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Wei BM, Fox LP, Kaffenberger BH, Korman AM, Micheletti RG, Mostaghimi A, Noe MH, Rosenbach M, Shinkai K, Kwah JH, Phillips EJ, Bolognia JL, Damsky W, Nelson CA. Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part I. Epidemiology, pathogenesis, clinicopathological features, and prognosis. J Am Acad Dermatol 2024; 90:885-908. [PMID: 37516359 DOI: 10.1016/j.jaad.2023.02.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/11/2023] [Accepted: 02/26/2023] [Indexed: 07/31/2023]
Abstract
Drug-induced hypersensitivity syndrome (DiHS), also known as drug reaction with eosinophilia and systemic symptoms (DRESS), is a severe cutaneous adverse reaction (SCAR) characterized by an exanthem, fever, and hematologic and visceral organ involvement. Anticonvulsants, antibiotics, and allopurinol are the most common triggers. The pathogenesis involves a complex interplay between drugs, viruses, and the immune system primarily mediated by T-cells. DiHS/DRESS typically presents with a morbilliform eruption 2-6 weeks after drug exposure, and is associated with significant morbidity, mortality, and risk of relapse. Long-term sequelae primarily relate to organ dysfunction and autoimmune diseases. Part I of this continuing medical education activity on DiHS/DRESS provides an update on epidemiology, novel insights into pathogenesis, and a description of clinicopathological features and prognosis.
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Affiliation(s)
- Brian M Wei
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | | | - Abraham M Korman
- Department of Dermatology, The Ohio State University, Columbus, Ohio
| | - Robert G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arash Mostaghimi
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Megan H Noe
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, California
| | - Jason H Kwah
- Department of Medicine, Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jean L Bolognia
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut; Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Caroline A Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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Ansah R, Arkoh EA, Quao BO, Groger M. Lack of Suspicion of Dapsone Hypersensitivity Syndrome in a Leprosy Patient: Case Report with Fatal Outcome. Res Rep Trop Med 2023; 14:135-139. [PMID: 38170098 PMCID: PMC10759403 DOI: 10.2147/rrtm.s434947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
Background Dapsone is an antibiotic used in the management of leprosy. Following the worldwide adoption of the dapsone-containing multidrug therapy for treating leprosy, an upsurge in the reported frequency of dapsone hypersensitivity syndrome (DHS) has been observed. DHS is associated with a high fatality rate among patients from low-resourced settings and patients with syndrome-associated hepatitis. Case Presentation This is a case of a Ghanaian male who, while being treated for leprosy with the multidrug therapy, developed exfoliative dermatitis and signs of liver damage, 6 weeks after treatment initiation. He was managed for dapsone-related exfoliative dermatitis and infectious causes of liver damage were investigated. However, the patient's condition rapidly deteriorated with a fatal outcome despite discontinuation of dapsone. DHS was only considered as a differential diagnosis postmortem. Conclusion This case highlights the importance of having a high index of suspicion for DHS in all patients on dapsone and the need for a thorough workup for all leprosy patients who present with exfoliative dermatitis and signs of liver involvement within the latency period of the syndrome, especially in low resource settings. Furthermore, it stresses the need for prompt and appropriate treatment as DHS can quickly become fatal in such settings.
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Affiliation(s)
- Ruth Ansah
- Center of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and I. Department of Internal Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Benedict Okoe Quao
- Ankaful Leprosy / General Hospital, Ankaful, Central Region, Ghana
- National Leprosy Control Program, Ghana Health Service, Accra, Ghana
| | - Mirjam Groger
- Center of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and I. Department of Internal Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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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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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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