1
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López E, Cabrera R, Lecaros C. Targeted therapy for immune mediated skin diseases. What should a dermatologist know? An Bras Dermatol 2024; 99:546-567. [PMID: 38521706 PMCID: PMC11221168 DOI: 10.1016/j.abd.2023.10.002] [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: 08/25/2023] [Revised: 09/25/2023] [Accepted: 10/14/2023] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Molecularly targeted therapies, such as monoclonal antibodies (mAbs) and Janus Kinase inhibitors (JAKis), have emerged as essential tools in the treatment of dermatological diseases. These therapies modulate the immune system through specific signaling pathways, providing effective alternatives to traditional systemic immunosuppressive agents. This review aims to provide an updated summary of targeted immune therapies for inflammatory skin diseases, considering their pathophysiology, efficacy, dosage, and safety profiles. METHODS The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search was conducted on PubMed over the past 10 years, focusing on randomized clinical trials, case reports, and case series related to targeted immune therapies in dermatology. Eligibility criteria were applied, and data were extracted from each study, including citation data, study design, and results. RESULTS We identified 1360 non-duplicate articles with the initial search strategy. Title and abstract review excluded 1150, while a full-text review excluded an additional 50 articles. The review included 143 studies published between 2012 and 2022, highlighting 39 drugs currently under investigation or in use for managing inflammatory skin diseases. STUDY LIMITATIONS The heterogeneity of summarized information limits this review. Some recommendations originated from data from clinical trials, while others relied on retrospective analyses and small case series. Recommendations will likely be updated as new results emerge. CONCLUSION Targeted therapies have revolutionized the treatment of chronic skin diseases, offering new options for patients unresponsive to standard treatments. Paradoxical reactions are rarely observed. Further studies are needed to fully understand the mechanisms and nature of these therapies. Overall, targeted immune therapies in dermatology represent a promising development, significantly improving the quality of life for patients with chronic inflammatory skin diseases.
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Affiliation(s)
- Edinson López
- Department of Dermatology, Facultad de Medicina Universidad del Desarrollo-Clínica Alemana de Santiago, Santiago, Chile
| | - Raúl Cabrera
- Department of Dermatology, Facultad de Medicina Universidad del Desarrollo-Clínica Alemana de Santiago, Santiago, Chile.
| | - Cristóbal Lecaros
- Department of Dermatology, Facultad de Medicina Universidad del Desarrollo-Clínica Alemana de Santiago, Santiago, Chile
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2
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Wu PC, Lin WC, Wang CW, Chung WH, Chen CB. Cutaneous adverse reactions associated with COVID-19 vaccines: Current evidence and potential immune mechanisms. Clin Immunol 2024; 263:110220. [PMID: 38642783 DOI: 10.1016/j.clim.2024.110220] [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: 09/26/2023] [Revised: 03/04/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
As the number of vaccinated individuals has increased, there have been increasing reports of cutaneous hypersensitivity reactions. The main COVID-19 vaccines administered include messenger ribonucleic acid vaccines, non-replicating viral vector vaccines, inactivated whole-virus vaccines, and protein-based vaccines. These vaccines contain active components such as polyethylene glycol, polysorbate 80, aluminum, tromethamine, and disodium edetate dihydrate. Recent advances in understanding the coordination of inflammatory responses by specific subsets of lymphocytes have led to a new classification based on immune response patterns. We categorize these responses into four patterns: T helper (Th)1-, Th2-, Th17/22-, and Treg-polarized cutaneous inflammation after stimulation of COVID-19 vaccines. Although the association between COVID-19 vaccination and these cutaneous adverse reactions remains controversial, the occurrence of rare dermatoses and their short intervals suggest a possible relationship. Despite the potential adverse reactions, the administration of COVID-19 vaccines is crucial in the ongoing battle against severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Po-Chien Wu
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wan-Chen Lin
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan; Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan; Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan; Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, 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
| | - Chun-Bing Chen
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan; Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan; Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
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3
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Valido K, Patel V, Murphy MJ, Junejo MH, Patel DK, Deutsch A, Turner N, Zaki TD, King B, Damsky W, Nelson CA. Treatment of prolonged drug reaction with eosinophilia and systemic symptoms syndrome with dupilumab using a molecularly-guided approach. JAAD Case Rep 2024; 48:49-53. [PMID: 38774671 PMCID: PMC11107093 DOI: 10.1016/j.jdcr.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024] Open
Affiliation(s)
- Kailyn Valido
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Vandan Patel
- Department of Dermatology, Hackensack Meridian Health Palisades Medical Center, North Bergen, New Jersey
| | - Michael J. Murphy
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Muhammad H. Junejo
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Devisha K. Patel
- Department of Internal Medicine, Northwell Health Lenox Hill Hospital, New York, New York
| | - Alana Deutsch
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Noel Turner
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Theodore D. Zaki
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Brett King
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Caroline A. Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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4
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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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5
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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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6
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Zhu X, Luo G, Zheng L. Update on HLA-B*15:02 allele associated with adverse drug reactions. Pharmacogenomics 2024; 25:97-111. [PMID: 38305022 DOI: 10.2217/pgs-2023-0173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
HLA alleles, part of the major histocompatibility complex, are strongly associated with adverse drug reactions (ADRs). This review focuses on HLA-B*15:02 and explores its association with ADRs in various ethnic populations and with different drugs, aiming to provide insights into the safe clinical use of drugs and minimize the occurrence of ADRs. Furthermore, the review explores the potential mechanisms by which HLA-B*15:02 may be associated with ADRs, aiming to gain new insights into drug modification and identification of haptens. In addition, it analyzes the frequency of the HLA-B*15:02, genotyping methods, cost-effectiveness and treatment measures for adverse reactions, thereby providing a theoretical basis for formulating clinical treatment plans.
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Affiliation(s)
- Xueting Zhu
- Clinical Medical Research Center, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Guanghua Luo
- Clinical Medical Research Center, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Lu Zheng
- Clinical Medical Research Center, The Third Affiliated Hospital of Soochow University, Changzhou, China
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7
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Jones K, Morgan AP, Whang A, Feeney CD. Fever, Rash, and Abdominal Pain in a 12-year-old Boy. Pediatr Rev 2023; 44:S9-S13. [PMID: 37777231 DOI: 10.1542/pir.2022-005805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
| | | | | | - Colby D Feeney
- Duke University Hospital, Durham, NC
- Departments of Medicine and Pediatrics, Duke University School of Medicine, Durham, NC
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8
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Dagnon da Silva M, Domingues SM, Oluic S, Radovanovic M, Kodela P, Nordin T, Paulson MR, Joksimović B, Adetimehin O, Singh D, Madrid C, Cardozo M, Baralic M, Dumic I. Renal Manifestations of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome: A Systematic Review of 71 Cases. J Clin Med 2023; 12:4576. [PMID: 37510691 PMCID: PMC10380880 DOI: 10.3390/jcm12144576] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/30/2023] Open
Abstract
Unlike other adverse drug reactions, visceral organ involvement is a prominent feature of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and correlates with mortality. The aim of this study was to systematically review cases published in PubMed-indexed, peer-reviewed journals in which patients had renal injury during the episode of DRESS syndrome (DS). We found 71 cases, of which 67 were adults and 56% were males. Female sex was associated with higher mortality. Chronic kidney disease (CKD) was present in 14% of patients who developed acute kidney injury (AKI) during DS. In 21% of cases, the kidneys were the only visceral organ involved, while 54% of patients had both liver and kidney involvement. Eosinophilia was absent in 24% of patients. The most common classes of medication associated with renal injury in DS were antibiotics in 34%, xanthine oxidase inhibitors in 15%, and anticonvulsants in 11%. Among antibiotics, vancomycin was the most common culprit in 68% of patients. AKI was the most common renal manifestation reported in 96% of cases, while isolated proteinuria or hematuria was present in only 4% of cases. In cases with AKI, 88% had isolated increase in creatinine and decrease in glomerular filtration (GFR), 27% had AKI concomitantly with proteinuria, 18% had oliguria, and 13% had concomitant AKI with hematuria. Anuria was the rarest manifestation, occurring in only 4% of patients with DS. Temporary renal replacement therapy was needed in 30% of cases, and all but one patient fully recovered renal function. Mortality of DS in this cohort was 13%, which is higher than previously reported. Medication class, latency period, or pre-existing CKD were not found to be associated with higher mortality. More research, particularly prospective studies, is needed to better recognize the risks associated with renal injury in patients with DS. The development of disease-specific biomarkers would also be useful so DS with renal involvement can be easier distinguished from other eosinophilic diseases that might affect the kidney.
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Affiliation(s)
| | | | - Stevan Oluic
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL 60402, USA
| | - Milan Radovanovic
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | | | - Terri Nordin
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Family Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Margaret R Paulson
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Bojan Joksimović
- Faculty of Medicine Foca, University of East Sarajevo, 73300 Foca, The Republic of Srpska, Bosnia and Herzegovina
| | - Omobolanle Adetimehin
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Devender Singh
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Nephrology, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Cristian Madrid
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Milena Cardozo
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Marko Baralic
- Department of Nephrology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Igor Dumic
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
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9
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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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10
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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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11
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Hypersensitivity to Biological Treatments in Juvenile Idiopathic Arthritis: How Should It Be Managed? J Clin Med 2022; 11:jcm11247291. [PMID: 36555908 PMCID: PMC9785630 DOI: 10.3390/jcm11247291] [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: 09/29/2022] [Revised: 12/06/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is one of the most frequent diseases in the practice of pediatric rheumatology. JIA treatments have been modified and improved with the use of biological drugs along with technological innovations. However, different types of hypersensitivity reactions to biological drugs have also been reported. Anaphylaxis and infusion reactions occurring during the intravenous infusion require a critical approach in the acute period. On the other hand, the detection of drug-related late-type reactions and the development of antibodies to the agent highlight the need for an understanding of the drug-induced etiology to prevent the patient from continuing the treatment with the culprit drug. The chronic disease process, concomitant immune dysregulation, and multiple drug use may result in these hypersensitivity reactions. In this review, the hypersensitivity reactions to the biological treatments used in patients with juvenile idiopathic arthritis and the management of these conditions are discussed.
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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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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: 27] [Impact Index Per Article: 13.5] [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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Jacobs I, Ceulemans M, Wauters L, Breynaert C, Vermeire S, Verstockt B, Vanuytsel T. Role of Eosinophils in Intestinal Inflammation and Fibrosis in Inflammatory Bowel Disease: An Overlooked Villain? Front Immunol 2021; 12:754413. [PMID: 34737752 PMCID: PMC8560962 DOI: 10.3389/fimmu.2021.754413] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/30/2021] [Indexed: 12/20/2022] Open
Abstract
Eosinophils are leukocytes which reside in the gastrointestinal tract under homeostatic conditions, except for the esophagus which is normally devoid of eosinophils. Research on eosinophils has primarily focused on anti-helminth responses and type 2 immune disorders. In contrast, the search for a role of eosinophils in chronic intestinal inflammation and fibrosis has been limited. With a shift in research focus from adaptive to innate immunity and the fact that the eosinophilic granules are filled with inflammatory mediators, eosinophils are becoming a point of interest in inflammatory bowel diseases. In the current review we summarize eosinophil characteristics and recruitment as well as the current knowledge on presence, inflammatory and pro-fibrotic functions of eosinophils in inflammatory bowel disease and other chronic inflammatory conditions, and we identify research gaps which should be covered in the future.
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Affiliation(s)
- Inge Jacobs
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Matthias Ceulemans
- Department of Chronic Diseases and Metabolism, Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lucas Wauters
- Department of Chronic Diseases and Metabolism, Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Christine Breynaert
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of General Internal Medicine, Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Chronic Diseases and Metabolism, Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Bram Verstockt
- Department of Chronic Diseases and Metabolism, Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Department of Chronic Diseases and Metabolism, Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Majeed U, Puiu T, Sluzevich J, Reynolds G, Acampora M, Moreno-Aspitia A, Bodiford KJ, Advani P. Case Report: Alpelisib-Induced Drug Reaction With Eosinophilia and Systemic Symptoms: A Rare Manifestation of a Common Side Effect. Front Oncol 2021; 11:726785. [PMID: 34504802 PMCID: PMC8421674 DOI: 10.3389/fonc.2021.726785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022] Open
Abstract
Alpelisib is a PIK3a inhibitor approved for the treatment of metastatic ER+ breast cancer in combination with fulvestrant. Although rash is a common side effect of this medication, we present the first case of drug reaction with eosinophilia and systemic symptoms (DRESS) upon initial exposure to alpelisib. Here we describe the clinical-pathological findings and management of our patient with alpelisib-induced life-threatening DRESS syndrome. The goal of this case report is to highlight association of alpelisib with DRESS syndrome, in clinical practice, so that alpelisib can be immediately stopped and treatment for this serious condition promptly initiated.
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Affiliation(s)
- Umair Majeed
- Division of Hematology Oncology, Mayo Clinic Florida, Jacksonville, FL, United States
| | - Tudor Puiu
- Division of Dermatology, Mayo Clinic Florida, Jacksonville, FL, United States
| | - Jason Sluzevich
- Division of Dermatology, Mayo Clinic Florida, Jacksonville, FL, United States
| | - Gina Reynolds
- Division of Hematology Oncology, Mayo Clinic Florida, Jacksonville, FL, United States
| | - Marites Acampora
- Division of Hematology Oncology, Mayo Clinic Florida, Jacksonville, FL, United States
| | - Alvaro Moreno-Aspitia
- Division of Hematology Oncology, Mayo Clinic Florida, Jacksonville, FL, United States
| | | | - Pooja Advani
- Division of Hematology Oncology, Mayo Clinic Florida, Jacksonville, FL, United States
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Janus kinase inhibitors in dermatology: Part I. A comprehensive review. J Am Acad Dermatol 2021; 86:406-413. [PMID: 34246698 DOI: 10.1016/j.jaad.2021.07.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 01/12/2023]
Abstract
The Janus kinase-signal transducer and activator of transcription (JAK-STAT) intracellular signaling pathway is utilized by many proinflammatory molecules to mediate downstream effects and activate gene transcription. Activation of the JAK-STAT pathway contributes to a number of inflammatory dermatoses. Clinical trials and smaller studies have demonstrated the efficacy of JAK inhibitors in the treatment of a variety of dermatologic conditions. Here, we review the use of JAK inhibitors for the treatment of a wide range of dermatologic diseases in a two-part review series.
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De La Cruz AC, Ashraf S, Shrestha N, Saad M. Myocarditis and Drug Rash With Eosinophilia and Systemic Symptoms Syndrome: A Deadly Combination. Cureus 2021; 13:e13496. [PMID: 33777581 PMCID: PMC7990470 DOI: 10.7759/cureus.13496] [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] [Indexed: 11/05/2022] Open
Abstract
DRESS syndrome (Drug Rash with Eosinophilia and Systemic Symptoms) is a severe delayed type IV hypersensitivity drug reaction by T helper cell 2 (Th2) and Interleukin 5 (IL-5) resulting in activation of eosinophils. It is mostly reported with antiepileptic drugs (AEDs), antibiotics, and allopurinol. Here, we present the second case of myocarditis secondary to DRESS syndrome caused by amoxicillin. Most of the case reports present with cross-reactivity among the anticonvulsants and beta-lactams, which is also rarely been reported. Amoxicillin could reactivate human herpesvirus 6 (HHV 6) and Epstein-Barr virus (EBV) with a presentation similar to DRESS syndrome, but our patient was neither taking the anticonvulsants nor have any viral infection in the recent past. His RegiSCAR score was 6, consistent with definite DRESS syndrome. Management includes identification and prompt withdrawal of the offending drug and supportive care for patients without severe organ involvement and systemic corticosteroids for patients with severe organ involvement.
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Affiliation(s)
| | - Shoaib Ashraf
- Internal Medicine, Bronx Care Health System, Bronx, USA
| | | | - Muhammad Saad
- General Internal Medicine, Bronx Care Health System, Bronx, USA
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Drug Reaction with Eosinophilia and Systemic Symptoms: A Complex Interplay between Drug, T Cells, and Herpesviridae. Int J Mol Sci 2021; 22:ijms22031127. [PMID: 33498771 PMCID: PMC7865935 DOI: 10.3390/ijms22031127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 12/14/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, also known as drug induced hypersensitivity (DiHS) syndrome is a severe delayed hypersensitivity reaction with potentially fatal consequences. Whilst recognised as T cell-mediated, our understanding of the immunopathogenesis of this syndrome remains incomplete. Here, we discuss models of DRESS, including the role of human leukocyte antigen (HLA) and how observations derived from new molecular techniques adopted in key studies have informed our mechanism-based understanding of the central role of Herpesviridae reactivation and heterologous immunity in these disorders.
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Abstract
PURPOSE OF REVIEW To provide updates on recent advances in the diagnosis and management of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. RECENT FINDINGS The number of identified HLA allele associations with DRESS continues to grow. There is increasing evidence indicating viral infection, reactivation, and cross-reactivity may play key roles in disease. Translational work illuminated JAK/STAT activation in recalcitrant disease. There is expanding recognition of rapid-onset DRESS resulting from specific drugs. SUMMARY DRESS is a severe form of adverse drug reaction with potential for significant morbidity and mortality. Recent research advances may improve clinical care. HLA screening can now be performed to prevent disease in susceptible patients and may help identify culprit drugs in the near future. Viral testing should be performed on every patient, and if positive, patients potentially treated with antiviral therapy. JAK inhibitors may be an effective treatment option for DRESS. Early onset of disease relative to drug exposure should not exclude the diagnosis of DRESS.
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Damsky W, Peterson D, Ramseier J, Al-Bawardy B, Chun H, Proctor D, Strand V, Flavell RA, King B. The emerging role of Janus kinase inhibitors in the treatment of autoimmune and inflammatory diseases. J Allergy Clin Immunol 2020; 147:814-826. [PMID: 33129886 DOI: 10.1016/j.jaci.2020.10.022] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 12/26/2022]
Abstract
Autoimmune and inflammatory diseases are common and diverse, and they can affect nearly any organ system. Much of the pathogenesis of these diseases is related to dysregulated cytokine activity. Historically, autoimmune and inflammatory diseases have been treated with medications that nonspecifically suppress the immune system. mAbs that block the action of pathogenic cytokines emerged 2 decades ago and have become widely useful. More recently, agents that simultaneously block multiple pathogenic cytokines via inhibition of the downstream Janus kinase (JAK)-signal transducer and activator of transcription pathway have emerged and are becoming increasingly important. These small-molecule inhibitors, collectively termed JAK inhibitors, are US Food and Drug Administration-approved in a few autoimmune/inflammatory disorders and are being evaluated in many others. Here, we review the biology of the JAK-signal transducer and activator of transcription pathway and the use of JAK inhibitors to treat autoimmune and inflammatory diseases across medical subspecialties.
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Affiliation(s)
- William Damsky
- Department of Dermatology, Yale University School of Medicine, New Haven, Conn.
| | - Danielle Peterson
- Department of Dermatology, Yale University School of Medicine, New Haven, Conn
| | - Julie Ramseier
- Department of Dermatology, Yale University School of Medicine, New Haven, Conn
| | - Badr Al-Bawardy
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Conn
| | - Hyung Chun
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Conn
| | - Deborah Proctor
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Conn
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University School of Medicine, Palo Alto, Calif
| | - Richard A Flavell
- Department of Immunobiology, Yale University School of Medicine, New Haven, Conn; Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, Conn
| | - Brett King
- Department of Dermatology, Yale University School of Medicine, New Haven, Conn.
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Liu Y, Jiang L. Tofacitinib for treatment in immune-mediated myocarditis: The first reported cases. J Oncol Pharm Pract 2020; 27:1078155220947141. [PMID: 32781887 DOI: 10.1177/1078155220947141] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICI) has demonstrated significant clinical benefit in advanced cancer. Despite favorable benefits, the use of ICI is accompanied by various side effects, which are inflammatory side effects potentially affecting any organ. Among which myocarditis is the most severe and has a relatively high mortality. However, there is no effective treatments, and many patients respond poorly to glucocorticoids and immunosuppressants. Therefore, it is urgent to explore effective treatments. CASES REPORT Here we describe two patients with metastatic cancer who developed immune-mediated myocarditis after receiving anti-programmed cell death protein (PD)-1 antibody. The main clinical manifestations are dyspnea. All patients had an elevation of cardiac enzyme, a variety of atypical electrocardiographic (ECG) abnormalities and preserved left ventricular ejection fraction (LVEF). All our patients underwent cardiac MRI (CMRI) and suggested typical features of myocarditis, including myocardial oedema and delayed enhancement.Management and outcome: All patients were treated promptly with glucocorticoids, followed by other immunosuppressive treatments include plasma exchange and intravenous immunoglobulin (IVIG). However, no significant improvement was observed and we then administered tofacitinib 5 mg twice daily to treat the refractory myocarditis and the elevated levels of pro-inflammatory cytokines. All patients recovered and were discharged. No major adverse reaction was reported during tofacitinib therapy. DISCUSSION To our knowledge, this is the first report in the world of patients with ICI-associated myocarditis treated with oral tofacitinib. Our results can at least provide a new option for clinical treatment of refractory myocarditis or other immune-related adverse events.
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Affiliation(s)
- Yun Liu
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, PR China
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Seree-aphinan C, Assanangkornchai N, Nilmoje T. Prolonged Extracorporeal Membrane Oxygenation Support In a Patient with Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome-associated Fulminant Myocarditis – A Case Report and Literature Review. Heart Int 2020; 14:112-117. [DOI: 10.17925/hi.2020.14.2.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/09/2020] [Indexed: 11/24/2022] Open
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