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Hansel A, Oms E, Tronnier M. [Drug reaction with eosinophilia and systemic symptoms (DRESS): a hypersensitivity reaction with various symptoms]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00105-024-05364-1. [PMID: 38811445 DOI: 10.1007/s00105-024-05364-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/04/2024] [Indexed: 05/31/2024]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is an illness which is difficult to diagnose because of its various symptoms. In our case, a patient with small spotted exanthema with nearly erythroderma and eosinophilia presented to the emergency room. Systemic steroid therapy was started on suspicion of a drug reaction. Over the course of time, the patient's general condition deteriorated significantly and the patient developed cholecystitis, Staphylococcus aureus bacteremia, pneumonitis and cytomegalovirus reactivation. With this case report, we want to show that DRESS is a disease that is difficult to treat and can develop after a long delay.
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Affiliation(s)
- A Hansel
- Klinik für Dermatologie, Venerologie und Allergologie, Helios Klinikum Hildesheim, Hildesheim, Deutschland.
| | - E Oms
- Klinik für Dermatologie, Venerologie und Allergologie, Helios Klinikum Hildesheim, Hildesheim, Deutschland
| | - M Tronnier
- Klinik für Dermatologie, Venerologie und Allergologie, Helios Klinikum Hildesheim, Hildesheim, Deutschland
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2
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Wei BM, Fox LP, Kaffenberger BH, Korman AM, Micheletti RG, Mostaghimi A, Noe MH, Rosenbach M, Shinkai K, Kwah JH, Phillips EJ, Bolognia JL, Damsky W, Nelson CA. Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part II diagnosis and management. J Am Acad Dermatol 2024; 90:911-926. [PMID: 37516356 DOI: 10.1016/j.jaad.2023.02.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/11/2023] [Accepted: 02/17/2023] [Indexed: 07/31/2023]
Abstract
Drug-induced hypersensitivity syndrome, also known as drug reaction with eosinophilia and systemic symptoms, is a severe cutaneous adverse reaction characterized by an exanthem, fever, and hematologic and visceral organ involvement. The differential diagnosis includes other cutaneous adverse reactions, infections, inflammatory and autoimmune diseases, and neoplastic disorders. Three sets of diagnostic criteria have been proposed; however, consensus is lacking. The cornerstone of management is immediate discontinuation of the suspected drug culprit. Systemic corticosteroids remain first-line therapy, but the literature on steroid-sparing agents is expanding. Longitudinal evaluation for sequelae is recommended. Adjunctive tests for risk stratification and drug culprit identification remain under investigation. Part II of this continuing medical education activity begins by exploring the differential diagnosis and diagnosis of drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms and concludes with an evidence-based overview of evaluation and treatment.
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Affiliation(s)
- Brian M Wei
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | | | - Abraham M Korman
- Department of Dermatology, The Ohio State University, Columbus, Ohio
| | - Robert G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arash Mostaghimi
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Megan H Noe
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, California
| | - Jason H Kwah
- Department of Medicine, Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jean L Bolognia
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - William Damsky
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Caroline A Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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Hung SI, Mockenhaupt M, Blumenthal KG, Abe R, Ueta M, Ingen-Housz-Oro S, Phillips EJ, Chung WH. Severe cutaneous adverse reactions. Nat Rev Dis Primers 2024; 10:30. [PMID: 38664435 DOI: 10.1038/s41572-024-00514-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 06/15/2024]
Abstract
Severe cutaneous adverse reactions (SCARs), which include Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (also known as drug-induced hypersensitivity syndrome), acute generalized exanthematous pustulosis, and generalized bullous fixed drug eruption, are life-threatening conditions. The pathogenesis of SCARs involves T cell receptors recognizing drug antigens presented by human leukocyte antigens, triggering the activation of distinct T cell subsets. These cells interact with keratinocytes and various immune cells, orchestrating cutaneous lesions and systemic manifestations. Genetic predisposition, impaired drug metabolism, viral reactivation or infections, and heterologous immunity influence SCAR development and clinical presentation. Specific genetic associations with distinct SCAR phenotypes have been identified, leading to the implementation of genetic screening before prescription in various countries to prevent SCARs. Whilst systemic corticosteroids and conventional immunomodulators have been the primary therapeutic agents, evolving strategies, including biologics and small molecules targeting tumour necrosis factor, different cytokines, or Janus kinase signalling pathways, signify a shift towards a precision management paradigm that considers individual clinical presentations.
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Affiliation(s)
- Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department and Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Mayumi Ueta
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saskia Ingen-Housz-Oro
- Dermatology Department, AP-HP, Henri Mondor Hospital, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Université Paris Est Créteil EpiDermE, Créteil, France
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei/Linkou branches, and Chang Gung University, Taoyuan, Taiwan.
- Department of Dermatology, Chang Gung Memorial Hospital, Xiamen branch, Xiamen, China.
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Shen Y, Cui SS, Teng XB, Han MF. Drug-induced hypersensitivity syndrome related to piperacillin-tazobactam: a case report and review of the literature. Front Med (Lausanne) 2024; 11:1338247. [PMID: 38606160 PMCID: PMC11006969 DOI: 10.3389/fmed.2024.1338247] [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: 11/14/2023] [Accepted: 03/18/2024] [Indexed: 04/13/2024] Open
Abstract
Allergic reactions to drugs caused by piperacillin-tazobactam are common in clinical practice. However, we also found a few cases of drug-induced hypersensitivity syndrome (DiHS)/Drug reaction with eosinophilia and systemic symptoms (DRESS) caused by piperacillin-tazobactam in our clinical work. We report a case of a 60-year-old female patient who was treated with piperacillin-tazobactam anti-infective therapy after the diagnosis of hematogenous lung abscess, developed fever, rash, and blood abnormalities after 26 days of application, and was later diagnosed as DIHS, which was improved after the administration of glucocorticoid and anti-allergic drugs. In addition, we also retrospectively analyzed 17 cases of DiHS caused by piperacillin-tazobactam from the PubMed databases between March 1980 and September 2023. The majority of the patients had an incubation period of more than 14 days, and the common clinical features included elevated eosinophil count/percentage, fever, rash, liver damage, and lymph node enlargement. After treatment with topical or systemic glucocorticoids, 16 of the 17 patients improved and one died because of the underlying condition. The clinical features of DiHS were diverse and included a long incubation period, skin rash, elevated eosinophils, and impaired organ function. Since some patients have atypical clinical features, clinicians should raise awareness of the disease, recognize these features early, and treat them promptly.
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Affiliation(s)
- Ya Shen
- Department of Respiratory and Critical Care Medicine, Fuyang Infectious Disease Clinical College of Anhui Medical University, Fuyang, Anhui, China
| | - Shun-shun Cui
- Department of Respiratory and Critical Care Medicine, Fuyang People's Hospital, Fuyang, Anhui, China
| | - Xiao-bao Teng
- Department of Respiratory and Critical Care Medicine, Fuyang Infectious Disease Clinical College of Anhui Medical University, Fuyang, Anhui, China
| | - Ming-feng Han
- Department of Respiratory and Critical Care Medicine, Fuyang Infectious Disease Clinical College of Anhui Medical University, Fuyang, Anhui, China
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Bettuzzi T, Sanchez-Pena P, Lebrun-Vignes B. Cutaneous adverse drug reactions. Therapie 2024; 79:239-270. [PMID: 37980248 DOI: 10.1016/j.therap.2023.09.011] [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: 08/31/2023] [Accepted: 09/14/2023] [Indexed: 11/20/2023]
Abstract
Cutaneous adverse drug reactions (ADRs) represent a heterogeneous field including various clinical patterns without specific features suggesting drug causality. Maculopapular exanthema and urticaria are the most common types of cutaneous ADR. Serious cutaneous ADRs, which may cause permanent sequelae or have fatal outcome, may represent 2% of all cutaneous ADR and must be quickly identified to guide their management. These serious reactions include bullous manifestations (epidermal necrolysis i.e. Stevens-Johnson syndrome and toxic epidermal necrolysis), drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP). Some risk factors for developing cutaneous ADRs have been identified, including immunosuppression, autoimmunity or genetic variants. All drugs can cause cutaneous ADRs, the most commonly implicated being antibiotics (especially aminopenicillins and sulfonamides), anticonvulsants, allopurinol, antineoplastic drugs, non-steroidal anti-inflammatory drugs and iodinated contrast media. Pathophysiology is related to immediate or delayed "idiosyncratic" immunologic mechanisms, i.e., usually not related to dose, and pharmacologic/toxic mechanisms, commonly dose-dependent and/or time-dependent. If an immuno-allergic mechanism is suspected, allergological explorations (including epicutaneous patch testing and/or intradermal test) are often possible to clarify drug causality, however these have a variable sensitivity according to the drug and to the ADR type. No in vivo or in vitro test can consistently confirm the drug causality. To determine the origin of a rash, a logical approach based on clinical characteristics, chronologic factors and elimination of differential diagnosis (especially infectious etiologies) is required, completed with a literature search. Reporting to pharmacovigilance system is therefore essential both to analyze drug causality at individual level, and to contribute to knowledge of the drug at population level, especially for serious cutaneous ADRs or in cases involving newly marketed drugs.
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Affiliation(s)
- Thomas Bettuzzi
- Service de dermatologie, hôpital Henri-Mondor, AP-HP, 94000 Créteil, France; EpiDermE, université Paris Est Créteil Val-de-Marne, 94000 Créteil, France
| | - Paola Sanchez-Pena
- Service de pharmacologie médicale, centre régional de pharmacovigilance de Bordeaux, CHU de Bordeaux, 33000 Bordeaux, France; Groupe FISARD de la Société française de dermatologie, France
| | - Bénédicte Lebrun-Vignes
- EpiDermE, université Paris Est Créteil Val-de-Marne, 94000 Créteil, France; Groupe FISARD de la Société française de dermatologie, France; Service de pharmacologie médicale, centre régional de pharmacovigilance Pitié-Saint-Antoine, groupe hospitalier AP-HP-Sorbonne université, 75013 Paris, France.
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St George-Hyslop F, Cherepacha N, Chugani B, Alabdeen Y, Sanchez-Espino LF, Mahood Q, Sibbald C, Verstegen RHJ. Clinical Presentation and Diagnosis of Drug Reaction with Eosinophilia and Systemic Symptoms (DReSS) in Children: A Scoping Review. Clin Rev Allergy Immunol 2024; 66:112-123. [PMID: 38466562 DOI: 10.1007/s12016-024-08983-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 03/13/2024]
Abstract
Effective treatment of drug reactions with eosinophilia and systemic symptoms (DReSS) requires early diagnosis and close monitoring. Diagnosing DReSS is especially challenging in children due to a low incidence rate, heterogeneous clinical presentation, and a lack of (pediatric) diagnostic criteria and clinical practice guidelines. We performed a scoping review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, to summarize the clinical presentation and diagnostic process of DReSS in children (aged 0-18 years). Data from 644 individuals showed that DReSS manifests differently in children compared to adults. Children have a higher number of organs involved, including higher rates of cardiac and respiratory involvement compared to adults. Children < 6 years of age appear more prone to develop neurologic symptoms. Conversely, eosinophilia, edema, and kidney involvement are less frequently observed in children. Anti-seizure medications are by far the most common causative drug class, but the range of implicated drugs increases as children get older. This study highlights that children with DReSS not only differ from adults but also that differences exist between children of different ages. As such, there is a need to establish pediatric-specific diagnostic criteria. These efforts will promote earlier diagnosis of DReSS and likely lead to improved clinical care offered to children and their families.
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Affiliation(s)
- Frances St George-Hyslop
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Nicole Cherepacha
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Bindiya Chugani
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Yousef Alabdeen
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Luis Fernando Sanchez-Espino
- Division of Dermatology, Department of Paediatrics, Stollery Children's Hospital, Edmonton, AB, Canada
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Quenby Mahood
- Hospital Library, The Hospital for Sick Children, Toronto, ON, Canada
| | - Cathryn Sibbald
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Dermatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ruud H J Verstegen
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
- Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
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Pinyopornpanish K, Pinyopornpanish K, Pinyopornpanish K, Benjanuwattra J, Teepapan P, Chungcharoenpanich A, Laisuan W. Omeprazole Induced Rapid Drug Reaction with Eosinophilia, Systemic Symptoms, and Cross-Reactivity in Delayed-Type Hypersensitivity Associated with Proton-Pump Inhibitors: A Case Report and Literature Review. Case Reports Immunol 2024; 2024:1317971. [PMID: 38213955 PMCID: PMC10781523 DOI: 10.1155/2024/1317971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/13/2024] Open
Abstract
Background Omeprazole, a proton pump inhibitor (PPI), is a widely used and generally safe agent for treating acid-related gastrointestinal conditions. However, drug reaction with eosinophilia and systemic symptoms (DRESSs) syndrome has been reported. Objectives To report a case of omeprazole-induced rapid DRESS syndrome and to review the literature. Methods Descriptive analysis of one new case and a case series from literature review. Results We report a case of 82-year-old woman presenting with rapid-onset of DRESS syndrome. The condition was initially suspected to be caused by antibiotic, but the definite diagnosis was eventually omeprazole-induced DRESS syndrome as suggested by the enzyme-linked immune absorbent spot (ELISpot) assay along with the clinical picture. Previous literatures regarding cases of PPI-induced DRESS syndrome were pooled for descriptive analysis. Among 21 PPI cases pooled, esomeprazole was the most commonly implicated PPI (52.4%), followed by pantoprazole (19.1%), and omeprazole along with lansoprazole (both 14.3%). The issue of cross-reactivities amongst PPIs remains uncertain. Nonetheless, in situations in which a PPIs are deemed necessary, a prudent approach could be considering a switch to an alternative agent with distinct chemical structure. Conclusion PPI is commonly used safely as an agent for acid-related gastrointestinal conditions. However, PPI-induced rapid DRESS syndrome can occur, particularly with prior exposure history. ELISpot is an in vitro test, useful in identifying the culprit agent in patients with delayed-type hypersensitivity reaction.
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Affiliation(s)
- Kanokkarn Pinyopornpanish
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Department of Medicine, Chiangmai University Hospital, Chiangmai, Thailand
| | | | | | - Juthipong Benjanuwattra
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Putthapon Teepapan
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Apinya Chungcharoenpanich
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wannada Laisuan
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Brüggen MC, Walsh S, Ameri MM, Anasiewicz N, Maverakis E, French LE, Ingen-Housz-Oro S. Management of Adult Patients With Drug Reaction With Eosinophilia and Systemic Symptoms: A Delphi-Based International Consensus. JAMA Dermatol 2024; 160:37-44. [PMID: 37966824 PMCID: PMC10652220 DOI: 10.1001/jamadermatol.2023.4450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/28/2023] [Indexed: 11/16/2023]
Abstract
Importance Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal drug hypersensitivity reaction. To our knowledge, there is no international consensus on its severity assessment and treatment. Objective To reach an international, Delphi-based multinational expert consensus on the diagnostic workup, severity assessment, and treatment of patients with DRESS. Design, Setting, and Participants The Delphi method was used to assess 100 statements related to baseline workup, evaluation of severity, acute phase, and postacute management of DRESS. Fifty-seven international experts in DRESS were invited, and 54 participated in the survey, which took place from July to September 2022. Main Outcomes/Measures The degree of agreement was calculated with the RAND-UCLA Appropriateness Method. Consensus was defined as a statement with a median appropriateness value of 7 or higher (appropriate) and a disagreement index of lower than 1. Results In the first Delphi round, consensus was reached on 82 statements. Thirteen statements were revised and assessed in a second round. A consensus was reached for 93 statements overall. The experts agreed on a set of basic diagnostic workup procedures as well as severity- and organ-specific further investigations. They reached a consensus on severity assessment (mild, moderate, and severe) based on the extent of liver, kidney, and blood involvement and the damage of other organs. The panel agreed on the main lines of DRESS management according to these severity grades. General recommendations were generated on the postacute phase follow-up of patients with DRESS and the allergological workup. Conclusions and Relevance This Delphi exercise represents, to our knowledge, the first international expert consensus on diagnostic workup, severity assessment, and management of DRESS. This should support clinicians in the diagnosis and management of DRESS and constitute the basis for development of future guidelines.
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Affiliation(s)
- Marie-Charlotte Brüggen
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
| | - Sarah Walsh
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
- Department of Dermatology, King’s College Hospital, London, England, United Kingdom
| | - M. Milad Ameri
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
| | - Natalie Anasiewicz
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Emanual Maverakis
- Department of Dermatology, University of California, Davis, Sacramento, California
| | - Lars E. French
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Saskia Ingen-Housz-Oro
- ToxiTEN group, European Reference Network for Rare Skin Diseases (ERN-Skin), Paris, France
- Department of Dermatology, Henri Mondor University Hospital, University of Paris-Est Créteil, Créteil, France
- Toxic Bullous Dermatoses TOXIBUL Reference Center, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France
- Univ Paris Est Créteil EpiDermE, Créteil, France
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Bahloul E, Trimeche K, Sellami K, Hammami F, Hayder F, Chaabouni R, Amouri M, Masmoudi A, Mseddi M, Boudeya S, Turki H. Characteristics of DRESS Syndrome in the Elderly: A Comparative Study of 55 Patients. Dermatitis 2024; 35:55-60. [PMID: 37669109 DOI: 10.1089/derm.2022.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare drug reaction characterized by a skin rash, eosinophilia, and organ involvement. Objective: Our purpose is to focus on the clinical and epidemiological characteristics of DRESS in the elderly and to identify the incriminated drugs. Methods: This is a retrospective study including patients, hospitalized for DRESS with a RegiSCAR ≥4. The population was divided into 2 groups according to age: 65 years or older (G1) and <65 years (G2). The statistical study was performed using the comparative and multivariate analysis. Results: We included 55 patients (30.9% G1 and 69.1% G2). Skin manifestations were comparable in both groups. Lymphadenopathy was less common in G1 with a statistically significant difference (P = 0.012). Renal impairment was more frequent in the elderly with a statistically significant result (P = 0.005). DRESS in the elderly group was significantly associated with the occurrence of sepsis (P = 0.008). Allopurinol was the most common culprit associated with DRESS in G1 (P = 0.001). Relapses and recurrences were comparable in both groups (P = 0.71). Conclusions: DRESS in the elderly is associated with a high risk of complications, mainly kidney involvement and sepsis. Allopurinol is the most incriminated drug.
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Affiliation(s)
- Emna Bahloul
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Khaoula Trimeche
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Khadija Sellami
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Fatma Hammami
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Faten Hayder
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Rim Chaabouni
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Meriem Amouri
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | | | - Madiha Mseddi
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Sonia Boudeya
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Hamida Turki
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
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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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11
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Martínez JD, Franco R, Sáenz LM, Alvarado AG, García JA, Delgado SM, Ionescu MA, Busilă C, Tatu AL. DRESS and Stevens-Johnson Syndrome Overlap Secondary to Allopurinol in a 50-Year-Old Man-A Diagnostic and Treatment Challenge: Case Report. Life (Basel) 2023; 13:2251. [PMID: 38137852 PMCID: PMC10744808 DOI: 10.3390/life13122251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/13/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a drug reaction commonly related to eosinophilia, from uncertain epidemiology, and without consensus for diagnosis and treatment globally. It presents a great challenge in its management and is characterized by fever, lymphadenopathy, skin rash, and multisystemic involvement. An aggressive and difficult-to-manage clinical case is presented in a 50-year-old man with chronic kidney disease due to diabetes mellitus type 2 and systemic arterial hypertension, who developed an unusual variant similar to DRESS and Stevens-Johnson syndrome (SJS) overlap secondary to allopurinol, with skin manifestations without eosinophilia, but fulfilling clinical and laboratory criteria for DRESS and SJS syndrome.
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Affiliation(s)
- José Dario Martínez
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitario José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico;
| | - Rodolfo Franco
- Department of Human Pathology, Faculty of Medicine, Hospital Universitario José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico; (R.F.); (J.A.G.)
| | - Luis Manuel Sáenz
- Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico; (L.M.S.); (S.M.D.)
| | - Americo Guadalupe Alvarado
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitario José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico;
| | - José Antonio García
- Department of Human Pathology, Faculty of Medicine, Hospital Universitario José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico; (R.F.); (J.A.G.)
| | - Sergio Máximo Delgado
- Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico; (L.M.S.); (S.M.D.)
| | - Marius-Anton Ionescu
- Department of Dermatology, University Hospital Saint Louis, 63110 Paris, France;
| | - Camelia Busilă
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, 800008 Galati, Romania;
| | - Alin Laurentiu Tatu
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, 800008 Galati, Romania;
- Dermatology Department, “Sfanta Cuvioasa Paraschiva” Hospital of Infectious Diseases, 800179 Galati, Romania
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12
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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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13
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Ishikawa Y, Ajima S, Hashizume H. Pityriasis rubra pilaris with simultaneous emergence of human herpesvirus-6 reactivation in a patient with drug-induced hypersensitivity syndrome. J Dermatol 2023; 50:e368-e369. [PMID: 37469202 DOI: 10.1111/1346-8138.16877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/02/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Yuto Ishikawa
- Department of Dermatology, Iwata City Hospital, Iwata, Japan
| | - Sayaka Ajima
- Department of Dermatology, Iwata City Hospital, Iwata, Japan
| | - Hideo Hashizume
- Department of Dermatology, Iwata City Hospital, Iwata, Japan
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14
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Mizukawa Y, Hama N, Miyagawa F, Takahashi H, Ogawa Y, Kurata M, Asada H, Abe R, Shiohara T. Drug-Induced Hypersensitivity Syndrome/Drug Reaction With Eosinophilia and Systemic Symptoms: Predictive Score and Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3169-3178.e7. [PMID: 37437776 DOI: 10.1016/j.jaip.2023.06.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 05/08/2023] [Accepted: 06/30/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND We previously developed a drug-induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) severity (DDS) score that may predict DIHS/DRESS-associated complications (DACs), including myocarditis, gastrointestinal bleeding, and autoimmune diseases. OBJECTIVE To externally confirm the predictive accuracy of the DDS score, clarify its ability to identify patients at high risk of DACs and fatal outcome, and determine which treatments might reduce or increase the risk. METHODS We conducted a nationwide multicenter retrospective study in which we followed 48 patients with DIHS/DRESS at 5 university hospitals in Japan for 1 year after onset. Patients were divided into mild, moderate, and severe DIHS/DRESS groups depending on their early DDS score. RESULTS Eight cases had DACs in the severe group (n = 17); no DACs were observed in the mild group (n = 12). Receiver-operating characteristic curve analysis showed that a cutoff DDS score of ≥4.0 and ≤2.0 could differentiate patients who would and would not develop DACs, respectively. In the moderate-to-severe disease groups, DACs occurred only in patients who received corticosteroids and not in those who received supportive care. None of the patients who received early treatment for cytomegalovirus developed DACs. Autoimmune DACs were significantly more common in patients who received pulse corticosteroid therapy. Four deaths occurred within the 1-year follow-up; all were in patients with infectious DACs who received systemic corticosteroids. CONCLUSION Our scoring system allows early identification of patients at increased risk for DACs. Risk factors for DACs include systemic or pulse corticosteroid therapy.
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Affiliation(s)
- Yoshiko Mizukawa
- Department of Dermatology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan.
| | - Natsumi Hama
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Fumi Miyagawa
- Department of Dermatology, Nara Medical University School of Medicine, Kashihara, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Youichi Ogawa
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Maiko Kurata
- Department of Dermatology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Hideo Asada
- Department of Dermatology, Nara Medical University School of Medicine, Kashihara, Japan
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tetsuo Shiohara
- Department of Dermatology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
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15
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Kitayama S, Makino T, Fujita K, Mori S, Furukawa F, Kagoyama K, Mizawa M, Shimizu T. Ganciclovir-induced drug reaction with eosinophilia and systemic symptoms. SKIN HEALTH AND DISEASE 2023; 3:e269. [PMID: 37799364 PMCID: PMC10549800 DOI: 10.1002/ski2.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 10/07/2023]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse reaction involving multiorgan failure, with a complex interaction of various drugs, human herpesvirus reactivation and immune abnormalities suggested as the aetiology. We herein present the case of a 70-year-old man with a one-week history of fever, facial oedema, erythematous macules and purpura on his trunk and extremities. He had anti-TIF1γ antibody-positive dermatomyositis and was treated with prednisolone sodium succinate (20 mg/day). Three weeks earlier, he was treated with ganciclovir (250 mg/day) for 7 days to treat asymptomatic cytomegalovirus viraemia. Laboratory investigations revealed eosinophilia with atypical lymphocytes and elevated liver enzyme levels. A histological examination showed interface dermatitis with necrotic keratinocytes, perivascular infiltration of lymphocytes and eosinophils in the upper dermis and erythrocyte extravasation without vasculitis. A lymphocyte transformation test (LTT) was positive for ganciclovir (stimulation index: 260%; normal: <180%). We diagnosed DRESS caused by ganciclovir on the basis of clinical findings and course (Definite; RegiSCAR score: 7). He was treated with prednisolone sodium succinate (40 mg/day) and topical clobetasol propionate (0.05%) ointment twice daily. After the initiation of treatment, the skin lesions and laboratory abnormalities gradually improved. To our knowledge, this is the first case of DRESS caused by ganciclovir. The patients in whom ganciclovir is used are often immunosuppressed and may be overlooked as the causative drug for DRESS by conventional skin tests. We considered that LTT is useful for identifying causative drugs of DRESS, especially in immunosuppressed patients, such as the present case.
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Affiliation(s)
- Shohei Kitayama
- Faculty of MedicineDepartment of DermatologyAcademic AssemblyUniversity of ToyamaToyamaJapan
| | - Teruhiko Makino
- Faculty of MedicineDepartment of DermatologyAcademic AssemblyUniversity of ToyamaToyamaJapan
| | - Kuniko Fujita
- Faculty of MedicineDepartment of DermatologyAcademic AssemblyUniversity of ToyamaToyamaJapan
| | - Shuichi Mori
- Faculty of MedicineDepartment of DermatologyAcademic AssemblyUniversity of ToyamaToyamaJapan
| | - Fumina Furukawa
- Faculty of MedicineDepartment of DermatologyAcademic AssemblyUniversity of ToyamaToyamaJapan
| | - Ko Kagoyama
- Faculty of MedicineDepartment of DermatologyAcademic AssemblyUniversity of ToyamaToyamaJapan
| | - Megumi Mizawa
- Faculty of MedicineDepartment of DermatologyAcademic AssemblyUniversity of ToyamaToyamaJapan
| | - Tadamichi Shimizu
- Faculty of MedicineDepartment of DermatologyAcademic AssemblyUniversity of ToyamaToyamaJapan
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16
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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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17
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Chuenboonngarm N, Puaratanaarunkon T, Washrawirul C, Triwatcharikorn J, Chancheewa B, Theerawattanawit C, Chongpison Y, Rerknimitr P, Klaewsongkram J. Key factors predicting the in-hospital mortality of patients with severe cutaneous adverse reactions in Thailand. J Eur Acad Dermatol Venereol 2023; 37:1881-1890. [PMID: 37212641 DOI: 10.1111/jdv.19222] [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: 12/11/2022] [Accepted: 05/05/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND At present, no predictive models are available to determine the probability of in-hospital mortality rates (HMRs) in all phenotypes of severe cutaneous adverse reactions (SCARs). OBJECTIVES Our study explored whether simple clinical and laboratory assessments could help predict the HMRs in any phenotypes of SCAR patients. METHODS Factors influencing HMRs in 195 adults diagnosed with different SCAR phenotypes were identified, and their optimal cut-offs were determined by Youden's index. Predictive equations for HMRs for all SCAR patients and Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) patients were determined using the exact logistic regression models. RESULTS Acute generalized exanthematous pustulosis (AGEP) patients were significantly older, with a short time from drug exposure to reaction, and higher neutrophil count compared to SJS/TEN and drug reaction with eosinophilia and systemic symptoms (DRESS, p < 0.001). Peripheral blood eosinophilia, atypical lymphocytosis and elevated liver transaminase enzymes were significantly higher in DRESS. SJS/TEN phenotype, age ≥ 71.5 years, neutrophil-to-lymphocyte ratio ≥ 4.08 (high NLR) and systemic infection were factors predicting in-hospital mortality in all SCAR subjects. The ALLSCAR model developed from these factors demonstrated high-diagnostic accuracy for predicting HMRs in all SCAR phenotypes (area under the receiver-operator curve (AUC) = 0.95). The risk of in-hospital death was significantly increased in SCAR patients with high NLR after adjusting for systemic infection. The model derived from high NLR, systemic infection and age yielded higher accuracy than SCORTEN (AUC = 0.77) for predicting the HMRs in SJS/TEN patients (AUC = 0.97). CONCLUSIONS Being older, having systemic infection, having a high NLR and SJS/TEN phenotype increases ALLSCAR scores, which in turn increases the risk of in-hospital mortality. These basic clinical and laboratory parameters can easily be obtained in any hospital setting. Despite its simple approach, further validation of the model is warranted.
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Affiliation(s)
- Nunthanach Chuenboonngarm
- Division of Dermatology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Thanaporn Puaratanaarunkon
- Division of Dermatology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Chanudda Washrawirul
- Division of Dermatology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Jidapa Triwatcharikorn
- Division of Dermatology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Bussabong Chancheewa
- Division of Dermatology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Chinathip Theerawattanawit
- Division of Dermatology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Yuda Chongpison
- Biostatistics Excellence Center, Research Affairs, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Pawinee Rerknimitr
- Division of Dermatology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Jettanong Klaewsongkram
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
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18
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Wilkerson RG. Drug Hypersensitivity Reactions. Immunol Allergy Clin North Am 2023; 43:473-489. [PMID: 37394254 DOI: 10.1016/j.iac.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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19
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Chen CB, Hung WK, Wang CW, Lee CC, Hung SI, Chung WH. Advances in understanding of the pathogenesis and therapeutic implications of drug reaction with eosinophilia and systemic symptoms: an updated review. Front Med (Lausanne) 2023; 10:1187937. [PMID: 37457584 PMCID: PMC10338933 DOI: 10.3389/fmed.2023.1187937] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/05/2023] [Indexed: 07/18/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms or drug-induced hypersensitivity syndrome (DRESS/DIHS) is one type of severe cutaneous adverse reaction (SCAR). It is featured by fever, widespread skin lesions, protracted clinical course, internal organ involvement, and possibly long-term autoimmune sequelae. The presence of high-risk human leukocyte antigen (HLA) alleles, hypersensitivity reaction after culprit drug ingestion, and human herpesvirus reactivation may all contribute to its complex clinical manifestations. Some recent studies focusing on the roles of involved cytokines/chemokines and T cells co-signaling pathways in DRESS/DIHS were conducted. In addition, some predictors of disease severity and prognosis were also reported. In this review, we provided an update on the current understanding of the pathogenesis, potential biomarkers, and the relevant therapeutic rationales of DRESS/DIHS.
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Affiliation(s)
- Chun-Bing Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wei-Kai Hung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
| | - Chih-Chun Lee
- Department of Medical Education, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
- Department of Dermatology, Beijing Tsinghua Chang Gung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
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20
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Lian BS, Ha JH, Sultana R, Chan LCE, Choo KJL, Yeo YW, Lee HY. Systemic Versus Topical Corticosteroids in the Treatment of DRESS: A Retrospective Cohort Study Followed by a Meta-Analysis. Am J Clin Dermatol 2023:10.1007/s40257-023-00776-6. [PMID: 37133714 DOI: 10.1007/s40257-023-00776-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe systemic drug hypersensitivity syndrome with significant risks of mortality and long-term sequelae. Management is challenging; whilst systemic corticosteroids are generally regarded as standard of care, there is a suggestion that topical corticosteroids may be a safe alternative. OBJECTIVE We aimed to compare the clinical outcomes of patients with DRESS treated with systemic corticosteroids and topical corticosteroids in an academic medical center. METHODS The medical records of patients diagnosed with DRESS at the Singapore General Hospital between 2009 and 2017 were retrospectively reviewed. A secondary systematic review and meta-analysis were performed to further clarify the outcomes. RESULTS Out of 94 patients with DRESS, 41 (44%) were treated with topical corticosteroids and 53 (56%) were treated with systemic corticosteroids. Patients receiving systemic corticosteroids were more likely to develop infective complications (32.1 vs 12.2%, p = 0.02). One-month and 12-month mortality, length of hospital stay, flares of DRESS, and viral reactivation were similar between the two groups. In our meta-analysis (six studies, n = 292), there were no significant differences in mortality or length of stay between patients treated with systemic or topical corticosteroids. LIMITATIONS This study was a non-controlled retrospective cohort study and the allocation of treatment may have been influenced by the severity of disease. Results of the secondary meta-analysis are limited by the quality of included studies. CONCLUSIONS Topical corticosteroids may be a safe and efficacious alternative to systemic corticosteroids in the treatment of mild-to-moderate DRESS. CLINICAL TRIAL REGISTRATION PROSPERO registration CRD42021285691.
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Affiliation(s)
- Bertrand ShengYang Lian
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Judy H Ha
- Duke-NUS Medical School, Singapore, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, The Academia, Singapore, Singapore
| | - Linus Chong En Chan
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Karen Jui Lin Choo
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Yi Wei Yeo
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
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21
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Kridin K, Brüggen MC, Walsh S, Bensaid B, Ranki A, Oppel E, Meyersburg D, Chua SL, Seeli C, Sandberg H, French LE, Vorobyev A, Ingen-Housz-Oro S. Management and treatment outcome of DRESS patients in Europe: An international multicentre retrospective study of 141 cases. J Eur Acad Dermatol Venereol 2023; 37:753-762. [PMID: 36479739 DOI: 10.1111/jdv.18808] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal drug hypersensitivity reaction. OBJECTIVE To explore treatment approaches across Europe and their impact on the disease course, as well as prognostic factors and culprit drugs. METHODS In this retrospective European multicentric study, we included patients with probable or certain DRESS (RegiSCAR score ≥ 4) between January 2016 and December 2020. Independent associations between clinical parameters and the risk of intensive care unit admission and mortality at three months were assessed using a multivariable-adjusted logistic regression model. RESULTS A total of 141 patients from 8 tertiary centres were included. Morbilliform exanthem was the most frequent cutaneous manifestation (78.0%). The mean affected body surface area (BSA) was 67%, 42% of the patients presented with erythroderma, and 24.8% had mucosal involvement. Based on systemic involvement, 31.9% of the patients had a severe DRESS. Anticonvulsants (24.1%) and sulphonamides (22.0%) were the most frequent causative agents. In all, 73% of the patients were treated with systemic glucocorticoids, and 25.5% received topical corticosteroids as monotherapy. Few patients received antiviral drugs or anti-IL5. No patients received intravenous immunoglobulins. The overall mortality was 7.1%. Independent predictors of mortality were older age (≥57.0 years; fully adjusted OR, 9.80; 95% CI, 1.20-79.93; p = 0.033), kidney involvement (fully adjusted OR, 4.70; 95% CI, 1.00-24.12; p = 0.049), and admission in intensive care unit (fully adjusted OR, 8.12; 95% CI, 1.90-34.67; p = 0.005). Relapse of DRESS and delayed autoimmune sequelae occurred in 8.5% and 12.1% of patients, respectively. CONCLUSIONS This study underlines the need for diagnostic and prognostic scores/markers as well as for prospective clinical trials of drugs with the potential to reduce mortality and complications of DRESS.
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Affiliation(s)
- Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Marie-Charlotte Brüggen
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Medical Campus Davos, Davos, Switzerland.,ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin)
| | - Sarah Walsh
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, King's College Hospital, London, UK
| | - Benoit Bensaid
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France.,Department of Dermatology, Edouard Herriot Hospital, Lyon, France
| | - Annamari Ranki
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, Allergology and Venereology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Helsinki, Finland
| | - Eva Oppel
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany
| | - Damian Meyersburg
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology and Allergology, University Hospital Salzburg of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ser-Ling Chua
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Corsin Seeli
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Heidi Sandberg
- Department of Dermatology, Allergology and Venereology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Helsinki, Finland
| | - Lars E French
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany.,Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Artem Vorobyev
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Saskia Ingen-Housz-Oro
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-Skin).,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France.,Department of Dermatology, AP-HP, Henri Mondor Hospital, Créteil, France.,Univ Paris Est Créteil EpiDermE, Créteil, France
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22
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Lee ES, Kiuchi Y, Inomata N, Sueki H. Increased expression of human herpes virus 6 receptor CD134/OX40 in skin lesions of patients with drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. J Dermatol 2023; 50:387-392. [PMID: 36121111 DOI: 10.1111/1346-8138.16575] [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: 02/24/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/30/2022]
Abstract
CD134/OX40, a member of the tumor necrosis factor receptor superfamily, is a cell-specific receptor for human herpesvirus 6 (HHV-6) variant B. Patients with drug-induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) present a significant increase in CD134 expression in peripheral blood CD4+ T cells. We aimed to investigate the frequency of CD134+ CD4 T cells infiltrating skin lesions in patients with DIHS/DRESS and its association with disease severity. We retrospectively included 21 patients with DIHS/DRESS and 11 patients with erythema multiforme (EM). By immunohistochemistry, the frequency of CD134+ CD4 T cells in DIHS was significantly higher than that in EM (p = 0.0083). The DIHS/DRESS severity score was significantly correlated with the frequency of CD134+ CD4 T cells (p = 0.0272); moreover, there was a significant difference between severe and mild/moderate cases. Double immunofluorescence staining revealed that numerous cells presented CD134/CD4 and CD134/Foxp3 overlap in patients with DIHS/DRESS. These data suggest increased susceptibility to HHV-6 infection at localized skin sites. HHV-6 may be involved in the mechanism underlying the progression and pathophysiology of DIHS/DRESS.
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Affiliation(s)
- Eun Seon Lee
- Departments of Dermatology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan.,Departments of Pharmacology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Yuji Kiuchi
- Departments of Pharmacology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Naoko Inomata
- Departments of Dermatology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Hirohiko Sueki
- Departments of Dermatology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
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23
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Verstegen RHJ, Phillips EJ, Juurlink DN. First-line therapy in drug reaction with eosinophilia and systemic symptoms (DReSS): Thinking beyond corticosteroids. Front Med (Lausanne) 2023; 10:1138464. [PMID: 36844223 PMCID: PMC9944398 DOI: 10.3389/fmed.2023.1138464] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Affiliation(s)
- Ruud H. J. Verstegen
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada,Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada,Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada,*Correspondence: Ruud H. J. Verstegen ✉
| | - Elizabeth J. Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States,Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, United States,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States,Department of Pharmacology, Vanderbilt University Medical School, Nashville, TN, United States
| | - David N. Juurlink
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada,Department of Medicine, University of Toronto, Toronto, ON, Canada,Division of General Internal Medicine, Sunnybrook, Toronto, ON, Canada,Division of Clinical Pharmacology and Toxicology, Sunnybrook, Toronto, ON, Canada
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24
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Teo YX, Friedmann PS, Polak ME, Ardern-Jones MR. Utility and Safety of Skin Tests in Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS): A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:481-491.e5. [PMID: 36154897 DOI: 10.1016/j.jaip.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 08/10/2022] [Accepted: 09/11/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Determination of culprit drug in drug reaction with eosinophilia and systemic symptoms (DRESS) is crucial. Skin tests have been used, although it remains unclear how sensitive these are. OBJECTIVE To determine the value of skin tests in the assessment of drug causality in DRESS. METHODS A systematic literature search was conducted for publications from 1996 onward of skin tests (skin prick test = SPT, patch test = PT, intradermal test = IDT) performed in clearly defined DRESS cases. Outcomes of testing, drug culpability assessments, and challenge test data were extracted. RESULTS A total of 17 articles met inclusion criteria. In 290 patients with DRESS, patch testing was most frequent (PT = 97.2% [n = 282], IDT = 12.4% [n = 36], SPT = 3.1% [n = 9]). Positive results were noted in 58.4% (n = 160 of 282) of PTs, 66.5% of IDTs, and 25% of SPTs. When confidence of drug causality was high (n = 73 of 194), testing did not correlate well with clinical suspicion: PTs, 37.6%; IDTs, 36.5%. Direct comparison of skin testing with provocation testing (n = 12) showed 83.3% correlation. Positive IDT results were reported in 8 negative PT cases. CONCLUSIONS Skin tests, particularly PTs and IDTs, have been reported as tools for diagnosis of causal drugs in DRESS. Heterogeneity in methodology, results analysis, and reporting of cohorts make meta-analysis to determine sensitivity and specificity of published literature impossible and highlight weaknesses in the field. We propose that international collaboration is essential to harmonize the methodology and reporting measures from hypersensitivity testing studies in larger cohorts.
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Affiliation(s)
- Ying Xin Teo
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Department of Dermatology, Southampton General Hospital, University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Peter Simon Friedmann
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Department of Dermatology, Southampton General Hospital, University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Marta Ewa Polak
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Michael Roger Ardern-Jones
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Department of Dermatology, Southampton General Hospital, University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom.
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25
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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: 8] [Impact Index Per Article: 8.0] [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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26
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Shen Q, Wang Q, Zang H, Yu L, Cong X, Chen X, Chen L. DRESS/DiHS syndrome induced by Propylthiouracil: a case report. BMC Endocr Disord 2023; 23:22. [PMID: 36691013 PMCID: PMC9869506 DOI: 10.1186/s12902-023-01273-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS), also known as Drug-induced hypersensitivity syndrome (DiHS), is a severe adverse drug reaction. Propylthiouracil, a member of thiouracils group, is widely used in medical treatment of hyperthyroidism. Propylthiouracil is associated with multiple adverse effects such as rash, agranulocytosis hepatitis and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, but rarely triggers DRESS/DiHS syndrome. Here, we describe a severe case of propylthiouracil-induced DRESS/DiHS syndrome. CASE PRESENTATION A 38-year-old female was treated with methimazole for hyperthyroidism at first. 4 weeks later, the patient developed elevated liver transaminase so methimazole was stopped. After liver function improved in 2 weeks, medication was switched to propylthiouracil therapy. The patient subsequently developed nausea and rash followed by a high fever, acute toxic hepatitis and multiple organ dysfunction (liver, lung and heart), which lasted for 1 month after propylthiouracil was started. According to the diagnostic criteria, the patient was diagnosed of DRESS/DiHS syndrome which was induced by propylthiouracil. As a result, propylthiouracil was immediately withdrawn. And patient was then treated with adalimumab, systematic corticosteroids and plasmapheresis in sequence. Symptoms were finally resolved 4 weeks later. CONCLUSIONS Propylthiouracil is a rare cause of the DRESS/DiHS syndrome, which typically consists of severe dermatitis and various degrees of internal organ involvement. We want to emphasize through this severe case that DRESS/DiHS syndrome should be promptly recognized to hasten recovery.
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Affiliation(s)
- Qiong Shen
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Qingyao Wang
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Huanhuan Zang
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Ling Yu
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Xiangguo Cong
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China
| | - Xinxin Chen
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China.
| | - Lei Chen
- Department of Endocrinology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 26 Daoqian Road, Suzhou, 215000, People's Republic of China.
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27
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Suzuki M, Koshikawa S, Watanabe H, Inomata N, Yamaguchi Y, Aihara M, Sueki H. Elevated serum osteopontin levels in patients with severe cutaneous adverse drug reactions. J Dermatol 2022; 50:536-540. [PMID: 36540013 DOI: 10.1111/1346-8138.16670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022]
Abstract
Osteopontin (OPN) was initially described as a protein involved in bone metabolism, but the roles played by OPN in the immune system and allergic reactions have attracted increasing attention. Here, we clarify the OPN-related dynamics of severe cutaneous adverse drug reactions, and assess whether the OPN level has utility for classifying such reactions and serving as a biomarker of severity. Serum OPN levels in patients with drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and erythema multiforme-type drug reaction (EM-DR) were quantified by ELISA. The OPN sources were analyzed by dual immunofluorescence assay of DIHS, SJS/TEN and EM-DR biopsy specimens. The serum OPN levels of DIHS/DRESS patients (489.1 ± 37.0 ng/mL) and SJS/TEN patients (508.5 ± 47.8 ng/mL) were significantly higher compared with controls (314.4 ± 14.3 ng/mL; p < 0.001). After treatment, the serum OPN level of DIHS/DRESS patients decreased to that of controls. In addition, OPN levels in DIHS/DRESS patients and SJS/TEN patients were higher than in patients with EM-DR (Mann-Whitney U test, p < 0.05). However, when the Kruskal-Wallis test was used to compare the OPN levels among the three groups of patients, the difference was not significant (p = 0.055). Dual immunofluorescence assay revealed that T lymphocytes and macrophages were the main OPN sources in DIHS, SJS/TEN and EM-DR patients. These data suggest that the OPN level can be used to evaluate the severity of inflammation in patients experiencing drug reactions.
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Affiliation(s)
- Marie Suzuki
- Department of Dermatology Showa University, School of Medicine Tokyo Japan
| | - Sachiko Koshikawa
- Department of Dermatology Showa University, School of Medicine Tokyo Japan
| | - Hideaki Watanabe
- Department of Dermatology Showa University, School of Medicine Tokyo Japan
- Department of Dermatology Showa University Northern Yokohama Hospital Yokohama Japan
| | - Naoko Inomata
- Department of Dermatology Showa University, School of Medicine Tokyo Japan
| | - Yukie Yamaguchi
- Department of Environmental Immuno‐Dermatology Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Michiko Aihara
- Department of Environmental Immuno‐Dermatology Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Hirohiko Sueki
- Department of Dermatology Showa University, School of Medicine Tokyo Japan
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Bellón T, Lerma V, Guijarro J, Ramírez E, Martínez C, Escudero C, Fiandor AM, Barranco R, de Barrio M, de Abajo F, Cabañas R. LTT and HLA testing as diagnostic tools in Spanish vancomycin-induced DRESS cases: A case-control study. Front Pharmacol 2022; 13:959321. [PMID: 36339612 PMCID: PMC9631441 DOI: 10.3389/fphar.2022.959321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/03/2022] [Indexed: 11/23/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe T-cell-mediated off-target adverse reaction. DRESS cases caused by vancomycin have often been reported. The HLA-A*32:01 allele has been associated with genetic susceptibility to vancomycin-induced DRESS in US citizens of European descent. We have analyzed the association of the HLA-A*32:01 allele in 14 Spanish DRESS cases in which vancomycin was suspected as the culprit drug, and the lymphocyte transformation test (LTT) as an in vitro assay to evaluate vancomycin sensitization. The results were compared to vancomycin-tolerant control donors. LTT was performed in 12 DRESS cases with PBMCs from resolution samples available and in a group of 12 tolerant donors. ROC curves determined that LTT is a suitable tool to identify patients sensitized to vancomycin (AUC = 0.9646; p < 0.0001). When a stimulation index >3 was regarded as a positive result, contingency tables determined 91% sensitivity, 91.67% specificity, 91% positive predictive value, and 91.67% negative predictive value (p = 0.0001, Fisher’s exact test). The HLA A*32:01 allele was determined by an allele-specific PCR assay in 14 cases and 25 tolerant controls. Among the DRESS cases, five carriers were identified (35.7%), while it was detected in only one (4%) of the tolerant donors, [odds ratio (OR) = 13.33; 95% CI: 1.364–130.3; p = 0.016]. The strength of the association increased when only cases with positive LTT to vancomycin were considered (OR = 24.0; 95% CI: 2.28–252.6; p = 4.0 × 10−3). Our results confirm the association of the risk allele HLA-A*32:01 with vancomycin-induced DRESS in Spanish cases, and support LTT as a reliable tool to determine vancomycin sensitization.
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Affiliation(s)
- Teresa Bellón
- Drug Hypersensitivity Laboratory, Institute for Health Research Hospital Universitario La Paz (IdiPaz), Madrid, Spain
- *Correspondence: Teresa Bellón,
| | - Victoria Lerma
- Clinical Pharmacology Unit, Hospital Universitario Príncipe de Asturias, Madrid, Spain
- Department of Biomedical Sciences, University of Alcalá (IRYCIS), Madrid, Spain
| | - Javier Guijarro
- Clinical Pharmacology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, IdiPAZ, School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Elena Ramírez
- Clinical Pharmacology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, IdiPAZ, School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Celia Martínez
- Drug Hypersensitivity Laboratory, Institute for Health Research Hospital Universitario La Paz (IdiPaz), Madrid, Spain
| | - Carmelo Escudero
- Allergy Department, Hospital Universitario Niño Jesús, Madrid, Spain
| | - Ana M. Fiandor
- Allergy Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
| | - Ruth Barranco
- Allergy Department, Hospital Universitario Doce de Octubre, Madrid, Spain
| | | | - Francisco de Abajo
- Clinical Pharmacology Unit, Hospital Universitario Príncipe de Asturias, Madrid, Spain
- Department of Biomedical Sciences, University of Alcalá (IRYCIS), Madrid, Spain
| | - Rosario Cabañas
- Allergy Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
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Muacevic A, Adler JR. Trimethoprim-Sulfamethoxazole-Induced Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Complicated by Acute Liver Failure. Cureus 2022; 14:e30852. [PMID: 36457619 PMCID: PMC9705226 DOI: 10.7759/cureus.30852] [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: 10/29/2022] [Indexed: 01/25/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a delayed adverse drug reaction that is characterized by fever, cutaneous manifestation, enlarged lymph nodes, hematologic abnormalities, and organ involvement. Multiple medications have been reported to cause DRESS with the presentation varying from drug to drug. Some cases are mild and can be managed by stopping the causative agent along with supportive measures; however, other cases can lead to multi-organ failure requiring systemic corticosteroids and organ transplant. Acute liver failure is a rare manifestation of DRESS. We report a patient who had recently completed a course of trimethoprim-sulfamethoxazole and presented with low-grade fever, diffuse skin rash, eosinophilia, elevated liver enzymes, acute kidney injury, and thrombocytopenia. DRESS was subsequently diagnosed based on history, physical examination, and relatively negative workup for an alternate diagnosis. The patient eventually showed improvement with steroid therapy without the need for a liver transplant. Due to its pharmacogenetic susceptibility, it is essential to recommend avoiding the causative medication for the patient's family members.
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30
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Ak T, Erdem S, Durmus RB, Kimyon U, Engin B, Bavunoglu I. How to Recognize and Manage Challenging DRESS Cases: Two Case Reports and A Review of the Literature. Dermatol Ther 2022; 35:e15785. [PMID: 35997939 DOI: 10.1111/dth.15785] [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: 05/25/2022] [Revised: 08/10/2022] [Accepted: 08/21/2022] [Indexed: 11/26/2022]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon systemic adverse drug reaction. Furthermore, it is a unique syndrome encompassing various manifestations of fever, facial edema, eosinophilia, atypical lymphocytosis, and organ dysfunction. Since there are no large prospective studies concerning DRESS syndrome, current treatment modalities for DRESS have been mainly determined based on various case reports and expert opinions. Corticosteroids are the mainstay of therapy after the cessation of the culprit drug. Although most cases recover within a couple of months, some may persist and even progress despite 1 mg/kg/day of prednisolone or its equivalent. We herein present two cases of severe DRESS syndrome. Both cases presented with organ dysfunction and remained unresponsive to initial treatment with 1 mg/kg/day of intravenous methylprednisolone. Therefore, plasmapheresis or pulse steroid therapy (250 mg/day methylprednisolone for three days) was used. In the follow-up period, patients' clinical conditions improved dramatically without recurrence. We aimed to share our experience in recognizing and managing severe DRESS cases in this manuscript. Furthermore, we reviewed the literature in comparison with the present cases. In conclusion, plasmapheresis or pulse steroid therapy (250 mg/day of methylprednisolone for three days) can be used to treat difficult DRESS cases where organ failure is about to happen.
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Affiliation(s)
- Tumay Ak
- Cerrahpasa Medical Faculty, Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sukran Erdem
- Cerrahpasa Medical Faculty, Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Rana Berru Durmus
- Cerrahpasa Medical Faculty, Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ugur Kimyon
- Cerrahpasa Medical Faculty, Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Burhan Engin
- Cerrahpasa Medical Faculty, Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Isil Bavunoglu
- Cerrahpasa Medical Faculty, Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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31
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Sogo A, Horiuchi H, Ueda T, Miyazaki H, Furuya R. Early-Onset Drug Hypersensitivity Syndrome in a Man With Pneumonia Due to Pre-sensitization to Olanzapine. Cureus 2022; 14:e26374. [PMID: 35911368 PMCID: PMC9328836 DOI: 10.7759/cureus.26374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/05/2022] Open
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32
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Anti-Cytomegalovirus Therapy: Whether and When to Initiate, Those Are the Questions. Pharmaceuticals (Basel) 2022; 15:ph15070797. [PMID: 35890096 PMCID: PMC9325238 DOI: 10.3390/ph15070797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022] Open
Abstract
Cytomegalovirus (CMV) reactivation in patients with autoimmune bullous disease (AIBD) or severe drug eruption treated with immunosuppressive therapy was traditionally thought to be merely an epiphenomenon of the underlying immunosuppression. However, a detailed review of the clinical course of these patients revealed that CMV reactivation occurs upon rapid immune recovery, which is termed immune reconstitution inflammatory syndrome (IRIS), and that the timely initiation of anti-CMV therapy, when combined with maintenance doses of immunosuppressive agents, contributes to a rapid resolution of severe infectious complications thought to be refractory to conventional immunosuppressive therapies and unrelated to CMV reactivation. Thus, CMV reactivation resulting in fatal outcomes (CMV-IRIS) can be prevented by the timely detection of CMV DNA or antigens in the blood and by rapidly starting anti-CMV therapy while maintaining immunosuppressive therapy. Anti-CMV therapy is highly recommended for patients with CMV-IRIS or severe drug eruption who have risk factors for CMV reactivation resulting in fatal outcomes.
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Ilina YV, Fedorova TA, Tazina SY, Sotnikova TI, Semenenko NA, Loshchits NV, Bolshakov SA, Kiseleva NV, Pavlov CS. DRESS syndrome on the background of adding meropenem to carbamazepine therapy: a clinical case. SECHENOV MEDICAL JOURNAL 2022. [DOI: 10.47093/2218-7332.2022.407.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Yu. V. Ilina
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T. A. Fedorova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S. Y. Tazina
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T. I. Sotnikova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N. A. Semenenko
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N. V. Loshchits
- City Clinical Hospital named after S.P. Botkin of the Moscow Healthcare Department
| | - S. A. Bolshakov
- City Clinical Hospital named after S.P. Botkin of the Moscow Healthcare Department
| | - N. V. Kiseleva
- Sechenov First Moscow State Medical University (Sechenov University)
| | - Ch. S. Pavlov
- Sechenov First Moscow State Medical University (Sechenov University)
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34
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Takamiyagi S, Iriki H, Asahina Y, Furuichi Y, Funakoshi T, Ichikawa M, Mikami Y, Okita H, Sakiyama T, Inazumi T, Amagai M, Takahashi H. Severe graft-versus-host disease-like enterocolitis accompanied with cytomegalovirus-reactivation in drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. J Dermatol 2022; 49:796-799. [PMID: 35502510 DOI: 10.1111/1346-8138.16415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/28/2022] [Accepted: 04/20/2022] [Indexed: 12/17/2022]
Abstract
Drug-induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe drug adverse reaction with skin eruption and visceral organ involvement. The characteristic clinical features of DIHS/DRESS are reactivation of human herpesviruses (HHV) and the development of autoimmune diseases, but their pathogenesis and associations are not yet understood. Here, we report a 66-year-old man who presented with fever, generalized erythema, diffuse lymphadenopathy, and diarrhea after 3 weeks of treatment with zonisamide. Reactivation of HHV-6 and cytomegalovirus (CMV) was detected during the clinical course. The patient was diagnosed with DIHS/DRESS and treated with systemic prednisolone, i.v. immunoglobulin therapy, and ganciclovir. However, severe enterocolitis persisted for 6 months. A series of examinations revealed features of both CMV enterocolitis, as indicated by identification of a few CMV-positive cells on immunohistochemical analysis, and graft-versus-host disease (GVHD)-like enterocolitis indicated by orange-peel appearance on endoscopic examination and histopathological loss of goblet cells. Intractable enterocolitis continued and the patient finally died of pneumonia. An autoimmune predisposition in DIHS/DRESS patients in combination with CMV reactivation was considered to trigger the severe enterocolitis of this case that showed GVHD-like features of the gastrointestinal tract. GVHD-like organ damage is a pathological condition rarely observed in DIHS/DRESS but should be recognized as one of the most severe complications of the disease.
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Affiliation(s)
- Saeko Takamiyagi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Hisato Iriki
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yasuhiko Asahina
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yuki Furuichi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Takeru Funakoshi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Masataka Ichikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Mikami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hajime Okita
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Tomo Sakiyama
- Department of Dermatology, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Toyoko Inazumi
- Department of Dermatology, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
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35
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Hama N, Abe R, Gibson A, Phillips EJ. Drug-Induced Hypersensitivity Syndrome (DIHS)/Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS): Clinical Features and Pathogenesis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1155-1167.e5. [PMID: 35176506 PMCID: PMC9201940 DOI: 10.1016/j.jaip.2022.02.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 05/16/2023]
Abstract
Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) is one example of a severe delayed T-cell-mediated adverse drug reaction. DIHS/DRESS presents with fever, widespread rash and facial edema, organ involvement, and hematological abnormalities, including eosinophilia and atypical lymphocytosis. DIHS/DRESS is associated with relapse 2 to 4 weeks after acute symptoms, often coinciding with reactivation of prevalent chronic persistent human herpesviruses such as human herpesvirus 6, EBV, and cytomegalovirus. The mortality of DIHS/DRESS is up to 10% and often related to unrecognized myocarditis and cytomegalovirus complications, with longer-term consequences that contribute to morbidity including autoimmune diseases such as thyroiditis. It is essential that all potential drug causes, including all new drugs introduced within the 8 weeks preceding onset of DIHS/DRESS symptoms, are identified. All potential drug culprits, as well as drugs that are closely related structurally to the culprit drug, should be avoided in the future. Systemic corticosteroids have remained the mainstay for the treatment of DIHS/DRESS with internal organ involvement. Steroid-sparing agents, such as cyclosporine, mycophenolate mofetil, and monthly intravenous immune globulin, have been successfully used for treatment, and careful follow-up for cytomegalovirus reactivation is recommended. Strong associations between HLA class I alleles and DIHS/DRESS predisposition include HLA-B∗13:01 and dapsone, HLA-B∗58:01 and allopurinol, and HLA-B∗32:01 and vancomycin. These have opened a pathway for prevention, risk stratification, and earlier diagnosis. Single-cell sequencing and other studies of immunopathogenesis promise to identify targeted treatment approaches.
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Affiliation(s)
- Natsumi Hama
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Andrew Gibson
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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36
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Drug Reaction with Eosinophilia and Systemic Symptoms (DReSS)/Drug-Induced Hypersensitivity Syndrome (DiHS)—Readdressing the DReSS. Biomedicines 2022; 10:biomedicines10050999. [PMID: 35625735 PMCID: PMC9138571 DOI: 10.3390/biomedicines10050999] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 12/17/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DReSS), also known as drug-induced hypersensitivity syndrome (DiHS), is a severe, systemic, T cell mediated drug reaction with combinations of cutaneous, hematologic, and internal organ involvement. Pathogenesis of DReSS is multi-factorial, involving drug-exposure, genetic predisposition through specific human leukocyte antigen (HLA) alleles and metabolism defects, viral reactivation, and immune dysregulation. Clinical features of this condition are delayed, stepwise, and heterogenous, making this syndrome challenging to recognize and diagnose. Two sets of validated diagnostic criteria exist that can be employed to diagnose DReSS/DiHS. Methods to improve early recognition of DReSS and predict disease severity has been a recent area of research focus. In vitro and in vivo tests can be employed to confirm the diagnosis and help identify culprit drugs. The mainstay treatment of DReSS is prompt withdrawal of the culprit drug, supportive treatment, and immunosuppression depending on the severity of disease. We present a comprehensive review on the most recent research and literature on DReSS, with emphasis on pathogenesis, clinical features, diagnosis, confirmatory testing modalities, and treatment. Additionally, this summary aims to highlight the differing viewpoints on this severe disease and broaden our perspective on the condition known as DReSS.
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37
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de Filippis R, De Fazio P, Kane JM, Schoretsanitis G. Pharmacovigilance approaches to study rare and very rare side-effects: example of clozapine-related DiHS/DRESS syndrome. Expert Opin Drug Saf 2022; 21:585-587. [PMID: 35417282 DOI: 10.1080/14740338.2022.2066078] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, 88100, Italy
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, 88100, Italy
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, 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
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, 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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38
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Sueki H, Watanabe Y, Sugiyama S, Mizukawa Y. Drug allergy and non-HIV immune reconstitution inflammatory syndrome. Allergol Int 2022; 71:185-192. [PMID: 35236619 DOI: 10.1016/j.alit.2021.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/25/2021] [Indexed: 12/16/2022] Open
Abstract
Non-HIV immune reconstitution inflammatory syndrome (non-HIV IRIS) is associated with the recovery from an immunocompromised condition. It is defined as inflammatory disorders caused by antigens, including drugs or pathogenic microorganisms present prior to immune recovery, or by the exacerbation of an inflammatory disorder that was already present. Drug-induced hypersensitivity syndrome is a prototype of IRIS, and the pathophysiology of non-HIV IRIS can be recognized in several disorders treated with corticosteroids, immunosuppressants, molecular-targeted drugs, TNF-α antibody drugs, immune checkpoint inhibitors, and dipeptidyl peptidase-4 inhibitors. This review focuses on the relationship between the immune mechanism of non-HIV IRIS and drug allergies, especially severe drug eruption. The antigen recognition mechanism in drug allergy varies depending on the clinical type and the causative drug. The p-i concept is the main mechanism in severe drug eruption such as Stevens-Johnson syndrome/toxic epidermal necrolysis, and drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Lymphocytes activated by an antigen other than a drug, such as a virus, can also develop drug allergy by the loose binding of drugs with immune receptors of T cells or human leukocyte antigen. Therefore, fluctuations in the immune environment affect the onset of severe drug eruption. Novel agents that cause major changes in immunity have been marketed mainly for autoimmune diseases and malignant tumors; therefore, it is necessary to consider their effects when treating severe drug eruptions. Moreover, although a list of diagnostic criteria for this syndrome has been drafted, predictive and diagnostic biomarkers for this syndrome needs to be urgently developed.
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39
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Lee JW, Lee SR, Kim MJ, Cho S, Youn SW, Yang MS, Kim SH, Kang HR, Kwon O. Skin manifestations and clinical features of drug reaction with eosinophilia and systemic symptoms (DRESS): A retrospective multicenter study of 125 patients. J Eur Acad Dermatol Venereol 2022; 36:1584-1592. [PMID: 35342995 DOI: 10.1111/jdv.18100] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse drug reaction generally accompanied by skin manifestations as the first and most frequent symptoms. However, skin manifestations and associated clinical features of DRESS have not been fully explored and evaluated. OBJECTIVES This study aimed to describe the skin manifestations of DRESS in detail and analyze their association with demographic characteristics and extra-cutaneous clinical features. METHODS We conducted this retrospective study on patients with DRESS diagnosed between September 2009 and August 2021 at three medical institutes and validated using the RegiSCAR score. Data regarding demographics, skin manifestations, and clinical characteristics were retrieved through thorough chart reviews. RESULTS Among 182 potential cases of DRESS, the validated 125 cases were analyzed. A widespread rash extending over more than 50% of the body surface area was observed in 122 patients (97.6%) and typical facial edema was experienced by 67 patients (53.6%). Polymorphous maculopapules were the most common rash morphology (106, 84.8%): specifically, exfoliative (59, 47.2%), urticarial (57, 45.6%), and purpuric forms (39, 31.2%) were common. Mucosal involvement was observed in 41 patients (32.8%). Patients with carboxamide antiepileptics (carbamazepine and oxcarbazepine) experienced more edema (P = .014) and typical facial edema than those with allopurinol (P = .021). The RegiSCAR score was higher in patients with purpura (P < .01). CONCLUSIONS Skin manifestations of DRESS exhibit a wide range of skin lesions and can vary according to the culprit drugs. Early suspicion and prompt intervention are needed to improve prognosis.
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Affiliation(s)
- J W Lee
- Department of Dermatology, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - S R Lee
- Department of Dermatology, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.,Department of Dermatology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea
| | - M J Kim
- Department of Dermatology, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - S Cho
- Department of Dermatology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea
| | - S W Youn
- Department of Dermatology, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - M S Yang
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea
| | - S H Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - H R Kang
- Drug Safety Center, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine.,Institute of Allergy and Clinical Immunology, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - O Kwon
- Department of Dermatology, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.,Laboratory of Cutaneous Aging and Hair Research, Clinical Research Institute, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.,Institute of Human-Environment Interface Biology, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea
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40
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Korekawa A, Nakajima K, Fukushi K, Nakano H, Sawamura D. Three cases of drug-induced hypersensitivity syndrome associated with mRNA-based coronavirus disease 2019 vaccines. J Dermatol 2022; 49:652-655. [PMID: 35243679 PMCID: PMC9111132 DOI: 10.1111/1346-8138.16347] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/10/2022] [Accepted: 02/19/2022] [Indexed: 12/17/2022]
Abstract
Drug-induced hypersensitivity syndrome (DiHS) is a severe drug eruption that can induce reactivation of herpesviruses such as human herpesvirus 6, resulting in symptom flare-up and organ damage. DiHS is known as drug reaction with eosinophilia and systemic symptoms (DRESS) in Europe. We report three cases of DiHS that could have been triggered by mRNA-based coronavirus disease 2019 (COVID-19) vaccines. In these three patients, symptoms of DiHS developed 2-6 days after the first dose of an mRNA-based COVID-19 vaccine. Although there have been no reports of DiHS/DRESS induced by mRNA-based COVID-19 vaccines in domestic and international journals despite the progress in vaccination worldwide, we speculate that mRNA-based COVID-19 vaccines might have triggered the development of DiHS/DRESS in our patients. In the current coronavirus epidemic, it might be important to assess mRNA-based COVID-19 vaccination status and date of vaccination when evaluating a patient with DiHS/DRESS.
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Affiliation(s)
- Ayumi Korekawa
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Koji Nakajima
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Karen Fukushi
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hajime Nakano
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Daisuke Sawamura
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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41
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de Groot AC. Patch testing in Drug reaction with eosinophilia and systemic symptoms (DRESS): a literature review. Contact Dermatitis 2022; 86:443-479. [PMID: 35233782 DOI: 10.1111/cod.14090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/15/2022] [Accepted: 02/24/2022] [Indexed: 11/27/2022]
Abstract
The literature on positive patch test results in drug reaction with eosinophilia and systemic symptoms (DRESS) is reviewed. 105 drugs were identified that have together caused 536 positive patch tests in 437 patients suffering from DRESS. By far most reactions (n=145) were caused by carbamazepine, followed by amoxicillin, isoniazid, phenytoin, ethambutol, fluindione, phenobarbital, rifampicin, and ceftriaxone; 43 drugs each caused a single case only. The drug classes causing the highest number of reactions are anticonvulsants (39%), beta-lactam antibiotics (20%), antituberculosis agents (11%), non-beta-lactam antibiotics (6%) and iodinated contrast media (5%). The sensitivity of patch testing (percentage of positive reactions) is high for anticonvulsants (notably carbamazepine), beta-lactam antibiotics (notably amoxicillin) and possibly iodinated contrast media. Allopurinol and sulfasalazine frequently cause DRESS, but never give positive patch tests. Patch testing in DRESS appears to be safe, although mild recurrence of DRESS symptoms, mostly skin reactions, may not be rare. Multiple drug hypersensitivity was found to occur in 16% of all patients, but it is argued that the true frequency is (far) higher. Clinical aspects of DRESS, including diagnosing the disease and identifying culprit drugs (patch tests, intradermal tests, in vitro tests, challenge tests) are also provided, emphasizing the role of patch testing. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anton C de Groot
- dermatologist np Schipslootweg 5, 8351, HV, Wapserveen, The Netherlands
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42
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Radovanovic M, Jevtic D, Calvin AD, Petrovic M, Paulson M, Rueda Prada L, Sprecher L, Savic I, Dumic I. "Heart in DRESS": Cardiac Manifestations, Treatment and Outcome of Patients with Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome: A Systematic Review. J Clin Med 2022; 11:jcm11030704. [PMID: 35160164 PMCID: PMC8836915 DOI: 10.3390/jcm11030704] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/17/2022] [Accepted: 01/25/2022] [Indexed: 02/07/2023] Open
Abstract
Cardiac involvement in drug reaction with eosinophilia and systemic symptoms (DS) is rare but associated with high mortality. The aim of this research was to systematically review case reports by PRISMA guidelines in order to synthetize the knowledge of cardiac manifestations of DS. We identified 42 cases from 36 case reports. Women were two times more affected than men. Two-thirds of patients had cardiac manifestation in the initial phase of the disease, while in one-third of cases cardiac manifestations developed later (mean time of 70 ± 63 days). The most common inciting medications were minocycline (19%) and allopurinol (12%). In 17% of patients, the heart was the only internal organ affected, while the majority (83%) had at least one additional organ involved, most commonly the liver and the kidneys. Dyspnea (55%), cardiogenic shock (43%), chest pain (38%), and tachycardia (33%) were the most common cardiac signs and symptoms reported. Patients frequently had an abnormal ECG (71.4%), and a decrease in left ventricular ejection fraction was the most common echocardiographic finding (45%). Endomyocardial biopsy or histological examination at autopsy was performed in 52.4%, with the predominant finding being fulminant eosinophilic myocarditis with acute necrosis in 70% of those biopsied. All patients received immunosuppressive therapy with intravenous steroids, while non-responders were more likely to have received IVIG, cyclosporine, mycophenolate, and other steroid-sparing agents (60%). Gender and degree of left ventricular systolic dysfunction were not associated with outcomes, but short latency between drug exposure and the first DRESS symptom onset (<15 days) and older age (above 65 years) was associated with death. This underscores the potential importance of heightened awareness and early treatment.
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Affiliation(s)
- Milan Radovanovic
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA; (M.R.); (A.D.C.); (M.P.); (L.R.P.); (L.S.)
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Djordje Jevtic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.J.); (I.S.)
| | - Andrew D. Calvin
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA; (M.R.); (A.D.C.); (M.P.); (L.R.P.); (L.S.)
- Department of Cardiovascular Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Marija Petrovic
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Margaret Paulson
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA; (M.R.); (A.D.C.); (M.P.); (L.R.P.); (L.S.)
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Libardo Rueda Prada
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA; (M.R.); (A.D.C.); (M.P.); (L.R.P.); (L.S.)
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Lawrence Sprecher
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA; (M.R.); (A.D.C.); (M.P.); (L.R.P.); (L.S.)
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Ivana Savic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.J.); (I.S.)
| | - Igor Dumic
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA; (M.R.); (A.D.C.); (M.P.); (L.R.P.); (L.S.)
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
- Correspondence:
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Sasidharanpillai S, Ajithkumar K, Jishna P, Khader A, Anagha K, Binitha M, Chathoth A. RegiSCAR DRESS (drug reaction with eosinophilia and systemic symptoms) validation scoring system and Japanese consensus group criteria for atypical drug-induced hypersensitivity syndrome (DiHS): A comparative analysis. Indian Dermatol Online J 2022; 13:40-45. [PMID: 35198466 PMCID: PMC8809161 DOI: 10.4103/idoj.idoj_196_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/23/2021] [Accepted: 06/30/2021] [Indexed: 11/04/2022] Open
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Takei S, Hama N, Mizukawa Y, Takahashi H, Miyagawa F, Asada H, Abe R. Purpura as an indicator of severity in drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms: evidence from a 49-case series. J Eur Acad Dermatol Venereol 2021; 36:e310-e313. [PMID: 34839562 DOI: 10.1111/jdv.17838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/23/2021] [Accepted: 11/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- S Takei
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - N Hama
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Y Mizukawa
- Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan
| | - H Takahashi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - F Miyagawa
- Department of Dermatology, Nara Medical University School of Medicine, Nara, Japan
| | - H Asada
- Department of Dermatology, Nara Medical University School of Medicine, Nara, Japan
| | - R Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Lamotrigine Induced DRESS Syndrome in a Child: A Case Report and Literature Review. CHILDREN 2021; 8:children8111063. [PMID: 34828776 PMCID: PMC8624037 DOI: 10.3390/children8111063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/09/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022]
Abstract
Lamotrigine is an important anticonvulsant drug. Its use, however, has been limited by the risk of potentially life-threatening dermatological reactions, such as a drug reaction with eosinophilia and systemic symptoms (DRESS). Here, we report the case of a 7-year-6-month-old girl with a history of epilepsy who developed a skin rash with dyspnoea after 2 weeks of lamotrigine treatment, with DRESS ultimately being diagnosed. After discontinuation of the offending drug and the initiation of systemic glucocorticosteroids, the DRESS symptoms were relieved and the patient was discharged in a stable condition. Anticonvulsant drugs such as lamotrigine are among the factors that induce DRESS in children. When a patient displays skin rash and systemic organ involvement following the initiation of an anticonvulsant drug, DRESS should not be overlooked as a diagnosis, and immunosuppressant drugs should be considered as an option for treating DRESS patients.
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Mizukawa Y, Aoyama Y, Takahashi H, Takahashi R, Shiohara T. Risk of progression to autoimmune disease in severe drug eruption: risk factors and the factor-guided stratification. J Invest Dermatol 2021; 142:960-968.e9. [PMID: 34808234 DOI: 10.1016/j.jid.2021.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 10/23/2021] [Accepted: 11/02/2021] [Indexed: 12/17/2022]
Abstract
The identification of risk factors is key not only to uncover the pathogenesis of autoimmune disease but also to predict progression to autoimmune disease. Drug-induced hypersensitivity syndrome (DiHS)/ drug reaction with eosinophilia and systemic symptoms (DRESS) is likely the best prototypic example for analyzing the sequential events. We conducted a retrospective study of 55 patients with DiHS/DRESS followed for the possibility of later development of autoimmune disease ∼18 years after resolution. Nine patients progressed to autoimmune sequelae regardless of treatment. The generation of autoantibodies preceded by 8 years in 8 of the 9 patients. The combination of increases in lymphocyte counts, severe liver damage, a rebound increase in globulin, persistent reactivations of Epstein-Barr virus and human herpesvirus-6, and low interleukin (IL)-2 and IL-4 at the acute/subacute phases, were significant risk factors for the future development of autoimmune disease. Based on these factors, we established a scoring system that can identify high-risk patients. When stratified these patients into three risk categories (low/intermediate/high), occurrence of autoimmune disease was exclusively detected in the high group. Our data represent the new scoring system to identify patients at high-risk of developing autoimmune disease, although a larger study is required to validate the scoring system.
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Affiliation(s)
- Yoshiko Mizukawa
- Department of Dermatology, Kyorin University School of Medicine, Mitaka, Tokyo 181-8611, Japan.
| | - Yumi Aoyama
- Department of Dermatology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Shinjuku, Tokyo 160-8582, Japan
| | - Ryo Takahashi
- Flow Cytometry Core Facility, Kyorin University School of Medicine, Mitaka, Tokyo 181-8611, Japan
| | - Tetsuo Shiohara
- Department of Dermatology, Kyorin University School of Medicine, Mitaka, Tokyo 181-8611, Japan
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Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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Serum Soluble OX40 as a Diagnostic and Prognostic Biomarker for Drug-Induced Hypersensitivity Syndrome/Drug Reaction with Eosinophilia and Systemic Symptoms. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:558-565.e4. [PMID: 34757063 DOI: 10.1016/j.jaip.2021.10.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/07/2021] [Accepted: 10/15/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) is a severe adverse drug reaction commonly associated with the reactivation of human herpesvirus 6 (HHV-6). There are currently no adequate biomarkers for the early diagnosis and detection of DIHS/DRESS. Notably, OX40 (CD134) has an important role in allergic inflammation and functions as a cellular receptor for HHV-6 entry. We previously reported that the membrane-bound form of OX40 in CD4+ T cells was upregulated in DIHS/DRESS. OBJECTIVE We sought to investigate the clinical significance of serum soluble OX40 (sOX40) in DIHS/DRESS. METHODS Serum sOX40 levels in patients with DIHS/DRESS (n = 39), maculopapular exanthema/erythema multiforme (n = 17), Stevens-Johnson syndrome/toxic epidermal necrolysis (n = 13), or autoimmune bullous diseases (n = 5), and levels in healthy volunteers (n = 5) were examined by enzyme-linked immunosorbent assay. Copy numbers of HHV-6, HHV-7, and cytomegalovirus in peripheral blood mononuclear cells were quantified using real-time PCR. RESULTS Serum sOX40 levels in patients with DIHS/DRESS in the acute stage were elevated in parallel with high OX40 expression on CD4+ T cells. Serum sOX40 levels were significantly positively correlated with disease severity and serum levels of thymus and activation-regulated chemokine, IL-5, and IL-10. Human herpesvirus 6-positive patients had higher sOX40 levels than did HHV-6-negative patients, and serum sOX40 levels were correlated with HHV-6 DNA loads. CONCLUSIONS Serum sOX40 levels can be a useful diagnostic marker for DIHS/DRESS that reflect disease severity. Elevated serum sOX40 levels also predict HHV-6 reactivation in patients with DIHS/DRESS.
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Abstract
Drug rash with eosinophilia and systemic symptoms (DRESS syndrome) is a severe, potentially life-threatening drug-induced hypersensitivity reaction characterized by cutaneous eruptions, fever, diffuse lymphadenopathy, along with eosinophilia and elevated liver enzymes. The severity and potential organ damage associated with DRESS mandates withdrawing the offending drug and provide a suitable replacement. We report a 55-year-old man who developed prolonged fever, generalized maculopapular rash and facial edema after 3 weeks of starting imatinib for chronic myeloid leukemia (CML). A diagnosis of DRESS was confirmed by eosinophilia and skin biopsy findings, along with a consistent RegiSCAR score. Imatinib was stopped and he was initiated on low-dose steroids, which led to complete resolution of rash and eosinophilia. A rechallenge with imatinib was positive, and he was switched to dasatinib for further therapy, following which he attained an optimal molecular response. DRESS following imatinib has only been reported in eight patients so far. In this report we summarize the current evidence for managing DRESS and its impact on the treatment of CML.
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Affiliation(s)
- S Kaur
- Department of Dermatology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - S Singh
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - R Singh
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - P Singla
- Department of Dermatology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Role of Multiple Comorbidities and Therapies in Conditioning the Clinical Severity of DRESS: A Mono-Center Retrospective Study of 25 Cases. Int J Mol Sci 2021; 22:ijms22137072. [PMID: 34209467 PMCID: PMC8268599 DOI: 10.3390/ijms22137072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 12/14/2022] Open
Abstract
DRESS/DiHS is a complex and potentially fatal drug reaction. Little is known about risk factors and elements that can help to identify patients with a severe reaction early. The aim of the study was to investigate those factors favoring the disease and its severity by analyzing the clinical conditions and therapies preceding the reaction. We conducted a retrospective analysis on patients admitted to our center between 2010 and 2020 who were discharged with a diagnosis of DRESS. We used the RegiSCAR diagnostic criteria. We defined the severity of DRESS using the criteria of Mizukawa et al. We included 25 patients (15 females) with a median age of 66 years. Skin involvement, eosinophilia, and liver injury were the most important aspects. Allopurinol was found to be the most involved drug. Reaction severity was significantly associated with the number of daily medications (p = 0.0067) and an age of at least 68 years (p = 0.013). In addition, 75% of severe cases had at least three comorbidities in history, and most of the severe cases were female. In our study the advanced age, the high number of comorbidities and home therapies, and the inflammatory state were found to be predisposing elements to the development of the disease and its severity.
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