevated eosinophil levels and increased eosinophil cationic protein levels, supporting the role of eosinophils in DRESS pathogenesis. Histopathologic analysis revealed various patterns often coexisting in the same biopsy in 83% of cases, with interface dermatitis being the most frequent, followed by the perivascular pattern and the spongiotic/eczematous pattern. We observed eosinophils in the biopsy samples in about 50% of patients, and the relationship between peripheral eosinophilia and eosinophils in skin biopsies was not significant. In addition to the RegiSCAR score, age may play a role in predicting disease severity, as older patients with lower scores had poorer outcomes. The prognosis of DRESS depended on early identification, discontinuation of the causative agent, and appropriate therapy. Systemic corticosteroids were the primary treatment option.
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Affiliation(s)
- Jan Walter Schroeder
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Valentina Caputo
- Unit of Surgical Pathology and Cytogenetics, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Emanuela Bonoldi
- Unit of Surgical Pathology and Cytogenetics, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Franco Rongioletti
- Vita-Salute San Raffaele University, Milan, Italy; Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
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26
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Doan KD, Akinsanya A, Kuhar M, Mesa H. Fatal eosinophilic myocarditis and submassive hepatic necrosis in lamotrigine induced DRESS syndrome. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:92. [PMID: 37880699 PMCID: PMC10601244 DOI: 10.1186/s13223-023-00848-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023]
Abstract
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a rare but severe and sometimes fatal adverse drug reaction that is known to occur with a number of antiepileptic drugs. It often follows a prolonged clinical course, which can worsen even after discontinuing the causative drug and administering steroid treatment. Failure to promptly identify the delayed involvement of vital organs, such as the heart and liver, may result in irreversible organ failure and death. We report a case of a presumed sudden death of a young woman who had a documented history of a protracted intermittent hypersensitivity reaction to lamotrigine. Postmortem examination revealed the presence of eosinophilic myocarditis and submassive hepatic necrosis diagnostic of fatal DRESS syndrome that progressed despite early discontinuation of the medication and improvement of dermatologic and hematologic symptoms following steroid therapy.
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Affiliation(s)
- Khanh Duy Doan
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Adeyinka Akinsanya
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, 350 W 11th St, Indianapolis, IN, 46202, USA
| | - Matthew Kuhar
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, 350 W 11th St, Indianapolis, IN, 46202, USA
| | - Hector Mesa
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, USA.
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, 350 W 11th St, Indianapolis, IN, 46202, USA.
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27
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Yan Q, Liu X, Lei H, Liu R, Hu Y. Analysis of clinical features of oxcarbazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis. Front Med (Lausanne) 2023; 10:1232969. [PMID: 37881633 PMCID: PMC10597665 DOI: 10.3389/fmed.2023.1232969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
Background Stevens-Johnson syndrome (SJS) is considered a hypersensitivity syndrome affecting the skin and mucous membranes. It has been reported that an anticonvulsant drug, oxcarbazepine, may cause Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN). However, the clinical features of oxcarbazepine-induced Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) remain ambiguous. This article aims to explore the clinical features of SJS/TEN. Methods Systematic searches of several Chinese and English databases were conducted for case reports published on PubMed, EMBASE, Web of Science, MEDLINE, CNKI from January 1, 2007 to March 1, 2023. Results A total of seventeen patients (10 males and 7 females) were included in this study, including nine adult patients and eight pediatric patients. The results showed that males seem to have a higher prevalence of SJS/TEN than females, and SJS/TEN usually occurs within 2 weeks after administration of oxcarbazepine (OXC). The main clinical manifestations among the included patients were rashes or maculopapules (17 cases, 100%), fever (11 cases, 64.7%), mucosal lesions (15 cases, 88.2%), conjunctivitis with/without ocular discharge (12 cases, 70.6%), and blisters (12 cases, 70.6%). After stopping OXC or switching to other drugs that treat primary disease as well as treatment with IVIG, glucocorticoid, anti-allergy, and fluid replacement, eight of the included patients recovered completely, and another eight of the included patients reported symptomatic improvement, while the prognosis of one of the included patients was not reported. Conclusion Diverse clinical signs and symptoms of SJS/TEN might result in misinterpretation and delayed diagnosis. It should be identified and treated immediately to avoid significant consequences and potentially jeopardize patients' lives.
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Affiliation(s)
- Qingzi Yan
- Department of Clinical Pharmacy, Xiangtan Central Hospital, Xiangtan, China
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28
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Kanabaj K, Jenerowicz D, Jankowska L, Żaba Z. DRESS syndrome - A dermatological emergency - Sulfasalazine-related acute drug reaction case report. Heliyon 2023; 9:e20021. [PMID: 37809745 PMCID: PMC10559731 DOI: 10.1016/j.heliyon.2023.e20021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/19/2023] [Accepted: 09/08/2023] [Indexed: 10/10/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) or drug-induced hypersensitivity syndrome (DIHS) is a severe skin reaction associated with general symptoms and mortality reaching up to 10% of cases. DRESS/DIHS is one of the few dermatological emergencies which need to be taken into consideration when dealing with a patient with acute exanthema and systemic symptoms like: fever, lymphadenopathy, muscle pain, hepatosplenomegaly, abnormal blood count results and systemic inflammation. The aim of this article is to summarize the literature finding regarding this dermatological emergency and present the case of a 42-year-old male suffering from DRESS syndrome as a consequence of sulfasalazine intake due to an inflammatory bowel disease, who was effectively treated with oral prednisolone and immediate drug withdrawal.
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Affiliation(s)
- Krzysztof Kanabaj
- Department of Dermatology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-356, Poznan, Poland
| | - Dorota Jenerowicz
- Department of Dermatology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-356, Poznan, Poland
| | - Lucyna Jankowska
- Department of Dermatology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-356, Poznan, Poland
| | - Zbigniew Żaba
- Department of Emergency Medicine, Poznan University of Medical Sciences, ul. Rokietnicka 7, 60-806, Poznan, Poland
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29
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Elkady D, Okorie CL, Estupiñan B, Modi MB, Cotler SJ, Lake E. A diagnostic challenge: Life-threatening drug reaction with eosinophilia and systemic symptoms in the setting of a SARS-CoV-2 and human herpesvirus-6 reactivation in a patient with severe hepatic injury on bupropion. JAAD Case Rep 2023; 39:101-105. [PMID: 37635861 PMCID: PMC10458671 DOI: 10.1016/j.jdcr.2023.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Affiliation(s)
- Djoni Elkady
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | | | - Blanca Estupiñan
- Division of Dermatology, Loyola University Medical Center, Maywood, Illinois
| | - Mitul B. Modi
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Scott J. Cotler
- Division of Hepatology, Loyola University Medical Center, Maywood, Illinois
| | - Eden Lake
- Division of Dermatology, Loyola University Medical Center, Maywood, Illinois
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30
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Mallaro HL, Rosenthal LJ. DRESS syndrome: quetiapine associated case report and literature review. Int Clin Psychopharmacol 2023; 38:356-360. [PMID: 37159165 DOI: 10.1097/yic.0000000000000474] [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] [Indexed: 05/10/2023]
Abstract
Drug rash with eosinophilia and systemic symptoms (DRESS syndrome) is a rare systemic adverse drug reaction with a high mortality rate. Cases of DRESS syndrome have been reported with almost all classes of psychiatric medications, but data remains limited. We describe the case of a 33-year-old woman who presented with acute respiratory distress syndrome secondary to severe pulmonary blastomycosis. Her hospital course was complicated by severe agitation for which the psychiatry consult team was involved and several medications were trialed including quetiapine. She developed a diffuse erythematous rash during her hospital stay and later eosinophilia and transaminitis consistent with DRESS syndrome due to either quetiapine or lansoprazole based on the timeline. Both medications were discontinued, and she was started on a prednisone taper leading to resolution of the rash, eosinophilia, and transaminitis. Her HHV-6 IgG titer later returned elevated at 1:1280. DRESS syndrome along with many other cutaneous drug reactions can be associated with psychiatric medications and familiarity and recognition are imperative. There are limited reports of quetiapine-associated DRESS syndrome in the literature; however, rash and eosinophilia should alert psychiatrists to the potential for quetiapine to be a precipitant for DRESS syndrome.
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Affiliation(s)
| | - Lisa J Rosenthal
- Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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31
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Jiang W, Xun Y. Drug reaction with eosinophilia and systemic symptoms syndrome secondary to Chinese oral herbal paste: a case report. Gastroenterol Rep (Oxf) 2023; 11:goad047. [PMID: 37576951 PMCID: PMC10423057 DOI: 10.1093/gastro/goad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/21/2023] [Accepted: 07/16/2023] [Indexed: 08/15/2023] Open
Affiliation(s)
- Weiyun Jiang
- Department of Liver Diseases, Hangzhou Sixth People’s Hospital/Xixi Hospital of Hangzhou, Zhejiang University, Hangzhou, Zhejiang, P. R. China
| | - Yunhao Xun
- Department of Liver Diseases, Hangzhou Sixth People’s Hospital/Xixi Hospital of Hangzhou, Zhejiang University, Hangzhou, Zhejiang, P. R. China
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32
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Molleti RR, Bidell MR, Tatara AW. Fidaxomicin-Associated Hypersensitivity Reactions: Report of a Morbilliform Drug Eruption. J Pharm Pract 2023; 36:993-997. [PMID: 36112954 DOI: 10.1177/08971900221078780] [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] [Indexed: 07/20/2023]
Abstract
PurposeWe report a probable case of morbilliform drug eruption secondary to fidaxomicin in a patient with Clostridioides difficile infection (CDI). Summary: A 62-year-old female presented to our institution's emergency department (ED) with symptoms consistent with Clostridioides difficile infection. The patient was prescribed 2 weeks of oral vancomycin for CDI prior to presentation. Given insufficient response to vancomycin, the patient was started on fidaxomicin with a planned 10-day course. After 2 doses of fidaxomicin, the patient developed a rash on her back that spread within 24 hours. The patient did not experience relief upon administration of a variety of medications for allergic reaction. Improvement was noted upon discontinuation of fidaxomicin. The Food and Drug Administration reports that < 2% of adults treated with fidaxomicin experience a rash as an adverse effect. Conclusion: Fidaxomicin was a probable cause of morbilliform drug eruption in our patient with CDI. The patient improved upon discontinuation of fidaxomicin.
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Affiliation(s)
- Radha R Molleti
- Department of Pharmacy, Memorial Hermann Memorial City Hospital, Houston, Texas, USA
| | - Monique R Bidell
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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33
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Manieri E, Dondi A, Neri I, Lanari M. Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome in childhood: a narrative review. Front Med (Lausanne) 2023; 10:1108345. [PMID: 37575981 PMCID: PMC10421667 DOI: 10.3389/fmed.2023.1108345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Despite being rare, the Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a serious, possibly fatal condition that may affect both adults and children who may be also burdened by delayed sequelae. It is an adverse drug reaction characterized by widespread skin involvement, fever, lymphadenopathy, visceral involvement, and laboratory abnormalities (eosinophilia, mononucleosis-like atypical lymphocytes). It is more frequently triggered by anticonvulsants, sulphonamides, or antibiotics, the latter being responsible for up to 30% of pediatric cases. The disease typically develops 2-8 weeks after exposure to the culprit medication, with fever and widespread skin eruption; mild viral prodromes are possible. Unfortunately, diagnosis is challenging due to the absence of a reliable test; however, a score by the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) allows to classify suspect patients into no, possible, probable, or definite DRESS cases. Moreover, rapid-onset DRESS syndrome has been described in recent years. It affects children more often than adults and differs from the most common form because it appears ≤15 days vs. >15 days after starting the drug, it is usually triggered by antibiotics or iodinated contrast media rather than by anticonvulsants and has a higher presence of lymphadenopathy. Differential diagnosis between rapid-onset antibiotic-driven DRESS syndrome, viral exanthems, or other drug eruptions may be challenging, but it is mandatory to define it as early as possible to start adequate treatment and monitor possible complications. The present review reports the latest evidence about the diagnosis and treatment of pediatric DRESS syndrome.
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Affiliation(s)
- Elisa Manieri
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Arianna Dondi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Iria Neri
- Division of Dermatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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34
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Dagnon da Silva M, Domingues SM, Oluic S, Radovanovic M, Kodela P, Nordin T, Paulson MR, Joksimović B, Adetimehin O, Singh D, Madrid C, Cardozo M, Baralic M, Dumic I. Renal Manifestations of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome: A Systematic Review of 71 Cases. J Clin Med 2023; 12:4576. [PMID: 37510691 PMCID: PMC10380880 DOI: 10.3390/jcm12144576] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/30/2023] Open
Abstract
Unlike other adverse drug reactions, visceral organ involvement is a prominent feature of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and correlates with mortality. The aim of this study was to systematically review cases published in PubMed-indexed, peer-reviewed journals in which patients had renal injury during the episode of DRESS syndrome (DS). We found 71 cases, of which 67 were adults and 56% were males. Female sex was associated with higher mortality. Chronic kidney disease (CKD) was present in 14% of patients who developed acute kidney injury (AKI) during DS. In 21% of cases, the kidneys were the only visceral organ involved, while 54% of patients had both liver and kidney involvement. Eosinophilia was absent in 24% of patients. The most common classes of medication associated with renal injury in DS were antibiotics in 34%, xanthine oxidase inhibitors in 15%, and anticonvulsants in 11%. Among antibiotics, vancomycin was the most common culprit in 68% of patients. AKI was the most common renal manifestation reported in 96% of cases, while isolated proteinuria or hematuria was present in only 4% of cases. In cases with AKI, 88% had isolated increase in creatinine and decrease in glomerular filtration (GFR), 27% had AKI concomitantly with proteinuria, 18% had oliguria, and 13% had concomitant AKI with hematuria. Anuria was the rarest manifestation, occurring in only 4% of patients with DS. Temporary renal replacement therapy was needed in 30% of cases, and all but one patient fully recovered renal function. Mortality of DS in this cohort was 13%, which is higher than previously reported. Medication class, latency period, or pre-existing CKD were not found to be associated with higher mortality. More research, particularly prospective studies, is needed to better recognize the risks associated with renal injury in patients with DS. The development of disease-specific biomarkers would also be useful so DS with renal involvement can be easier distinguished from other eosinophilic diseases that might affect the kidney.
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Affiliation(s)
| | | | - Stevan Oluic
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL 60402, USA
| | - Milan Radovanovic
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | | | - Terri Nordin
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Family Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Margaret R Paulson
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Bojan Joksimović
- Faculty of Medicine Foca, University of East Sarajevo, 73300 Foca, The Republic of Srpska, Bosnia and Herzegovina
| | - Omobolanle Adetimehin
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Devender Singh
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Nephrology, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Cristian Madrid
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Milena Cardozo
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Marko Baralic
- Department of Nephrology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Igor Dumic
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
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35
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Awad A, Goh MS, Trubiano JA. Drug Reaction With Eosinophilia and Systemic Symptoms: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1856-1868. [PMID: 36893848 DOI: 10.1016/j.jaip.2023.02.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/30/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a potentially life-threatening drug reaction; recognizing the diversity of its clinical presentations, implicated drugs, and management modalities can aid in diagnosis and reduce morbidity and mortality. OBJECTIVE To review the clinical features, drug causes, and treatments deployed in DRESS. METHODS This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to review publications relating to DRESS published between 1979 and 2021. Only publications with a RegiSCAR score of 4 or greater were included (indicating "probable" or "definite" DRESS). The PRISMA guidelines were used for data extraction and the Newcastle-Ottawa scale for quality assessment (Pierson DJ. Respir Care 2009;54:1372-8). The main outcomes included implicated drugs, patient demographics, clinical manifestations, treatment, and sequelae for each included publication. RESULTS A total of 1124 publications were reviewed, and 131 met the inclusion criteria, amounting to 151 cases of DRESS. The most implicated drug classes were antibiotics, anticonvulsants, and anti-inflammatories, although up to 55 drugs were implicated. Cutaneous manifestations were present in 99% of cases, with a median onset of 24 days and maculopapular rash the most common morphology. Common systemic features were fever, eosinophilia, lymphadenopathy, and liver involvement. Facial edema was present in 67 cases (44%). Systemic corticosteroids were the mainstay of DRESS-specific treatment. A total of 13 cases (9%) resulted in mortality. CONCLUSION DRESS diagnosis should be considered in the presence of a cutaneous eruption, fever, eosinophilia, liver involvement, and lymphadenopathy. The class of implicated drug may influence outcome, as allopurinol was associated with 23% of cases that resulted in death (3 cases). Given potential DRESS complications and mortality, it is important that DRESS is recognized early so that any suspect drugs are ceased promptly.
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Affiliation(s)
- Andrew Awad
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Hospital, Heidelberg, VIC, Australia.
| | - Michelle S Goh
- Department of Dermatology, Austin Health, Heidelberg, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Hospital, Heidelberg, VIC, Australia; Department of Infectious Diseases, University of Melbourne, Parkville, VIC, Australia
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Kong D, Dixit K, Konje S, Gandhi K, Salman S, Moras E, Agarwal V. Drug Reaction With Eosinophilia and Systemic Symptoms-Associated Perimyocarditis After Initiation of Anti-tuberculosis Therapy: A Case Report. Cureus 2023; 15:e37399. [PMID: 37181989 PMCID: PMC10171903 DOI: 10.7759/cureus.37399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2023] [Indexed: 05/16/2023] Open
Abstract
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.
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Affiliation(s)
- Darren Kong
- Medicine, Mount Sinai Morningside, New York, USA
| | - Keshav Dixit
- Medicine, Mount Sinai Morningside, New York, USA
| | - Swiri Konje
- Medicine, Mount Sinai Morningside, New York, USA
| | - Kruti Gandhi
- Medicine, Mount Sinai Morningside, New York, USA
| | - Sidra Salman
- Medicine, Mount Sinai Morningside, New York, USA
| | - Errol Moras
- Medicine, Mount Sinai Morningside, New York, USA
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Ashifha S, Vijayashree J, Vudayana K, Chintada D, P P, G P, Unnikrishnan P. A Study of Cutaneous Adverse Drug Reactions at a Tertiary Care Center in Andhra Pradesh, India. Cureus 2023; 15:e37596. [PMID: 37197134 PMCID: PMC10184741 DOI: 10.7759/cureus.37596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION Practically all physicians encounter a diverse range of suspected cutaneous adverse drug reactions (CADRs) in their daily clinical practice. The skin and mucosa are the most often encountered areas for the early presentation of numerous adverse drug reactions. Cutaneous adverse drug reactions are classified as benign or severe. The clinical manifestations of drug eruptions can range from mild maculopapular exanthema to severe cutaneous adverse drug reactions (SCARs). OBJECTIVE To determine the varied clinical and morphological presentations of CADRs and to identify the culprit drug and common drugs causing CADRs. MATERIALS AND METHODS Patients with clinical features suspected of CADRs presenting to the outpatient department (OPD) of dermatology, venereology, and leprosy (DVL) between December 2021 to November 2022 at Great Eastern Medical School and Hospital (GEMS), Srikakulam, Andhra Pradesh, India, were considered for the study. This was a cross-sectional, observational study. The patient's clinical history was taken in detail. This included chief complaints (symptoms, site of onset, duration, drug history, latency time between drug administration and the appearance of cutaneous lesions), family history, associated diseases, the morphology of lesions, and mucosal examination. Upon drug discontinuation, improvement in cutaneous lesions and systemic features were noted. A complete general examination, systemic examination, dermatological tests, and mucosal examination were performed. RESULTS A total of 102 patients were involved in the study, of whom 55 were males and 47 were females. The male-to-female ratio was 1.17:1, with a slight male majority. The most common age group was 31 to 40 years for both males and females. Itching was the predominant complaint in 56 patients (54.9%). The mean latency period was shortest in urticaria (2.13+/- 0.99 hours) and longest in lichenoid drug eruption (4.33+/- 3.93 months). Most patients developed symptoms after a week of taking the drug (53.92%). A history of similar complaints was present in 38.23% of patients. Analgesics and antipyretics (39.2%) were the most common culprit drugs followed by antimicrobials (29.4%). Among analgesics and antipyretics, aceclofenac (24.5%) was the commonest culprit drug. Benign CADRs were observed in 89 patients (87.25%), and severe cutaneous adverse reactions (SCARs) were observed in 13 patients (12.74%). The common CADRs presented were drug-induced exanthem (27.4%). Imatinib-induced psoriasis vulgaris and lithium-induced scalp psoriasis were observed in one patient each. Severe cutaneous adverse reactions were observed in 13 patients (12.74%). Anticonvulsants, nonsteroidal anti-inflammatory drugs (NSAIDs), and antimicrobials were the culprit drugs for SCARs. Eosinophilia was present in three patients, deranged liver enzymes was present in nine patients, a deranged renal profile was present in seven patients, and death occurred in one patient with toxic epidermal necrolysis (TEN) of SCARs. CONCLUSION Before prescribing any drug to a patient, a detailed drug history and family history of drug reactions need to be obtained. Patients should be advised to avoid over-the-counter usage of medications and self-administration of drugs. If adverse drug reactions occur, it is advised to avoid readministration of the culprit drug. Drug cards must be prepared and given to the patient, mentioning the culprit drug as well as the cross-reacting drugs.
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Affiliation(s)
- Shaik Ashifha
- Dermatology, Venereology and Leprosy, Great Eastern Medical School and Hospital, Srikakulam, IND
| | - Jami Vijayashree
- Dermatology, Venereology and Leprosy, Great Eastern Medical School and Hospital, Srikakulam, IND
| | - Kirankanth Vudayana
- Dermatology, Venereology and Leprosy, Great Eastern Medical School and Hospital, Srikakulam, IND
| | - Dilipchandra Chintada
- Dermatology, Venereology and Leprosy, Great Eastern Medical School and Hospital, Srikakulam, IND
| | - Pavani P
- Dermatology, Venereology and Leprosy, Great Eastern Medical School and Hospital, Srikakulam, IND
| | - Pallavi G
- Dermatology, Venereology and Leprosy, Great Eastern Medical School and Hospital, Srikakulam, IND
| | - Pooja Unnikrishnan
- Dermatology, Venereology and Leprosy, Great Eastern Medical School and Hospital, Srikakulam, IND
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Waldron JL, James F, Vogrin S, Chua KYL, Holmes NE, DeLuca J, Goh MS, Douglas AP, Trubiano JA. A Shorter Time to Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS): Redefining Beta-Lactam-Associated DRESS. Clin Infect Dis 2023; 76:772-774. [PMID: 36190825 DOI: 10.1093/cid/ciac798] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jamie L Waldron
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Fiona James
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine-St Vincent's Health, University of Melbourne, Fitzroy, Victoria, Australia
| | - Kyra Y L Chua
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Joseph DeLuca
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Michelle S Goh
- Department of Dermatology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Abby P Douglas
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
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Evaluation of Delayed-Type Hypersensitivity to Antineoplastic Drugs-An Overview. Cancers (Basel) 2023; 15:cancers15041208. [PMID: 36831549 PMCID: PMC9954236 DOI: 10.3390/cancers15041208] [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: 11/28/2022] [Revised: 01/30/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
Nowadays, clinical practice encounters the problem of delayed-type hypersensitivity (DTH) induced by several drugs. Antineoplastic treatments are among the drugs which show an elevated proportion of DHT reactions, leading to the worsening of patients' quality of life. The range of symptoms in DHT reactions can vary from mild, such as self-limiting maculopapular eruptions, to severe, such as Stevens-Johnson Syndrome. The development of these reactions supposes a negative impact, not only by limiting patients' quality of life, but also leading to economic loss due to market withdrawal of the affected drugs and high hospitalization costs. However, despite this problem, there are no available standard in vitro or in vivo methods that allow for the evaluation of the sensitizing potential of drugs in the preclinical phase. Therefore, the aim of this review is to summarize the skin reactions caused by the different antineoplastic families, followed by a comprehensive evaluation of the in vitro and in vivo methods used to detect DTHs and that could be suitable to test antineoplastic hypersensitivity reactions.
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Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome in a Child with Cystic Fibrosis. Case Reports Immunol 2023; 2023:1006376. [PMID: 36778654 PMCID: PMC9911254 DOI: 10.1155/2023/1006376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/24/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023] Open
Abstract
Background Drug reaction with eosinophilia and systemic symptoms (DRESSs) syndrome is an idiosyncratic drug-induced reaction that rarely occurs in children but can lead to serious complications. It manifests most commonly with fever, extensive skin eruptions, and eosinophilia. Symptoms typically develop two to six weeks after the initiation of the inciting drug. Visceral organ involvement especially the liver can also occur and if not recognized early and the inciting drug is not stopped immediately, it can lead to liver failure. Therefore, early diagnosis is important but can be very challenging because of disease rarity, lack of a diagnostic test, and its overlap with other common pediatric allergic and infectious conditions. Case Presentation. A 2.5-year-old boy with known diagnosis of cystic fibrosis, bilateral bronchiectasis, pancreatic insufficiency, and chronic airway colonization with Pseudomonas aeruginosa was admitted to our hospital with acute pulmonary exacerbation of CF lung disease. He was treated with intravenous piperacillin-tazobactam and intravenous amikacin in addition to airway clearance. On day 18 of treatment, the patient developed high grade fever followed by diffuse erythematous and pruritic maculopapular rash. Blood tests showed high eosinophilia, high C-reactive protein (CRP), and high liver enzymes levels. The clinical features and the laboratory findings were consistent with the DRESS syndrome. Therefore, all antibiotics were discontinued. Progressive resolution of the symptoms was observed within two days. Laboratory abnormalities were also normalized in the follow-up clinic visit 4 months later. Conclusion Our case demonstrates the importance of early recognition of the DRESS syndrome in children who develop fever and skin rashes with eosinophilia while undergoing long-term antibiotic treatment. Prompt discontinuation of the offending drug is the cornerstone therapy and results in the resolution of symptoms and prevention of serious complications.
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Yordanova K, Pföhler C, Schweitzer LF, Bourg C, Adam L, Vogt T. Etanercept leads to a rapid recovery of a Dabrafenib-/Trametinib-associated toxic epidermal necrolysis-like severe skin reaction. SKIN HEALTH AND DISEASE 2023; 3:e185. [PMID: 36751314 PMCID: PMC9892424 DOI: 10.1002/ski2.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Krista Yordanova
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Claudia Pföhler
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Luca F. Schweitzer
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Catherine Bourg
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Leonie Adam
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Thomas Vogt
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
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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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Luu LA, Makin TA, Borish L, Snavely EA, Meyer JS, Zlotoff BJ, Zeichner SL. Fever, Rash, and Cough in a 7-Year-Old Boy. Pediatrics 2023; 151:e2022058194. [PMID: 36601710 DOI: 10.1542/peds.2022-058194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 01/06/2023] Open
Abstract
A 7-year-old boy presented to the emergency department with fever, cough, congestion, abdominal pain, myalgias, and morbilliform rash. Several aspects of the patient's history, including recent travel, living on a farm, exposure to sick contacts, and new medications, resulted in a wide differential diagnosis. Initial laboratory testing revealed leukocytosis with neutrophilia and elevated atypical lymphocytes, but did not reveal any infectious causes of illness. He was discharged from the hospital, but then represented to the emergency department a day later with worsening rash, continued fever, abdominal pain, and poor intake. He was then admitted. A more comprehensive laboratory evaluation was initiated. During this hospital course, the patient's physical examination changed when he developed head and neck edema, and certain laboratory trends became clearer. With the assistance of several specialists, the team was able to reach a more definitive diagnosis and initiate treatment to appropriately manage his condition.
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Affiliation(s)
| | | | | | | | | | | | - Steven L Zeichner
- Pediatrics and Microbiology, Immunology, and Cancer Biology, University of Virginia, Charlottesville, Virginia
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Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Focus on the Pathophysiological and Diagnostic Role of Viruses. Microorganisms 2023; 11:microorganisms11020346. [PMID: 36838310 PMCID: PMC9966117 DOI: 10.3390/microorganisms11020346] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a heterogeneous, multiorgan and potentially life-threatening drug-hypersensitivity reaction (DHR) that occurs several days or weeks after drug initiation or discontinuation. DHRs constitute an emerging issue for public health, due to population aging, growing multi-organ morbidity, and subsequent enhanced drug prescriptions. DRESS has more consistently been associated with anticonvulsants, allopurinol and antibiotics, such as sulphonamides and vancomycin, although new drugs are increasingly reported as culprit agents. Reactivation of latent infectious agents such as viruses (especially Herpesviridae) plays a key role in prompting and sustaining aberrant T-cell and eosinophil responses to drugs and pathogens, ultimately causing organ damage. However, the boundaries of the impact of viral agents in the pathophysiology of DRESS are still ill-defined. Along with growing awareness of the multifaceted aspects of immune perturbation caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the ongoing SARS-CoV-2-related disease (COVID-19) pandemic, novel interest has been sparked towards DRESS and the potential interactions among antiviral and anti-drug inflammatory responses. In this review, we summarised the most recent evidence on pathophysiological mechanisms, diagnostic approaches, and clinical management of DRESS with the aim of increasing awareness on this syndrome and possibly suggesting clues for future research in this field.
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Liu M, Ci XY, Huang H, Zhang MJ. Antiepileptic drug-induced hypersensitivity syndrome with liver function abnormality and fever as the first manifestation: A case report. Medicine (Baltimore) 2023; 102:e32657. [PMID: 36701733 PMCID: PMC9857269 DOI: 10.1097/md.0000000000032657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
RATIONALE Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe cutaneous drug reaction characterized by fever, lymphadenopathy, hematologic abnormalities, single or multiple organ involvement, and viral reactivation.[1] The most frequently reported offending drugs are aromatic antiepileptic agents, antibiotics, and allopurinol.[2] Though a relatively rare syndrome, DRESS can lead to severe multi-organ system dysfunction, and in some cases even death. DRESS is one of the severe drug eruptions in dermatological diseases, but it is difficult to diagnose for internist. In this paper, a typical drug hypersensitivity syndrome with abnormal liver function and fever as the first manifestations was reported. The objective of this study was to improve the understanding of rare drug hypersensitivity syndrome in digestion and other fields, and to avoid missed diagnosis and misdiagnosis. PATIENT CONCERNS A 33-year-old Chinese female was initially diagnosed with acute hepatic insufficiency. Combined with the suspicious drug history, she developed DRESS with fever, target erythema, left lymph node enlargement, hematological abnormalities, and abnormal liver function. DIAGNOSES Combined with the above characteristics, liver toxicity is the main manifestation, accompanied by fever, mainly moderate to high fever (above 38 °C) , sporadic rash, other organs (kidney, immune system) damage, and a marked increase in eosinophil granulocytic. Therefore the patient was diagnosed with definite case of DRESS syndrome based on clinical and laboratory findings. INTERVENTIONS Hormones (methylprednisolone 60 mg/day for 12 days and 80 mg/day for 12 days) and immunoglobulins (intravenous immunoglobulin 10 g/day for 5 days and 20 g/day for 7 days) were given. OUTCOMES The patient was discharged from the hospital after recovery. One month after discharge, she was re-admitted to the hospital because of elevated blood sugar and was diagnosed as diabetes. LESSONS DRESS syndrome is a rare but life-threatening hypersensitivity reaction. The mortality will be very high if it's not diagnosed and treated timely. This paper presents a successful case of methylprednisolone plus intravenous immunoglobulin therapy, which provides a stronger evidence for the future diagnosis and treatment of the disease.
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Affiliation(s)
- Mei Liu
- Department of Gastroenterology, Shandong Provincial Qianfoshan Hospital, Shandong First Medical University, Jinan, Shandong, China
| | - Xin-Yu Ci
- Department of Gastroenterology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
| | - Han Huang
- Department of Gastroenterology, Shandong Provincial Qianfoshan Hospital, Shandong First Medical University, Jinan, Shandong, China
| | - Mei-Juan Zhang
- Department of Health Management, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering Laboratory for Health Management, Jinan, Shandong, China
- * Correspondence: Mei-Juan Zhang, Department of Health Management, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering Laboratory for Health Management, No.16766 Jingshi Road, Jinan, Shandong 250014, China (e-mail: )
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Muacevic A, Adler JR, Schaufelberger B, De La Torre E, Smugar SS. A Comprehensive Analysis of Topiramate and Drug Reaction With Eosinophilia and Systemic Symptoms. Cureus 2023; 15:e33713. [PMID: 36643088 PMCID: PMC9836740 DOI: 10.7759/cureus.33713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2023] [Indexed: 01/13/2023] Open
Abstract
Introduction Recent publications have described drug reaction with eosinophilia and systemic symptoms (DRESS) with topiramate. Topiramate has been associated with other severe cutaneous adverse reactions, including Stevens-Johnson syndrome, but a relationship to DRESS has not been established. To determine if there is a causal association between topiramate and DRESS, we conducted a comprehensive review of the data in the Janssen Research & Development Global Safety Database (GSD), signaling databases, and the literature. Methods The primary data were post-marketing reports of DRESS in the Janssen topiramate GSD (cumulative through 1 July 2022), representing >14,000,000 patient-years (PY) exposure. Cases were reviewed, assigned a Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) score, and assessed for overall contribution of topiramate to DRESS based on temporality, concomitant medications, dechallenge/rechallenge, and baseline patient factors. Statistical disproportionality was evaluated in European Medicines Agency's EudraVigilance (EV) safety database and the United States Food and Drug Administration Adverse Event Reporting System (FAERS). For EV, the overall disproportionality threshold was the lower limit of the 95% confidence interval (CI) for the reporting odds ratio (ROR025) >1 and N ≥5. The overall threshold for FAERS was the Empirical Bayesian Geometric Mean (EBGM) ≥2, lower bound of the 90% CI (EB05) of >1, and N ≥3. To account for the role of concomitant drugs, Empirical Bayes regression-adjusted arithmetic mean (ERAM) scores were calculated, with a threshold ≥2, a lower bound of the 90% CI (ER05) of >1, and N ≥3. An integrated search of major biomedical literature was performed for reports of topiramate and DRESS. Results There were 17 reports of DRESS in the GSD (reporting rate 0.12/100,000 PY). RegiSCAR scores ranged from -3 to 7 (average -0.4). No cases met full diagnostic criteria and were highly confounded by the presence of other suspect drugs. Disproportionality scores exceeded thresholds for statistical significance in FAERS (N=72, EBGM=2.06, EB05=1.69), but not in EV (N=33, ROR025=0.79). When accounting for co-administered drugs, ERAM was statistically significant for carbamazepine (4.53), lamotrigine (ERAM=6.54), phenytoin (ERAM=2.91), and zonisamide (ERAM=2.25) exceeding disproportionality thresholds, but the score of topiramate was no longer significant (0.25). Conclusion A comprehensive review of all available evidence does not support a causal association between topiramate and DRESS.
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Pope EI, Au H, Levy DM, Verstegen RHJ. Case report: Drug reaction with eosinophilia and systemic symptoms (DRESS)-induced hemophagocytic disorder. Front Pharmacol 2022; 13:1023522. [DOI: 10.3389/fphar.2022.1023522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
Hemophagocytic disorders are severe and life-threatening conditions that can be genetic in origin [i.e., primary hemophagocytic lymphohistiocytosis (HLH)] or result from infections (i.e., secondary hemophagocytic lymphohistiocytosis), rheumatologic disease [i.e., macrophage activation syndrome (MAS)], and less frequently immunodeficiency or metabolic disease. Although rare, drug-induced hemophagocytosis needs to be considered in the work-up as it requires specific management strategies. Most drug-induced hemophagocytic disorders are related to Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). We present the case of a 7-year-old girl who initially presented with fever, maculopapular rash, and unilateral lymphadenopathy, who went on to develop hemophagocytosis secondary to DRESS caused by prolonged combination treatment with amoxicillin/clavulanic acid and trimethoprim/sulfamethoxazole. This case illustrates the importance of considering adverse drug reactions in the evaluations of patients with a hemophagocytic process.
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El-Houssini OM, Mohammad MA. Versatile TLC-Densitometric Methods for the Synchronous Estimation of Cinnarizine and Acefylline Heptaminol in The Presence of Potential Impurity and Their Reported Degradation Products. J Chromatogr Sci 2022; 60:832-839. [PMID: 34875682 DOI: 10.1093/chromsci/bmab129] [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: 03/20/2021] [Indexed: 11/12/2022]
Abstract
From evolution, thin-layer chromatography (TLC) attracts attention as a versatile technique for efficient separation and identification of many drug substances and chemicals. Owing to its simplicity and other outstanding advantages, TLC is extensively used by chromatographers in quantification and purity profiling objectives. In the present study two TLC-Densitometric methods are established and validated for the synchronous estimation of Cinnarizine (Cinn) and Acefyline Heptaminol (Acef) in the presence of Cinn/Acef reported degradation products and Thoephylline (Theo) as Acef potential impurity. The proposed methods are based on densitometric measurements of the spots of Cinn and Acef after separation from their degradation products. Separation is attained on silica gel sheet with dichloromethane: methanol: formic acid as a developing system in ratio: (15, 1, 0.5, by volume) and (15, 0.75, 0.4, by volume) for Cinn (method 1) and Acef (method 2) degradation, consecutively. Quantification is done at 254 nm over concentration ranges of 0.2-1.8 and 2-18 μg/spot for Cinn and Acef; respectively, with mean percentage recoveries of 99.18 ± 0.60/99.84 ± 0.53 and 99.19 ± 0.93/99.66 ± 0.58 for method 1 and method 2; consecutively. The two methods are fully validated and proven to be selective, robust and retained their accuracy in up to 50% of Cinn/Acef reported degradation products and Theo. Moreover, the two methods are applied to a coformulated drug product comprising Cinn and Acef showing satisfactory results. Comparison of the obtained results by the proposed methods with that of the reference ones statistically shows no significant differences.
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Affiliation(s)
- Ola M El-Houssini
- National Organization for Drug Control and Research (NODCAR), 51 wezerat El- Zeraa Street St, Agouza P.O. Box 12553 Giza 35521, Egypt
| | - Mohammad A Mohammad
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El-Aini Street, Cairo 11562, Egypt
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Muacevic A, Adler JR. COVID-19 Vaccine: A Common Suspect but Rare Culprit in Drug Rash With Eosinophilia and Systemic Symptoms (DRESS) Syndrome. Cureus 2022; 14:e31310. [PMID: 36514624 PMCID: PMC9735271 DOI: 10.7759/cureus.31310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a rare drug reaction that commonly presents with rash, fever, lymphadenopathy, eosinophilia, and multiorgan involvement. We present a case of this syndrome in a 31-year-old male who presented with a diffuse erythematous morbilliform rash with high fever and elevated liver enzymes. Upon history taking, the patient reported acute onset of multiple seizures that required intubation and ICU admission six weeks prior, which started 24 hours after receiving the Johnson and Johnson Janssen coronavirus disease 2019 (COVID-19) vaccine. During that hospitalization, he was given antiseizure medications Keppra (levetiracetam) and Dilantin (phenytoin), which he was eventually discharged home with. During our encounter with the patient, Dermatology was consulted and recommended punch skin biopsy, which revealed spongiotic dermatitis with subcorneal pustules along with superficial perivascular and mixed lymphocytic and neutrophilic infiltrate with dermal edema and rare eosinophils. Given these findings in conjunction with the patient's fever, elevated liver function, and cervical lymphadenopathy, the rash was consistent with DRESS syndrome or a pustular drug eruption likely secondary to phenytoin or levetiracetam. This case was eventually resolved with treatment with oral and topical corticosteroids and close outpatient follow-up with Dermatology. Prompt diagnosis and treatment of DRESS syndrome are therefore critical as the mortality rate can be as high as 10% in the setting of liver failure.
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