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Pichler WJ. Delayed drug hypersensitivity reactions: How p-i transforms pharmacology into immunology. Allergol Int 2024:S1323-8930(24)00088-1. [PMID: 39294038 DOI: 10.1016/j.alit.2024.08.006] [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: 07/03/2024] [Revised: 08/09/2024] [Accepted: 08/14/2024] [Indexed: 09/20/2024] Open
Abstract
Delayed drug hypersensitivity reactions (dDHRs) are iatrogenic diseases, which are mostly due to non-covalent interactions of a drug with the immune receptors HLA and/or TCR causing T-cell activation. This is also known as pharmacological interaction with immune receptors or p-i. P-i activation differs from classical antigen-driven immune reactions: a) drug binding induces structural changes in TCR-HLA proteins which make them look like allo-like TCR-HLA-complexes, able to elicit allo-like stimulations of T cells with cytotoxicity and IFNγ production, notably without the involvement of innate immunity; b) drug binding to TCR and/or HLA can increase the affinity of TCR-HLA interactions, which may affect signaling and IL-5 production by CD4+ T cells, and thus contribute to eosinophilia commonly found in dDHRs or induce oligoclonal T cell expansions; c) Both, antigen and p-i stimulations can induce eosinophil- or neutrophil-rich inflammations; but these stimulations should be distinguished as their underlying mechanism and development differ; and d) p-i stimulation can - like graft versus host reactions - result in long-lasting T-cell activations, which can lead to viremia, occasional autoimmunity, or a new syndrome characterized by multiple drug hypersensitivity (MDH). In summary, dDHRs are not allergic reactions but represent peculiar T-cell activations, similar to allo-like stimulations. Understanding and considering the p-i mechanism is needed for preventive measures and optimal treatments of dDHR. In addition, it may help to understand TCR signaling, alloreactivity, and may even open a new way of specific immune stimulations.
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Steininger J, Bauer A, Hasler H, Beissert S, Abraham S. Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) after administration of corticosteroids: Case series and review of literature. Contact Dermatitis 2024; 91:146-151. [PMID: 38769741 DOI: 10.1111/cod.14594] [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: 03/06/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Cutaneous manifestations of drug-induced type IV reactions vary widely, with symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) being a less common presentation. Corticosteroids (CS), primarily known for their anti-inflammatory effects, rarely induce hypersensitivity reactions. OBJECTIVE The aim of this case series is to report four cases of SDRIFE following systemic prednisolone therapy and to review existing CS classification proposals to better understand cross-reactivity of CS. PATIENTS/METHODS Patients recruited at a German dermatology centre underwent allergologic evaluation including prick and patch testing with various CS. Positive cases underwent oral challenge testing with alternative agents. The classification systems of Coopman et al. and Baeck et al. were taken into account. DISCUSSION Despite a paucity of literature, CS-induced type IV reactions do occur, including SDRIFE. Classification systems based on chemical structure provide insight into cross-reactivity patterns. Provocation tests with alternative CS highlight the complexity of managing CS hypersensitivity. CONCLUSION SDRIFE may develop following systemic prednisolone therapy. Classification systems are helpful in understanding cross-reactivity and help in the selection of alternative preparations but are not always reliable. Individualised assessment is crucial for managing CS hypersensitivity, with consideration of alternative agents and emergency use of CS when necessary.
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Affiliation(s)
- Julian Steininger
- Department of Dermatology, University Allergy Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Andrea Bauer
- Department of Dermatology, University Allergy Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Helena Hasler
- Department of Dermatology, University Allergy Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stefan Beissert
- Department of Dermatology, University Allergy Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Susanne Abraham
- Department of Dermatology, University Allergy Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Puccio J, Kirven RM, Kaffenberger BH, Chung C, Korman AM. Toxic Flexural Epidermolysis in hospitalized patients. Arch Dermatol Res 2024; 316:416. [PMID: 38888807 DOI: 10.1007/s00403-024-03160-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/22/2024] [Accepted: 06/05/2024] [Indexed: 06/20/2024]
Affiliation(s)
- Jordyn Puccio
- Ohio State University College of Medicine, Columbus, OH, USA
| | - Rachel M Kirven
- Department of Dermatology, The Ohio State University Wexner Medical Center, 540 Officenter Place, Suite 240, Columbus, OH, 43230, USA
| | - Benjamin H Kaffenberger
- Department of Dermatology, The Ohio State University Wexner Medical Center, 540 Officenter Place, Suite 240, Columbus, OH, 43230, USA
| | - Catherine Chung
- Department of Dermatology, The Ohio State University Wexner Medical Center, 540 Officenter Place, Suite 240, Columbus, OH, 43230, USA
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Abraham M Korman
- Department of Dermatology, The Ohio State University Wexner Medical Center, 540 Officenter Place, Suite 240, Columbus, OH, 43230, USA.
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Chaudet KM, Russell-Goldman E, Horn TD, Schuler AM, Chan MP, Nazarian RM. Characterization of T-Helper Immune Phenotype in Symmetrical Drug-Related Intertriginous and Flexural Exanthema (SDRIFE) Endorses a Delayed-Type Hypersensitivity Reaction. Am J Dermatopathol 2024; 46:71-78. [PMID: 38133537 DOI: 10.1097/dad.0000000000002455] [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: 12/23/2023]
Abstract
ABSTRACT Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a cutaneous drug eruption with a characteristic distribution of erythema on the gluteal/inguinal region and intertriginous areas with unclear pathogenesis. In this study, we aimed to characterize the T-helper immune phenotype in SDRIFE in comparison with psoriasis and eczema to further the understanding of the pathophysiology and immune response of this rare disorder. Immunohistochemical staining was performed on 9 skin biopsies each from SDRIFE, psoriasis, and eczema using immunohistochemistry for CD3 and dual CD4/T-bet, CD4/GATA3, and CD4/RORC to quantify the percentage of Th1, Th2, and Th17 cells, respectively. A significant difference was detected in the average percentage of Th1 between all 3 groups with the highest percentage of Th1 cells seen in psoriasis, followed by SDRIFE and eczema. SDRIFE showed significantly lower Th2 expression as compared to both psoriasis and eczema. There was a trend towards a higher average percentage of Th17 in psoriasis and SDRIFE, and the ratio of Th17:Th2 was significantly higher in samples of SDRIFE compared with both eczema and psoriasis. The findings characterize SDRIFE as a Th1 and possibly Th17-driven process, which could inform future therapeutic options and substantiate the model of SDRIFE as a delayed-type hypersensitivity reaction.
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Affiliation(s)
- Kristine M Chaudet
- Pathologist, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Eleanor Russell-Goldman
- Pathologist, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston MA
| | - Thomas D Horn
- Pathologist, Departments of Dermatology and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; and
| | - Amy M Schuler
- Pathologist, Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - May P Chan
- Pathologist, Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Rosalynn M Nazarian
- Pathologist, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Lyons D, Barry R, Ni Raghallaigh S. Symmetrical drug-related intertriginous and flexural exanthema: a rare and unusual drug eruption. BMJ Case Rep 2024; 17:e258348. [PMID: 38199652 PMCID: PMC10806825 DOI: 10.1136/bcr-2023-258348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
| | - Rory Barry
- Dermatology, Beaumont Hospital, Dublin, Ireland
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KIM EY, AWH KC, LAROCCA CA. Everolimus-induced Symmetrical Drug-related Intertriginous and Flexural Exanthema. Acta Derm Venereol 2023; 103:adv12197. [PMID: 38112207 PMCID: PMC10753590 DOI: 10.2340/actadv.v103.12197] [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: 04/04/2023] [Accepted: 05/30/2023] [Indexed: 12/21/2023] Open
Abstract
Abstract is missing (Short communication)
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Affiliation(s)
- Emily Y. KIM
- Center for Cutaneous Oncology, Dana-Farber Brigham Cancer Center, Boston, MA
| | - Katherine C. AWH
- Center for Cutaneous Oncology, Dana-Farber Brigham Cancer Center, Boston, MA
- Department of Dermatology, Brigham and Women’s Hospital, 41 Louis Pasteur Avenue, Boston MA 02115, USA. E-mail:
| | - Cecilia A. LAROCCA
- Center for Cutaneous Oncology, Dana-Farber Brigham Cancer Center, Boston, MA
- Department of Dermatology, Brigham and Women’s Hospital, 41 Louis Pasteur Avenue, Boston MA 02115, USA. E-mail:
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Caro-Chang LA, Fung MA. The role of eosinophils in the differential diagnosis of inflammatory skin diseases. Hum Pathol 2023; 140:101-128. [PMID: 37003367 DOI: 10.1016/j.humpath.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
Eosinophils are known to be present in inflammatory skin diseases, but their diagnostic utility is not well established. Upon review of the published status of lesional eosinophils, several categories were identified. 1) Lesional eosinophils highly characteristic such that, in their absence, the pathologist may question the diagnosis. These include arthropod bite reactions and scabies, urticarial dermatitis, and other eosinophilic dermatoses. 2) Lesional eosinophils rare or absent, such that, in their presence, the pathologist may question the diagnosis. These include pityriasis lichenoides, graft versus host disease, and connective tissue disorders. 3) Lesional eosinophils variable and, while in some cases expected, are not required for diagnosis. These include drug reactions, atopic dermatitis and allergic contact dermatitis. 4) Lesional eosinophils variable and not expected but may be seen to a limited extent. These include lichen planus and psoriasis.
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Roche D, Murray G, Hackett C, Tobin AM. A flexural exanthem following postexposure prophylaxis. Clin Exp Dermatol 2022; 47:1204-1206. [PMID: 35297086 PMCID: PMC9313790 DOI: 10.1111/ced.15131] [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: 08/10/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Abstract
We report a case of symmetrical drug-related intertriginous and flexural exanthema following antiretroviral postexposure prophylactic medications, tenofovir and emtricitabine, commencement of which preceded the onset of the rash. Tenofovir and emtricitabine are both nucleoside reverse transcriptase inhibitor medications, commonly used to prevent development of AIDS.
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Affiliation(s)
- Darren Roche
- Department of Dermatology, Tallaght University Hospital, Dublin, Ireland
| | - Gregg Murray
- Department of Dermatology, Tallaght University Hospital, Dublin, Ireland
| | - Catriona Hackett
- Department of Dermatology, Tallaght University Hospital, Dublin, Ireland
| | - Anne-Marie Tobin
- Department of Dermatology, Tallaght University Hospital, Dublin, Ireland
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