1
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Liu Y, Wang D, Wu S, Liu X, Xiao C. Literature review of the clinical features of sulfasalazine-induced drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome (DRESS/DIHS). Front Pharmacol 2024; 15:1488483. [PMID: 39687296 PMCID: PMC11646734 DOI: 10.3389/fphar.2024.1488483] [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: 08/30/2024] [Accepted: 11/18/2024] [Indexed: 12/18/2024] Open
Abstract
Background Sulfasalazine (SSZ) is commonly prescribed for the treatment of ulcerative colitis, rheumatoid arthritis, and ankylosing spondylitis. However, it can also trigger a severe drug reaction known as Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) or Drug-Induced Hypersensitivity Syndrome (DIHS). This article aims to analyze the clinical characteristics of DRESS/DIHS induced by SSZ and provide evidence for clinical diagnosis, treatment, and prevention. Methods We gathered relevant literature on SSZ-induced DRESS/DIHS published from 1 January 2005, to 21 July 2024, by searching both English and Chinese databases. Results Thirty-nine patients (15 males and 24 females) were included in the study, with a median age of 47 years (range: 11-82 years). Following SSZ administration, the median onset time of DRESS/DIHS was 28 days (range: 10-60 days). These patients exhibited clinical symptoms such as fever (100%), rash (100%), digestive system responses (38.5%), and edema (35.9%). Organ involvement was observed in 38 patients, with commonly affected organs being lymph nodes (78.9%), liver (94.7%), kidney (15.8%), heart (13.2%), and lung (7.9%). All patients had hematological abnormalities, primarily eosinophilia (69.2%) and atypical lymphocytosis (35.9%). Additional hematological changes included agranulocytosis (5.1%), hemophagocytic syndrome (5.1%), and pancytopenia (2.6%). Virus reactivation occurred in 21 patients (53.8%). The primary treatment for DRESS/DIHS due to SSZ is the immediate cessation of the drug, followed by systemic corticosteroid administration. Alternative treatments such as cyclosporine, intravenous immunoglobulin (IVIG), mycophenolate mofetil, cyclophosphamide, and rituximab require further investigation to establish their efficacy. Conclusion SSZ may lead to DRESS/DIHS. To make a conclusive diagnosis, healthcare providers should conduct a thorough assessment by examining the patient's clinical presentation, conducting physical evaluations, and analyzing laboratory findings. Immediate discontinuation of SSZ is recommended, and corticosteroids are often considered an efficacious treatment for DRESS/DIHS.
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Affiliation(s)
- Ya Liu
- Department of Clinical Pharmacy, Xiangtan Central Hospital (The Affiliated Hospital of Hunan University), Xiangtan, China
| | - Danxia Wang
- Department of Pharmacy, People’s Hospital of Ningxiang City, Hunan University of Chinese Medicine, Changsha, China
| | - Shiwei Wu
- Department of Clinical Pharmacy, Xiangtan Central Hospital (The Affiliated Hospital of Hunan University), Xiangtan, China
| | - Xiang Liu
- Department of Clinical Pharmacy, Xiangtan Central Hospital (The Affiliated Hospital of Hunan University), Xiangtan, China
| | - Can Xiao
- Department of Clinical Pharmacy, Xiangtan Central Hospital (The Affiliated Hospital of Hunan University), Xiangtan, China
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2
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Thomson P, Fragkas N, Kafu LM, Aithal GP, Lucena MI, Terracciano L, Meng X, Pirmohamed M, Brees D, Kullak‐Ublick GA, Odermatt A, Hammond T, Kammüller M, Naisbitt DJ. Patients with naproxen-induced liver injury display T-cell memory responses toward an oxidative (S)-O-desmethyl naproxen metabolite but not the acyl glucuronide. Allergy 2024; 79:200-214. [PMID: 37515456 PMCID: PMC10952231 DOI: 10.1111/all.15830] [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] [Received: 03/24/2023] [Revised: 05/30/2023] [Accepted: 06/13/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Exposure to nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (IBU) and naproxen (NAP) is associated with idiosyncratic drug-induced liver injury (DILI). Carboxylate bioactivation into reactive metabolites (e.g., acyl glucuronides, AG) and resulting T-cell activation is hypothesized as causal for this adverse event. However, conclusive evidence supporting this is lacking. METHODS In this work, we identify CD4+ and CD8+ T-cell hepatic infiltration in a biopsy from an IBU DILI patient. Lymphocyte transformation test and IFN-γ ELIspot, conducted on peripheral blood mononuclear cells (PBMCs) of patients with NAP-DILI, were used to explore drug-specific T-cell activation. T-cell clones (TCC) were generated and tested for drug specificity, phenotype/function, and pathways of T-cell activation. Cells were exposed to NAP, its oxidative metabolite 6-O-desmethyl NAP (DM-NAP), its AG or synthesized NAP-AG human-serum albumin adducts (NAP-AG adduct). RESULTS CD4+ and CD8+ T-cells from patients expressing a range of different Vβ receptors were stimulated to proliferate and secrete IFN-γ and IL-22 when exposed to DM-NAP, but not NAP, NAP-AG or the NAP-AG adduct. Activation of the CD4+ TCC was HLA-DQ-restricted and dependent on antigen presenting cells (APC); most TCC were activated with DM-NAP-pulsed APC, while fixation of APC blocked the T-cell response. Cross-reactivity was not observed with structurally-related drugs. CONCLUSION Our results confirm hepatic T-cell infiltrations in NSAID-induced DILI, and show a T-cell memory response toward DM-NAP indicating an immune-mediated basis for the adverse event. Whilst bioactivation at the carboxylate group is widely hypothesized to be pathogenic for NSAID associated DILI, we found no evidence of this with NAP.
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Affiliation(s)
- Paul Thomson
- Molecular& Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
| | - Nik Fragkas
- Novartis Institutes for BioMedical ResearchBaselSwitzerland
| | - Laila M. Kafu
- Molecular& Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
| | - Guruprasad P. Aithal
- NIHR Nottingham Biomedical Research Centre and Nottingham Digestive Diseases Centre, Translational Medical Sciences, West Block, Queen's Medical CentreUniversity of NottinghamNottinghamUK
| | - M. Isabel Lucena
- Unidad de Gestión Clínica de Aparato Digestivo y Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga‐IBIMA, Hospital Universitario Virgen de la VictoriaUniversidad de Málaga, CIBERehdMalagaSpain
| | | | - Xiaoli Meng
- Molecular& Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
| | - Munir Pirmohamed
- Molecular& Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
| | | | - Gerd A. Kullak‐Ublick
- University Hospital ZurichUniversity of ZurichZurichSwitzerland
- Novartis Global Drug DevelopmentBaselSwitzerland
| | - Alex Odermatt
- Division of Molecular & Systems Toxicology, Department of Pharmaceutical SciencesUniversity of BaselBaselSwitzerland
| | - Thomas Hammond
- Division of Molecular & Systems Toxicology, Department of Pharmaceutical SciencesUniversity of BaselBaselSwitzerland
- Oncology Safety, Clinical Pharmacology and Safety Sciences R&DCambridgeUK
| | | | - Dean J. Naisbitt
- Molecular& Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
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3
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Pichler WJ, Thoo L, Yerly D. Drug hypersensitivity and eosinophilia: The decisive role of p-i stimulation. Allergy 2023; 78:2596-2605. [PMID: 37395496 DOI: 10.1111/all.15795] [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: 03/29/2023] [Revised: 05/31/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
Eosinophilia is a common finding in drug hypersensitivity reactions (DHR). Its cause is unclear, as neither antigen/allergen-driven inflammation nor clonal expansion is involved. Most delayed-DHRs are due to p-i (pharmacologic interaction of drugs with immune receptors). These are off-target activities of drugs with immune receptors that result in various types of T-cell stimulation, some of which involve excessive IL-5 production. Functional and phenotypic studies of T-cell clones and their TCR-transfected hybridoma cell lines revealed that some p-i-induced drug stimulations occur without CD4/ CD8 co-receptor engagement. The CD4/CD8 co-receptors link Lck (lymphocyte-specific protein tyrosine kinase) and LAT (linker for activation of T cells) to the TCR. Alteration of Lck or LAT can result in a TCR signalosome with enhanced IL-5 production. Thus, if a more affine TCR-[drug/peptide/HLA] interaction allows bypassing the CD4 co-receptor, a modified Lck/LAT activation may lead to a TCR signalosome with elevated IL-5 production. This "IL-5-TCR-signalosome" hypothesis could also explain eosinophilia in superantigen or allo-stimulation (graft-versus-host disease), in which evasion of CD4/CD8 co-receptors has also been described. It may open new therapeutic possibilities in certain eosinophilic diseases by directly targeting the IL-5-TCR signalosome.
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4
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Wang M, Tang L. Vancomycin-induced elevation of liver enzyme levels in a 3-year-old boy with bacterial meningitis: A pediatric case report. J Am Pharm Assoc (2003) 2023; 63:1242-1244. [PMID: 37028760 DOI: 10.1016/j.japh.2023.03.013] [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: 02/07/2023] [Revised: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Vancomycin as a glycopeptide antibiotic agent plays a vital role in the treatment of gram-positive bacterial infections, especially methicillin-resistant Staphylococcus aureus. Vancomycin-induced liver disease is rarely reported previously; isolated cases have been reported only in adults and none in children except in a 3-month-old girl published in a Chinese journal. CASE SUMMARY A 3-year-old boy received vancomycin for the treatment of bacterial meningitis for more than 3 weeks. The baseline liver enzyme levels of alanine aminotransferase (ALT) (12 U/L), aspartate aminotransferase (AST) (18 U/L), and gamma-glutamyl transferase (GGT) (26 U/L) were obtained after administering vancomycin for 2 days. Liver enzyme levels of ALT (191 U/L), AST (175 U/L), and GGT (92 U/L) were obviously elevated after administering vancomycin for 22 days; this elevation was reversed after vancomycin discontinuation. This case suggested that regular examination of liver function is necessary for all individuals who initiated vancomycin. PRACTICE IMPLICATIONS This is a rarely known case of vancomycin-induced elevation of ALT and AST and the first reported case of vancomycin causing GGT elevation in children, which suggested that regular examination of liver function is required during the use of vancomycin in children and could help avoid progressive liver injury. This case adds to the limited number of reports on vancomycin-induced liver disease.
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5
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Pichler WJ, Brüggen MC. Viral infections and drug hypersensitivity. Allergy 2023; 78:60-70. [PMID: 36264263 DOI: 10.1111/all.15558] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/24/2022] [Accepted: 10/14/2022] [Indexed: 12/30/2022]
Abstract
Virus infections and T-cell-mediated drug hypersensitivity reactions (DHR) can influence each other. In most instances, systemic virus infections appear first. They may prime the reactivity to drugs in two ways: First, by virus-induced second signals: certain drugs like β-lactam antibiotics are haptens and covalently bind to various soluble and tissue proteins, thereby forming novel antigens. Under homeostatic conditions, these neo-antigens do not induce an immune reaction, probably because co-stimulation is missing. During a virus infection, the hapten-modified peptides are presented in an immune-stimulatory environment with co-stimulation. A drug-specific immune reaction may develop and manifest as exanthema. Second, by increased pharmacological interactions with immune receptors (p-i): drugs tend to bind to proteins and may even bind to immune receptors. Without viral infections, this low affine binding may be insufficient to elicit T-cell activation. During a viral infection, immune receptors are more abundantly expressed and allow more interactions to occur. This increases the overall avidity of p-i reactions and may even be sufficient for T-cell activation and symptoms. There is a situation where the virus-DHR sequence of events is inversed: in drug reaction with eosinophilia and systemic symptoms (DRESS), a severe DHR can precede reactivation and viremia of various herpes viruses. One could explain this phenomenon by the massive p-i mediated immune stimulation during acute DRESS, which coincidentally activates many herpes virus-specific T cells. Through p-i stimulation, they develop a cytotoxic activity by killing herpes peptide-expressing cells and releasing herpes viruses. These concepts could explain the often transient nature of DHR occurring during viral infections and the often asymptomatic herpes-virus viraemia after DRESS.
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Affiliation(s)
| | - Marie-Charlotte Brüggen
- Allergy Unit, Department of Dermatology, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University Zürich, Zürich, Switzerland.,Christine Kühne - Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
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6
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Chung KB, Hwang JH, Kim D. A Case of Vancomycin-Induced Drug Reaction with Eosinophilia, Systemic Symptoms and Multiorgan Involvement Proven Using Lymphocyte Transformation Test. Ann Dermatol 2023; 35:140-145. [PMID: 37041708 PMCID: PMC10112376 DOI: 10.5021/ad.20.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/03/2021] [Accepted: 02/20/2021] [Indexed: 03/16/2023] Open
Abstract
Drug-induced hypersensitivity syndrome (DiHS), also referred to as drug reaction with eosinophilia and systemic symptoms (DRESS), is a rare but potentially life-threatening condition induced by drug hypersensitivity that leads to significant morbidity and mortality and often occurs in patients undergoing combination antibiotic therapy. Due to a recent increase in the incidence of methicillin-resistant Staphylococcus aureus infections, the occurrence of vancomycin-induced DiHS/DRESS has increased rapidly. However, because of insufficient pharmacogenetic data on vancomycin-induced drug eruptions in Asians coupled with the risk of re-eliciting the symptoms by provocation tests, confirmation of the culprit drug in vancomycin-induced DiHS/DRESS is often challenging. Here, we report a case of vancomycin-induced DiHS/DRESS, where the causal relationship was confirmed using a lymphocyte transformation test (LTT). A 51-year-old woman was treated with combination antibiotics, including vancomycin, for infective pericarditis. The patient subsequently developed fever, facial edema, generalized rash followed by multiple internal organ involvement, including the kidney, lung, liver, and heart. Thus, based on the International Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) criteria, the case was diagnosed as 'definite' DiHS/DRESS, although the culprit drug was obscured by combination antibiotic therapy. The LTT confirmed that vancomycin, but not other glycopeptide antibiotics, specifically induced T-cell proliferation in this case. Collectively, our case suggests that clinicians can utilize LTT to identify the causative medication of DiHS/DRESS when the clinical information is limited to defining the culprit drug.
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Affiliation(s)
- Kyung Bae Chung
- Department of Dermatology and Cutaneous Biology Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Hye Hwang
- Department of Dermatology and Cutaneous Biology Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Doyoung Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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7
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Beas R, Montrose J, Montalvan-Sanchez E, Baek JJ, Alkashash AM, Ghabril M. Acute Liver Injury in the setting of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome with Cocaine as suspected culprit agent: A case report. Clin Res Hepatol Gastroenterol 2022; 46:102023. [PMID: 36126865 DOI: 10.1016/j.clinre.2022.102023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 02/05/2023]
Abstract
Drug Reaction with Eosinophilia and Systemic Response (DRESS) syndrome is a rare hypersensitivity reaction characterized by rash, fever, lymphadenopathy, and visceral involvement. The liver is frequently involved in DRESS, with increased liver enzymes and hepatomegaly. Over 40 drugs have been implicated in the induction of DRESS, however other illicit substances have also been linked to this. Prompt identification of this syndrome is imperative for management. We report the case of patient presenting with acute liver injury and eosinophilia, who developed a rash meeting criterion for DRESS, with Cocaine as the suspected culprit agent, and was successfully treated with conservative measures.
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Affiliation(s)
- Renato Beas
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Jonathan Montrose
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | | | - James Jaewoo Baek
- Indiana University School of Medicine, Indianapolis, IN, United States
| | | | - Marwan Ghabril
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States; Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States.
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8
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Sato H, Takase K, Harada A, Ozono I, Kodama Y, Ishitobi T, Imada T, Ohnuma H, Kin S. Atypical, Levetiracetam-induced Hypersensitivity Syndrome Complicated by Fulminant Liver Failure in a Patient Undergoing Hemodialysis. Intern Med 2022; 61:2911-2916. [PMID: 35228427 PMCID: PMC9593156 DOI: 10.2169/internalmedicine.8985-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A 59-year-old man undergoing hemodialysis was administered levetiracetam, after which he developed a systemic rash, high fever, severe liver dysfunction, and leukocytopenia with reactivation of human herpes virus 6. Atypical drug-induced hypersensitivity (DIHS) was diagnosed, and prednisolone was administered at 60 mg/day. However, liver failure rapidly progressed, and the patient died 12 days following treatment. Despite the rarity of DIHS with concomitant fulminant liver failure from levetiracetam and sufficient clearance thereof by hemodialysis, our case suggests that this syndrome may still ensue, resulting in mortality, even in hemodialysis patients. Although no treatment has yet been established, strict monitoring and aggressive treatment may be required.
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Affiliation(s)
- Hirotaka Sato
- Department of Nephrology, Shimane Prefectural Central Hospital, Japan
| | - Kentaro Takase
- Department of Nephrology, Shimane Prefectural Central Hospital, Japan
| | - Aiko Harada
- Department of General Medicine, Shimane Prefectural Central Hospital, Japan
| | - Iori Ozono
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Japan
| | - Yasuhide Kodama
- Department of Gastroenterology, Shimane Prefectural Central Hospital, Japan
| | - Tomoko Ishitobi
- Department of Dermatology, Shimane Prefectural Central Hospital, Japan
| | - Toshihiro Imada
- Department of General Medicine, Shimane Prefectural Central Hospital, Japan
| | - Hideyuki Ohnuma
- Department of Pathology, Shimane Prefectural Central Hospital, Japan
| | - Seikon Kin
- Department of Nephrology, Shimane Prefectural Central Hospital, Japan
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9
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Chen DH, Zhou HR, Zhang YG, Shen GY, Xu C, Guan CL. Drug hypersensitivity syndrome induced by sulfasalazine: A case report. Medicine (Baltimore) 2022; 101:e30060. [PMID: 35984191 PMCID: PMC9388030 DOI: 10.1097/md.0000000000030060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Drug hypersensitivity syndrome (DHS) induced by sulfasalazine is a serious systemic delayed adverse drug reaction, which is associated with significant morbidity and mortality. PATIENT CONCERNS A 52-year-old man was hospitalized for developing a rash after 3 weeks of sulfasalazine treatment for ulcerative colitis (UC). DIAGNOSIS The patient was diagnosed with DHS based on his drug history, clinical manifestations, and laboratory test results. INTERVENTIONS The patient was administered intravenous glucocorticoids. The patient's condition improved after treatment with human immunoglobulin and antihistamines. OUTCOMES Combination therapy of glucocorticoid and gamma globulin, the whole-body pruritus disappeared, and no new rash appeared. The whole-body rash subsided or turned dark red. CONCLUSION This article describes the diagnosis and treatment process of a case of sulfasalazine-induced DHS and reviews the relevant literature to improve clinician understanding and avoid misdiagnosis and missed diagnosis.
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Affiliation(s)
- Dong-Hui Chen
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Hai-Rong Zhou
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Yong-Gang Zhang
- Department of Clinical Laboratory, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Guan-Yuan Shen
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Chong Xu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
- * Correspondence: Chun-Li Guan and Chong Xu, Department of General Practice, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, China (e-mail: , )
| | - Chun-Li Guan
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
- * Correspondence: Chun-Li Guan and Chong Xu, Department of General Practice, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, China (e-mail: , )
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10
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Sim DW, Yu J, Koh YI. Efficacy of add-on therapy with intravenous immunoglobulin in steroid hyporesponsive DRESS syndrome. Clin Transl Sci 2021; 15:782-788. [PMID: 34796665 PMCID: PMC8932711 DOI: 10.1111/cts.13201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/18/2021] [Accepted: 11/08/2021] [Indexed: 12/17/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare, potentially life-threatening, delayed, drug-induced hypersensitivity reaction. Immediate withdrawal of the culprit drug and administration of systemic corticosteroids is the most widely accepted treatment. However, it is difficult to manage patients with DRESS syndrome who are not responsive to systemic steroids. We studied the efficacy of intravenous immunoglobulins (IVIGs) in patients with DRESS syndrome unresponsive to systemic steroids. We retrospectively reviewed patients with DRESS syndrome who received IVIG in addition to systemic steroids during 2012-2017 and compared the clinical features and course of DRESS syndrome, before and after IVIG treatment. Eighteen DRESS patients (9 men) were included. The most frequent offending drugs were dapsone in five patients, followed by vancomycin in three patients, and carbamazepine in three patients. Rash, fever, lymphadenopathy, atypical lymphocytes, and hepatic involvement were common clinical findings. IVIG treatment was added within a median time of 7 days from the commencement of systemic steroid therapy. After IVIG treatment (total dosage: 1-2 g/kg), the fever resolved within a median time of 1 day (range, 0-3) and liver enzymes improved substantially within a median time of 13 days (range, 0-27). No severe adverse reactions related to IVIG therapy were observed in this study; however, there was one case of mortality. The addition of IVIG in DRESS syndrome in cases refractory to systemic steroid treatment may be helpful in hastening recovery. However, comparative studies using a placebo group are needed.
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Affiliation(s)
- Da Woon Sim
- Division of Allergy, Asthma, and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Jieun Yu
- Division of Allergy, Asthma, and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Young-Il Koh
- Division of Allergy, Asthma, and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
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11
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Liu W, Zeng X, Liu Y, Liu J, Li C, Chen L, Chen H, Ouyang D. The Immunological Mechanisms and Immune-Based Biomarkers of Drug-Induced Liver Injury. Front Pharmacol 2021; 12:723940. [PMID: 34721020 PMCID: PMC8554067 DOI: 10.3389/fphar.2021.723940] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022] Open
Abstract
Drug-induced liver injury (DILI) has become one of the major challenges of drug safety all over the word. So far, about 1,100 commonly used drugs including the medications used regularly, herbal and/or dietary supplements, have been reported to induce liver injury. Moreover, DILI is the main cause of the interruption of new drugs development and drugs withdrawn from the pharmaceutical market. Acute DILI may evolve into chronic DILI or even worse, commonly lead to life-threatening acute liver failure in Western countries. It is generally considered to have a close relationship to genetic factors, environmental risk factors, and host immunity, through the drug itself or its metabolites, leading to a series of cellular events, such as haptenization and immune response activation. Despite many researches on DILI, the specific biomarkers about it are not applicable to clinical diagnosis, which still relies on the exclusion of other causes of liver disease in clinical practice as before. Additionally, circumstantial evidence has suggested that DILI is mediated by the immune system. Here, we review the underlying mechanisms of the immune response to DILI and provide guidance for the future development of biomarkers for the early detection, prediction, and diagnosis of DILI.
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Affiliation(s)
- Wenhui Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China.,Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Xiangchang Zeng
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China.,Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Yating Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China.,Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Jinfeng Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China.,Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Chaopeng Li
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha, China
| | - Lulu Chen
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha, China
| | - Hongying Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China.,Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Dongsheng Ouyang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China.,Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Changsha, China.,Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha, China
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12
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Characterizing DRESS syndrome recurrence: a systematic review. Arch Dermatol Res 2021; 314:721-728. [PMID: 34505944 DOI: 10.1007/s00403-021-02274-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
Recurrence of DRESS syndrome is poorly characterized, and dermatologists must be prepared to predict, identify, and manage patients after treatment of the initial presentation. In this study, a primary literature search was conducted using PubMed, capturing all articles recording cases of DRESS syndrome recurrence. Forty-two articles were included for review comprising a total of 60 patients. The average age of patients was 46.3 years and time to recurrence was 123 days. Recurrent episodes presented more frequently with a higher fever and eosinophil absolute peak. Relapse was most often attributed to the introduction of a new medication (n = 18). Of the 17 cases in which outcome data were available, the survival rate of those experiencing recurrence was 71%. Viral reactivation with HHV-6 and organ involvement of the liver were frequently recorded complications. In essence, viral reactivation, severe internal organ involvement, and hematological abnormalities all portended a poorer prognosis in those experiencing DRESS syndrome recurrence. An adequate course of treatment should be maintained until clinical and laboratory parameters normalize, with a slow taper to minimize the likelihood of relapse in those most at risk.
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13
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Ogese MO, Lister A, Gardner J, Meng X, Alfirevic A, Pirmohamed M, Park BK, Naisbitt DJ. Deciphering adverse drug reactions: in vitro priming and characterization of vancomycin-specific T-cells from healthy donors expressing HLA-A*32:01. Toxicol Sci 2021; 183:139-153. [PMID: 34175955 PMCID: PMC8404995 DOI: 10.1093/toxsci/kfab084] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Drug rash with eosinophilia with systemic symptoms (DRESS) is a serious adverse event associated with use of the glycopeptide antibiotic vancomycin. Vancomycin-induced drug rash with eosinophilia with systemic symptoms is associated with the expression of human leukocyte antigen (HLA)-A*32:01, suggesting that the drug interacts with this HLA to activate CD8+ T cells. The purpose of this study was to utilize peripheral blood mononuclear cell from healthy donors to: (1) investigate whether expression of HLA-A*32:01 is critical for the priming naïve of T cells with vancomycin and (2) generate T-cell clones (TCC) to determine whether vancomycin exclusively activates CD8+ T cells and to define cellular phenotype, pathways of drug presentation and cross-reactivity. Dendritic cells were cultured with naïve T cells and vancomycin for 2 weeks. On day 14, cells were restimulated with vancomycin and T-cell proliferation was assessed by [3H]-thymidine incorporation. Vancomycin-specific TCC were generated by serial dilution and repetitive mitogen stimulation. Naïve T cells from HLA-A*02:01 positive and negative donors were activated with vancomycin; however the strength of the induced response was significantly stronger in donors expressing HLA-A*32:01. Vancomycin-responsive CD4+ and CD8+ TCC from HLA-A*32:01+ donors expressed high levels of CXCR3 and CCR4, and secreted IFN‐γ, IL-13, and cytolytic molecules. Activation of CD8+ TCC was HLA class I-restricted and dependent on a direct vancomycin HLA binding interaction with no requirement for processing. Several TCC displayed cross-reactivity with teicoplanin and daptomycin. To conclude, this study provides evidence that vancomycin primes naïve T cells from healthy donors expressing HLA-A*32:01 through a direct pharmacological binding interaction. Cross-reactivity of CD8+ TCC with teicoplanin provides an explanation for the teicoplanin reactions observed in vancomycin hypersensitive patients.
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14
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Thomson PJ, Kafu L, Meng X, Snoeys J, De Bondt A, De Maeyer D, Wils H, Leclercq L, Vinken P, Naisbitt DJ. Drug-specific T-cell responses in patients with liver injury following treatment with the BACE inhibitor atabecestat. Allergy 2021; 76:1825-1835. [PMID: 33150583 DOI: 10.1111/all.14652] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/01/2020] [Accepted: 10/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Atabecestat is an orally administered BACE inhibitor developed to treat Alzheimer's disease. Elevations in hepatic enzymes were detected in a number of in trial patients, which resulted in termination of the drug development programme. Immunohistochemical characterization of liver tissue from an index case of atabecestat-mediated liver injury revealed an infiltration of T-lymphocytes in areas of hepatocellular damage. This coupled with the fact that liver injury had a delayed onset suggests that the adaptive immune system may be involved in the pathogenesis. The aim of this study was to generate and characterize atabecestat(metabolite)-responsive T-cell clones from patients with liver injury. METHODS Peripheral blood mononuclear cells were cultured with atabecestat and its metabolites (diaminothiazine [DIAT], N-acetyl DIAT & epoxide) and cloning was attempted in a number of patients. Atabecestat(metabolite)-responsive clones were analysed in terms of T-cell phenotype, function, pathways of T-cell activation and cross-reactivity with structurally related compounds. RESULTS CD4+ T-cell clones activated with the DIAT metabolite were detected in 5 out of 8 patients (up to 4.5% cloning efficiency). Lower numbers of CD4+ and CD8+ clones displayed reactivity against atabecestat. Clones proliferated and secreted IFN-γ, IL-13 and cytolytic molecules following atabecestat or DIAT stimulation. Certain atabecestat and DIAT-responsive clones cross-reacted with N-acetyl DIAT; however, no cross-reactivity was observed between atabecestat and DIAT. CD4+ clones were activated through a direct, reversible compound-HLA class II interaction with no requirement for protein processing. CONCLUSION The detection of atabecestat metabolite-responsive T-cell clones activated via a pharmacological interactions pathway in patients with liver injury is indicative of an immune-based mechanism for the observed hepatic enzyme elevations.
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Affiliation(s)
- Paul J. Thomson
- MRC Centre for Drug Safety Science Department of Molecular and Clinical Pharmacology University of Liverpool Liverpool UK
| | - Laila Kafu
- MRC Centre for Drug Safety Science Department of Molecular and Clinical Pharmacology University of Liverpool Liverpool UK
| | - Xiaoli Meng
- MRC Centre for Drug Safety Science Department of Molecular and Clinical Pharmacology University of Liverpool Liverpool UK
| | - Jan Snoeys
- Drug Metabolism and Pharmacokinetics Janssen R&D Beerse Belgium
| | - An De Bondt
- Discovery Sciences Janssen R&D Beerse Belgium
| | | | - Hans Wils
- Discovery Sciences Janssen R&D Beerse Belgium
| | | | | | - Dean J. Naisbitt
- MRC Centre for Drug Safety Science Department of Molecular and Clinical Pharmacology University of Liverpool Liverpool UK
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15
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Winward J, Lyckholm L, Brown SM, Mokadem M. Republished: Case of relapsing sulfasalazine-induced hypersensitivity syndrome upon re-exposure. Drug Ther Bull 2021; 59:174-175. [PMID: 34031176 DOI: 10.1136/dtb.2021.235803rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jason Winward
- Internal Medicine, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Laurel Lyckholm
- Internal Medicine, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Samuel M Brown
- Internal Medicine-Division of Pulmonary and Critical Care Medicine, The University of Utah School of Medicine and Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Mohamad Mokadem
- Internal Medicine, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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16
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Afiouni R, Zeinaty P, Kechichian E, Zoghaib S, Matar S, Helou-Mallat J, Tomb R. Pediatric drug reaction with eosinophilia and systemic symptoms: A systematic review of the literature, with a focus on relapsing cases. Pediatr Dermatol 2021; 38:125-131. [PMID: 33155729 DOI: 10.1111/pde.14446] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse drug reaction with systemic symptoms. This study aims to investigate clinical features, causative drugs, and available treatments for pediatric DRESS, particularly for relapsing cases. METHODS A systematic search of the English and French literature on pediatric DRESS was conducted using the Medline, Embase, and Cochrane collaboration databases. Confirmed cases of pediatric DRESS fulfilling the RegiSCAR diagnostic criteria with a probable or a definite diagnosis were included. RESULTS After full-text article review, 144 articles were included, representing a total of 354 pediatric patients with a mean age of 8.8 years. The mean time from the drug intake until the onset of the first symptom was 18.9 days. Antiepileptic drugs were the main trigger, followed by anti-infectious agents. Relapsing DRESS was reported in 17 children. In comparison to non-relapsing cases, relapsing patients had more comorbidities. The initial clinical presentation was more commonly erythroderma. Facial edema, fever, and enlarged lymph nodes in more than two sites were more commonly found in relapsing cases. Systemic steroids were more frequently administered. CONCLUSION Pediatric DRESS is a potentially severe adverse drug reaction. Antiepileptic agents are the most common causative agents. Fever, facial edema, lymph node enlargement, and pharyngeal and visceral involvement predicted DRESS reactivation in children. Corticosteroids were the mainstay of treatment.
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Affiliation(s)
- Rym Afiouni
- Department of Dermatology, Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Perla Zeinaty
- Department of Dermatology, Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Elio Kechichian
- Department of Dermatology, Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Samer Zoghaib
- Department of Dermatology, Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Stephanie Matar
- Department of Dermatology, Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Josiane Helou-Mallat
- Department of Dermatology, Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Roland Tomb
- Department of Dermatology, Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
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17
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Subhani M, Dong V, Connolly A, Salisbury J, Miquel R, Walsh S, Pirani T. Trimethoprim-induced drug reaction with eosinophilia and systemic symptoms (DRESS) associated with reactivation of human herpes virus-6 (HHV-6) leading to acute liver failure. Clin Case Rep 2020; 8:2568-2573. [PMID: 33363781 PMCID: PMC7752394 DOI: 10.1002/ccr3.3218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 12/17/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome can have insidious symptoms which may lead to acute liver failure and death. Prompt recognition, stopping offending drug, and initiating corticosteroid are the mainstay of treatment. Early involvement of a specialist liver unit is vital.
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Affiliation(s)
- Mohsan Subhani
- Liver Intensive Therapy Unit (LITU)King's College HospitalLondonUK
- University of NottinghamNottinghamUK
| | - Victor Dong
- Liver Intensive Therapy Unit (LITU)King's College HospitalLondonUK
| | - Aveen Connolly
- Department of DermatologyKing's College HospitalLondonUK
| | | | - Rosa Miquel
- Liver Histopathology LaboratoryKing's College HospitalLondonUK
| | - Sarah Walsh
- Department of DermatologyKing's College HospitalLondonUK
| | - Tasneem Pirani
- Liver Intensive Therapy Unit (LITU)King's College HospitalLondonUK
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18
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Calil IL, Tustumi F, Pinheiro RSN, Tanigawa RY, Cruz Junior RJ, Bento de Sousa JH, Pecora RAA, D'Albuquerque LAC. Liver transplantation after DRESS syndrome: A case report and review of the literature. Clin Case Rep 2020; 8:3008-3012. [PMID: 33363869 PMCID: PMC7752342 DOI: 10.1002/ccr3.3334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/18/2020] [Accepted: 08/18/2020] [Indexed: 12/17/2022] Open
Abstract
This study reports a patient with DRESS syndrome, associated with liver failure, treated with orthotopic liver transplantation.
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Affiliation(s)
| | - Francisco Tustumi
- Hospital Israelita Albert EinsteinSao PauloBrazil
- Universidade de São PauloSao PauloBrazil
- Centro Universitário LusíadaSantosBrazil
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19
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Winward J, Lyckholm L, Brown SM, Mokadem M. Case of relapsing sulfasalazine-induced hypersensitivity syndrome upon re-exposure. BMJ Case Rep 2020; 13:13/9/e235803. [PMID: 32933910 DOI: 10.1136/bcr-2020-235803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Sulfasalazine-induced hypersensitivity syndrome (SIHS) is a serious systemic delayed adverse drug reaction that is associated with significant morbidity and mortality. Here, we report the first case, to our knowledge, of a patient with previously unidentified SIHS who developed a significantly more rapid and extreme recurrence on re-exposure to sulfasalazine. The patient is a 58-year-old woman with asymptomatic Crohn's disease who, 10 days after initiating sulfasalazine, developed fevers, diffuse rash, pancytopenia, hypotension and hepatitis without a definitive source of infection. Sixteen days after her first hospitalisation, she was restarted on sulfasalazine and was readmitted within 10 hours with a similar but more serious presentation, requiring vasopressors. She did recover completely without any further recurrence to date, after definitively discontinuing sulfasalazine. This case demonstrates the importance of recognising SIHS early in patients to prevent re-exposure to sulfasalazine and to ensure timely initiation of appropriate treatment.
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Affiliation(s)
- Jason Winward
- Internal Medicine, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Laurel Lyckholm
- Internal Medicine, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Samuel M Brown
- Internal Medicine-Division of Pulmonary and Critical Care Medicine, The University of Utah School of Medicine and Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Mohamad Mokadem
- Internal Medicine, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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20
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Naisbitt DJ, Olsson‐Brown A, Gibson A, Meng X, Ogese MO, Tailor A, Thomson P. Immune dysregulation increases the incidence of delayed-type drug hypersensitivity reactions. Allergy 2020; 75:781-797. [PMID: 31758810 DOI: 10.1111/all.14127] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/05/2019] [Accepted: 11/18/2019] [Indexed: 12/14/2022]
Abstract
Delayed-type, T cell-mediated, drug hypersensitivity reactions are a serious unwanted manifestation of drug exposure that develops in a small percentage of the human population. Drugs and drug metabolites are known to interact directly and indirectly (through irreversible protein binding and processing to the derived adducts) with HLA proteins that present the drug-peptide complex to T cells. Multiple forms of drug hypersensitivity are strongly linked to expression of a single HLA allele, and there is increasing evidence that drugs and peptides interact selectively with the protein encoded by the HLA allele. Despite this, many individuals expressing HLA risk alleles do not develop hypersensitivity when exposed to culprit drugs suggesting a nonlinear, multifactorial relationship in which HLA risk alleles are one factor. This has prompted a search for additional susceptibility factors. Herein, we argue that immune regulatory pathways are one key determinant of susceptibility. As expression and activity of these pathways are influenced by disease, environmental and patient factors, it is currently impossible to predict whether drug exposure will result in a health benefit, hypersensitivity or both. Thus, a concerted effort is required to investigate how immune dysregulation influences susceptibility towards drug hypersensitivity.
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Affiliation(s)
- Dean J. Naisbitt
- MRC Centre for Drug Safety Science Department of Clinical and Molecular Pharmacology The University of Liverpool Liverpool UK
| | - Anna Olsson‐Brown
- MRC Centre for Drug Safety Science Department of Clinical and Molecular Pharmacology The University of Liverpool Liverpool UK
| | - Andrew Gibson
- MRC Centre for Drug Safety Science Department of Clinical and Molecular Pharmacology The University of Liverpool Liverpool UK
| | - Xiaoli Meng
- MRC Centre for Drug Safety Science Department of Clinical and Molecular Pharmacology The University of Liverpool Liverpool UK
| | - Monday O. Ogese
- MRC Centre for Drug Safety Science Department of Clinical and Molecular Pharmacology The University of Liverpool Liverpool UK
| | - Arun Tailor
- MRC Centre for Drug Safety Science Department of Clinical and Molecular Pharmacology The University of Liverpool Liverpool UK
| | - Paul Thomson
- MRC Centre for Drug Safety Science Department of Clinical and Molecular Pharmacology The University of Liverpool Liverpool UK
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21
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Abstract
Cutaneous adverse drug reactions are unpredictable and include various different skin conditions of varying degrees of severity. The most concerning are usually referred to as severe cutaneous adverse reactions (SCARs) and include acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DiHS) or hypersensitivity syndrome (HSS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). All are delayed type IV hypersensitivity reactions in which a T-cell-mediated drug-specific immune response is responsible for causing the disease. Nonetheless, specific T-cell subpopulations develop in response to certain environmental conditions and produce cytokines that orchestrate the various phenotypes. Cytotoxic T lymphocytes (CTLs), T-helper type 1 (Th1), Th2, Th17, and regulatory T cells (Treg), among other T-cell subpopulations, participate in the development of SCAR phenotypes. Cell subpopulations belonging to the innate immune system, comprising natural killer cells, innate lymphoid cells, monocytes, macrophages and dendritic cells, can also participate in shaping specific immune responses in various clinical conditions. Additionally, tissue-resident cells, including keratinocytes, can contribute to epidermal damage by secreting chemokines that attract pro-inflammatory immunocytes. The final phenotypes in each clinical entity result from the complex interactions between a variety of cell lineages, their products, soluble mediators and genetic and environmental factors. Although the pathophysiology of these reactions is not fully understood, intensive research in recent years has led to major progress in our understanding of the contribution of certain cell types and soluble mediators to the variability of SCAR phenotypes.
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Affiliation(s)
- Teresa Bellón
- La Paz Hospital Health Research Institute-IdiPAZ, Pº Castellana 261, 28046, Madrid, Spain.
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22
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Mosedale M, Watkins PB. Understanding Idiosyncratic Toxicity: Lessons Learned from Drug-Induced Liver Injury. J Med Chem 2020; 63:6436-6461. [PMID: 32037821 DOI: 10.1021/acs.jmedchem.9b01297] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Idiosyncratic adverse drug reactions (IADRs) encompass a diverse group of toxicities that can vary by drug and patient. The complex and unpredictable nature of IADRs combined with the fact that they are rare makes them particularly difficult to predict, diagnose, and treat. Common clinical characteristics, the identification of human leukocyte antigen risk alleles, and drug-induced proliferation of lymphocytes isolated from patients support a role for the adaptive immune system in the pathogenesis of IADRs. Significant evidence also suggests a requirement for direct, drug-induced stress, neoantigen formation, and stimulation of an innate response, which can be influenced by properties intrinsic to both the drug and the patient. This Perspective will provide an overview of the clinical profile, mechanisms, and risk factors underlying IADRs as well as new approaches to study these reactions, focusing on idiosyncratic drug-induced liver injury.
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Affiliation(s)
- Merrie Mosedale
- Institute for Drug Safety Sciences and Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina 27599, United States
| | - Paul B Watkins
- Institute for Drug Safety Sciences and Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina 27599, United States
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23
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Vancomycin-induced drug rash with eosinophilia and systemic symptoms (DRESS). BMJ Case Rep 2020; 13:13/2/e232302. [DOI: 10.1136/bcr-2019-232302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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24
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Managing the challenge of drug-induced liver injury: a roadmap for the development and deployment of preclinical predictive models. Nat Rev Drug Discov 2019; 19:131-148. [DOI: 10.1038/s41573-019-0048-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 12/13/2022]
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25
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Hammond S, Thomson PJ, Ogese MO, Naisbitt DJ. T-Cell Activation by Low Molecular Weight Drugs and Factors That Influence Susceptibility to Drug Hypersensitivity. Chem Res Toxicol 2019; 33:77-94. [PMID: 31687800 DOI: 10.1021/acs.chemrestox.9b00327] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Drug hypersensitivity reactions adversely affect treatment outcome, increase the length of patients' hospitalization, and limit the prescription options available to physicians. In addition, late stage drug attrition and the withdrawal of licensed drugs cost the pharmaceutical industry billions of dollars. This significantly increases the overall cost of drug development and by extension the price of licensed drugs. Drug hypersensitivity reactions are characterized by a delayed onset, and reactions tend to be more serious upon re-exposure. The role of drug-specific T-cells in the pathogenesis of drug hypersensitivity reactions and definition of the nature of the binding interaction of drugs with HLA and T-cell receptors continues to be the focus of intensive research, primarily because susceptibility is associated with expression of one or a small number of HLA alleles. This review critically examines the mechanisms of T-cell activation by drugs. Specific examples of drugs that activate T-cells via the hapten, the pharmacological interaction with immune receptors and the altered self-peptide repertoire pathways, are discussed. Furthermore, the impacts of drug metabolism, drug-protein adduct formation, and immune regulation on the development of drug antigen-responsive T-cells are highlighted. The knowledge gained from understanding the pathways of T-cell activation and susceptibility factors for drug hypersensitivity will provide the building blocks for the development of predictive in vitro assays that will prevent or help to minimize the incidence of these reactions in clinic.
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Affiliation(s)
- Sean Hammond
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool L69 3GE , U.K
| | - Paul J Thomson
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool L69 3GE , U.K
| | - Monday O Ogese
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool L69 3GE , U.K
| | - Dean J Naisbitt
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool L69 3GE , U.K
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26
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Ogese MO, Jenkins RE, Adair K, Tailor A, Meng X, Faulkner L, Enyindah BO, Schofield A, Diaz‐Nieto R, Ressel L, Eagle GL, Kitteringham NR, Goldring CE, Park BK, Naisbitt DJ, Betts C. Exosomal Transport of Hepatocyte-Derived Drug-Modified Proteins to the Immune System. Hepatology 2019; 70:1732-1749. [PMID: 31070244 PMCID: PMC6899733 DOI: 10.1002/hep.30701] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 04/22/2019] [Indexed: 12/31/2022]
Abstract
Idiosyncratic drug-induced liver injury (DILI) is a rare, often difficult-to-predict adverse reaction with complex pathomechanisms. However, it is now evident that certain forms of DILI are immune-mediated and may involve the activation of drug-specific T cells. Exosomes are cell-derived vesicles that carry RNA, lipids, and protein cargo from their cell of origin to distant cells, and they may play a role in immune activation. Herein, primary human hepatocytes were treated with drugs associated with a high incidence of DILI (flucloxacillin, amoxicillin, isoniazid, and nitroso-sulfamethoxazole) to characterize the proteins packaged within exosomes that are subsequently transported to dendritic cells for processing. Exosomes measured between 50 and 100 nm and expressed enriched CD63. Liquid chromatography-tandem mass spectrometry (LC/MS-MS) identified 2,109 proteins, with 608 proteins being quantified across all exosome samples. Data are available through ProteomeXchange with identifier PXD010760. Analysis of gene ontologies revealed that exosomes mirrored whole human liver tissue in terms of the families of proteins present, regardless of drug treatment. However, exosomes from nitroso-sulfamethoxazole-treated hepatocytes selectively packaged a specific subset of proteins. LC/MS-MS also revealed the presence of hepatocyte-derived exosomal proteins covalently modified with amoxicillin, flucloxacillin, and nitroso-sulfamethoxazole. Uptake of exosomes by monocyte-derived dendritic cells occurred silently, mainly through phagocytosis, and was inhibited by latrunculin A. An amoxicillin-modified 9-mer peptide derived from the exosomal transcription factor protein SRY (sex determining region Y)-box 30 activated naïve T cells from human leukocyte antigen A*02:01-positive human donors. Conclusion: This study shows that exosomes have the potential to transmit drug-specific hepatocyte-derived signals to the immune system and provide a pathway for the induction of drug hapten-specific T-cell responses.
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Affiliation(s)
- Monday O. Ogese
- New Modality Safety, Clinical Pharmacology and Safety Sciences, R&D BiopharmaceuticalsAstraZenecaCambridgeUnited Kingdom,MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Rosalind E. Jenkins
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Kareena Adair
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Arun Tailor
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Xiaoli Meng
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Lee Faulkner
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Bright O. Enyindah
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Amy Schofield
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Rafael Diaz‐Nieto
- North Western Hepatobiliary UnitAintree University Hospital NHS Foundation TrustLiverpoolUnited Kingdom
| | - Lorenzo Ressel
- Department of Veterinary Pathology and Public Health, Institute of Veterinary ScienceUniversity of Liverpool, Leahurst CampusNestonUnited Kingdom
| | - Gina L. Eagle
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Neil R. Kitteringham
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Chris E. Goldring
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - B. Kevin Park
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Dean J. Naisbitt
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Catherine Betts
- New Modality Safety, Clinical Pharmacology and Safety Sciences, R&D BiopharmaceuticalsAstraZenecaCambridgeUnited Kingdom
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27
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Devarbhavi H, Raj S. Drug-induced liver injury with skin reactions: Drugs and host risk factors, clinical phenotypes and prognosis. Liver Int 2019; 39:802-811. [PMID: 30515930 DOI: 10.1111/liv.14004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/30/2018] [Accepted: 11/07/2018] [Indexed: 02/13/2023]
Abstract
While dermatologic manifestations of adverse drug reactions are frequent, drug-induced liver injury is rare. Numerous drugs are implicated in either Drug-Induced Liver Injury or Drug-Induced Skin Injury. However, concomitant Drug-Induced Liver Injury and Drug-Induced Skin Injury are uncommon, not well characterized and appear to be caused by a limited number of drugs. These are often associated with immuno-allergic or hypersensitivity features such as fever, skin rash, blisters or peeling of skin, eosinophilia, lymphadenopathy and mucositis. Liver injury can range from asymptomatic elevation of liver biochemical tests to severe hepatitis and acute liver failure needing liver transplantation. Severe cutaneous adverse reaction, particularly drug reaction with eosinophilia and systemic symptoms is commonly associated with internal organ involvement, the liver being the most frequently involved in approximately 90% of the cases. In Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis, abnormalities in liver biochemistry tests are common but severe liver disease is rare. There is a strong association of Human Leukocyte Antigen genotype with both drug reaction with eosinophilia and systemic symptoms and Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. It is likely that the delayed immune-mediated reaction triggering skin reaction is also responsible for hepatitis. Drug-specific lymphocytes are found in the organs involved and also in circulating blood, which along with the cytokines and chemokines play a role in pathogenesis. Anti-epileptic drugs, allopurinol, sulfonamides, antibiotics and nevirapine are the top five causes of concomitant liver and skin injury. This review will focus on drug and host factors causing concomitant Drug-Induced Skin Injury and Drug-Induced Liver Injury and discuss the characteristics of liver involvement in patients with severe cutaneous adverse reaction.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Sujata Raj
- Department of Dermatology, St. John's Medical College Hospital, Bangalore, India
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Charfi O, Lakhoua G, Aouinti I, Kastalli S, Daghfous R, El Aidli S, Zaiem A. Recurrence of DRESS syndrome to escitalopram or neosensitization? Therapie 2019; 74:504-506. [PMID: 30967240 DOI: 10.1016/j.therap.2019.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 11/19/2018] [Accepted: 02/25/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Ons Charfi
- Centre national de pharmacovigilance Chalbi Belkahia, 1006 Tunis, Tunisia; Université Tunis El Manar, faculté de médecine, unité de recherche UR17ES12, La Rabta, 1007 Tunis, Tunisia.
| | - Ghozlane Lakhoua
- Centre national de pharmacovigilance Chalbi Belkahia, 1006 Tunis, Tunisia; Université Tunis El Manar, faculté de médecine, unité de recherche UR17ES12, La Rabta, 1007 Tunis, Tunisia
| | - Imen Aouinti
- Centre national de pharmacovigilance Chalbi Belkahia, 1006 Tunis, Tunisia; Université Tunis El Manar, faculté de médecine, unité de recherche UR17ES12, La Rabta, 1007 Tunis, Tunisia
| | - Sarrah Kastalli
- Centre national de pharmacovigilance Chalbi Belkahia, 1006 Tunis, Tunisia; Université Tunis El Manar, faculté de médecine, unité de recherche UR17ES12, La Rabta, 1007 Tunis, Tunisia
| | - Riadh Daghfous
- Centre national de pharmacovigilance Chalbi Belkahia, 1006 Tunis, Tunisia; Université Tunis El Manar, faculté de médecine, unité de recherche UR17ES12, La Rabta, 1007 Tunis, Tunisia
| | - Sihem El Aidli
- Centre national de pharmacovigilance Chalbi Belkahia, 1006 Tunis, Tunisia; Université Tunis El Manar, faculté de médecine, unité de recherche UR17ES12, La Rabta, 1007 Tunis, Tunisia
| | - Ahmed Zaiem
- Centre national de pharmacovigilance Chalbi Belkahia, 1006 Tunis, Tunisia; Université Tunis El Manar, faculté de médecine, unité de recherche UR17ES12, La Rabta, 1007 Tunis, Tunisia
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Eliassen E, Krueger G, Luppi M, Ablashi D. Lymphoproliferative Syndromes Associated with Human Herpesvirus-6A and Human Herpesvirus-6B. Mediterr J Hematol Infect Dis 2018; 10:e2018035. [PMID: 29755712 PMCID: PMC5937953 DOI: 10.4084/mjhid.2018.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 12/28/2022] Open
Abstract
Human herpesvirus 6A and 6B (HHV-6A and HHV-6B) have been noted since their discovery for their T-lymphotropism. Although it has proven difficult to determine the extent to which HHV-6A and HHV-6B are involved in the pathogenesis of many diseases, evidence suggests that primary infection and reactivation of both viruses may induce or contribute to the progression of several lymphoproliferative disorders, ranging from benign to malignant and including infectious mononucleosis-like illness, drug induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS), and nodular sclerosis Hodgkin's lymphoma. Herein, we discuss the conditions associated with the lymphoproliferative capacity of HHV-6, as well as the potential mechanisms behind them. Continued exploration on this topic may add to our understanding of the interactions between HHV-6 and the immune system and may open the doors to more accurate diagnosis and treatment of certain lymphoproliferative disorders.
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Affiliation(s)
- Eva Eliassen
- HHV-6 Foundation, Santa Barbara, California, USA
| | - Gerhard Krueger
- Department of Pathology and Laboratory Medicine, University of Texas, Houston, Texas, USA
| | - Mario Luppi
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
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Mustafa SS, Ostrov D, Yerly D. Severe Cutaneous Adverse Drug Reactions: Presentation, Risk Factors, and Management. Curr Allergy Asthma Rep 2018; 18:26. [PMID: 29574562 DOI: 10.1007/s11882-018-0778-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF STUDY Immune-mediated adverse drug reactions occur commonly in clinical practice and include mild, self-limited cutaneous eruptions, IgE-mediated hypersensitivity, and severe cutaneous adverse drug reactions (SCAR). SCARs represent an uncommon but potentially life-threatening form of delayed T cell-mediated reaction. The spectrum of illness ranges from acute generalized exanthematous pustulosis (AGEP) to drug reaction with eosinophilia with systemic symptoms (DRESS), to the most severe form of illness, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). RECENT FINDINGS There is emerging literature on the efficacy of cyclosporine in decreasing mortality in SJS/TEN. The purpose of our review is to discuss the typical presentations of these conditions, with a special focus on identifying the culprit medication. We review risk factors for developing SCAR, including HLA alleles strongly associated with drug hypersensitivity. We conclude by discussing current strategies for the management of these conditions.
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Affiliation(s)
- S Shahzad Mustafa
- Allergy and Clinical Immunology, Rochester Regional Health System, Rochester, NY, USA. .,University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - David Ostrov
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Daniel Yerly
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Bern, Switzerland
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Wilcox O, Hassanein M, Armstrong J, Kassis N. Case report: atypical presentation of vancomycin induced DRESS syndrome: a case report and review of the literature. BMC Pulm Med 2017; 17:217. [PMID: 29282040 PMCID: PMC5745618 DOI: 10.1186/s12890-017-0564-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 12/15/2017] [Indexed: 12/18/2022] Open
Abstract
Background Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe hypersensitivity drug reaction involving the skin and multiple internal organ systems. The symptoms typically present with fever and skin rash, and rapidly progress to multiple organ failures. Vancomycin is a rare drug to cause DRESS syndrome with 23 cases reported to date. Case presentation We described a case of a 39 year-old man who was treated with vancomycin for osteomyelitis of the foot. The patient subsequently developed acute respiratory distress syndrome (ARDS) followed by rash and acute interstitial nephritis. These symptoms were improved by withdrawal of vancomycin and a pulsed corticosteroid regimen. According to the European Registry of Severe Cutaneous Adverse Reaction Criteria (RegiSCAR) (Kardaun et al, British Journal of Dermatology, 169:1071-1080, 2013), the probability of vancomycin induced DRESS syndrome was scored as “Definite”. A literature search of vancomycin induced DRESS syndrome was also performed and the overall pulmonary involvement was estimated as 5%. To our knowledge, this was the first case reported with pulmonary involvement as the initial symptom. Conclusion This is the first case to report pulmonary manifestation as the initial symptom in vancomycin induced DRESS syndrome. Prompt recognition of this entity can expedite proper treatment and hasten recovery. Electronic supplementary material The online version of this article (10.1186/s12890-017-0564-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olivia Wilcox
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - Mohamed Hassanein
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - John Armstrong
- Pulmonary Critical Care, Sparrow Medical Group, Lansing, MI, USA
| | - Nader Kassis
- Nephrology, Sparrow Medical Group, Lansing, MI, USA.
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Pavlos R, White KD, Wanjalla C, Mallal SA, Phillips EJ. Severe Delayed Drug Reactions: Role of Genetics and Viral Infections. Immunol Allergy Clin North Am 2017; 37:785-815. [PMID: 28965641 PMCID: PMC5702581 DOI: 10.1016/j.iac.2017.07.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Adverse drug reactions (ADRs) are a significant source of patient morbidity and mortality and represent a major burden to health care systems and drug development. Up to 50% of such reactions are preventable. Although many ADRs can be predicted based on the on-target pharmacologic activity, ADRs arising from drug interactions with off-target receptors are recognized. Off-target ADRs include the immune-mediated ADRs (IM-ADRs) and pharmacologic drug effects. In this review, we discuss what is known about the immunogenetics and pathogenesis of IM-ADRs and the hypothesized role of heterologous immunity in the development of IM-ADRs.
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Affiliation(s)
- Rebecca Pavlos
- Institute for Immunology and Infectious Diseases, Murdoch University, 6150 Murdoch, Western Australia, Australia
| | - Katie D White
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Celestine Wanjalla
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Simon A Mallal
- Institute for Immunology and Infectious Diseases, Murdoch University, 6150 Murdoch, Western Australia, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, 6150 Murdoch, Western Australia, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Acute Liver Failure/Injury Related to Drug Reaction With Eosinophilia and Systemic Symptoms: Outcomes and Prognostic Factors. Transplantation 2017; 101:1830-1837. [PMID: 28207633 DOI: 10.1097/tp.0000000000001655] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare severe adverse drug-induced reaction with multiorgan involvement. The outcome and prediction of those patients who develop severe acute liver injury (sALI) or acute liver failure (ALF) remain little known. METHODS A multicenter retrospective study of patients admitted with a diagnosis of DRESS-related sALI or ALF. Histological review was performed on liver core biopsies from native livers. RESULTS Sixteen patients (11 women, 5 men; mean age, 39±17.2 years) were classified as having definite (n=13) or probable (n=3) DRESS. At admission, 3 patients had hepatic encephalopathy; median levels of prothrombin time, INR, and total bilirubin were, respectively, 33% (Q1-Q3, 21-41), 2.74 (1.98-4.50), and 94 μmol/L (Q1-Q3, 39.5-243.5). Nine patients received corticosteroid therapy. Overall, 9 patients improved spontaneously and 7 worsened (liver transplantation [LT] (n=5), deceased (n=2)). Transplantation-free and post-LT survival was 56% and 60%, respectively. After LT, DRESS recurrence was observed in 3 of 5 patients. Systemic corticosteroid therapy was not significantly associated with a clinical improvement. In the multivariate analysis, factor V level less than 40% at day 0 and factor V levels of 40% or greater at admission but decreasing at day 2 were associated with worse outcome. Pathological findings (n=7) revealed atypical lymphoid infiltrates, Kupffer cell hyperplasia with erythrophagocytosis, and an inconstant presence of eosinophils. CONCLUSIONS The spontaneous prognosis of patients with sALI/ALF due to DRESS is poor and was not improved by corticosteroid therapy. Histology is helpful to establish diagnosis. Dynamic variables regarding factor V values are predictive of a poor outcome.
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Weaver RJ, Betts C, Blomme EAG, Gerets HHJ, Gjervig Jensen K, Hewitt PG, Juhila S, Labbe G, Liguori MJ, Mesens N, Ogese MO, Persson M, Snoeys J, Stevens JL, Walker T, Park BK. Test systems in drug discovery for hazard identification and risk assessment of human drug-induced liver injury. Expert Opin Drug Metab Toxicol 2017; 13:767-782. [PMID: 28604124 DOI: 10.1080/17425255.2017.1341489] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The liver is an important target for drug-induced toxicities. Early detection of hepatotoxic drugs requires use of well-characterized test systems, yet current knowledge, gaps and limitations of tests employed remains an important issue for drug development. Areas Covered: The current state of the science, understanding and application of test systems in use for the detection of drug-induced cytotoxicity, mitochondrial toxicity, cholestasis and inflammation is summarized. The test systems highlighted herein cover mostly in vitro and some in vivo models and endpoint measurements used in the assessment of small molecule toxic liabilities. Opportunities for research efforts in areas necessitating the development of specific tests and improved mechanistic understanding are highlighted. Expert Opinion: Use of in vitro test systems for safety optimization will remain a core activity in drug discovery. Substantial inroads have been made with a number of assays established for human Drug-induced Liver Injury. There nevertheless remain significant gaps with a need for improved in vitro tools and novel tests to address specific mechanisms of human Drug-Induced Liver Injury. Progress in these areas will necessitate not only models fit for application, but also mechanistic understanding of how chemical insult on the liver occurs in order to identify translational and quantifiable readouts for decision-making.
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Affiliation(s)
- Richard J Weaver
- a Research & Biopharmacy, Institut de Recherches Internationales Servier , Suresnes , France
| | - Catherine Betts
- b Pathology Sciences, Drug Safety and Metabolism , AstraZeneca R&D , Cambridge , UK
| | | | - Helga H J Gerets
- d Non Clinical Development, Chemin du Foriest , UCB BioPharma SPRL , Braine L'Alleud , Belgium
| | | | - Philip G Hewitt
- f Non-Clinical Development, Merck KGaA , Darmstadt , Germany
| | - Satu Juhila
- g In Vitro Biology , Orion Pharma , Espoo , Finland
| | - Gilles Labbe
- h Investigative Toxicology, Preclinical Safety , Sanofi R&D , Paris , France
| | | | - Natalie Mesens
- i Preclinical Development & Safety, Janssen (Pharmaceutical Companies of Johnson & Johnson) Turnhoutseweg 30 , Beerse , Belgium
| | - Monday O Ogese
- j Pathology Sciences, Drug Safety and Metabolism , AstraZeneca R&D , Cambridge , UK
| | - Mikael Persson
- k Innovative Medicines and Early Clinical Development, Drug Safety and Metabolism, Discovery Safety , AstraZeneca R&D , Mölndal , Sweden
| | - Jan Snoeys
- l Pharmacokinetics Dynamics & Metabolism, Janssen (Pharmaceutical Companies of Johnson & Johnson) Turnhoutseweg 30 , Beerse , Belgium
| | - James L Stevens
- m Dept of Toxicology , Lilly Research Laboratories, Eli Lilly and Company , Indianapolis , Indiana , USA
| | - Tracy Walker
- n Investigative Safety & Drug Metabolism , GlaxoSmithKline, David Jack Centre for Research and Development , Ware , Herts , Hertfordshire, UK
| | - B Kevin Park
- o Institute of Translational Medicine , University of Liverpool , Liverpool , UK
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Pichler WJ, Srinoulprasert Y, Yun J, Hausmann O. Multiple Drug Hypersensitivity. Int Arch Allergy Immunol 2017; 172:129-138. [PMID: 28315874 PMCID: PMC5472211 DOI: 10.1159/000458725] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Multiple drug hypersensitivity (MDH) is a syndrome that develops as a consequence of massive T-cell stimulations and is characterized by long-lasting drug hypersensitivity reactions (DHR) to different drugs. The initial symptoms are mostly severe exanthems or drug rash with eosinophilia and systemic symptoms (DRESS). Subsequent symptoms due to another drug often appear in the following weeks, overlapping with the first DHR, or months to years later after resolution of the initial presentation. The second DHR includes exanthema, erythroderma, DRESS, Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), hepatitis, and agranulocytosis. The eliciting drugs can be identified by positive skin or in vitro tests. The drugs involved in starting the MDH are the same as for DRESS, and they are usually given in rather high doses. Fixed drug combination therapies like sulfamethoxazole/trimethoprim or piperacillin/tazobactam are frequently involved in MDH, and 30-40% of patients with severe DHR to combination therapy show T-cell reactions to both components. The drug-induced T-cell stimulation appears to be due to the p-i mechanism. Importantly, a permanent T-cell activation characterized by PD-1+/CD38+ expression on CD4+/CD25low T cells can be found in the circulation of patients with MDH for many years. In conclusion, MDH is a drug-elicited syndrome characterized by a long-lasting hyperresponsiveness to multiple, structurally unrelated drugs with clinically diverse symptoms.
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Affiliation(s)
- Werner J. Pichler
- Department of Immunology, ADR-AC, Bern, Siriraj Hospital, Mahidol University, NSW, Australia
| | - Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - James Yun
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Oliver Hausmann
- Department of Immunology, ADR-AC, Bern, Siriraj Hospital, Mahidol University, NSW, Australia
- Department of Immunology, Löwenpraxis, Luzern, Switzerland, NSW, Australia
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Human leukocyte antigen and idiosyncratic adverse drug reactions. Drug Metab Pharmacokinet 2017; 32:21-30. [DOI: 10.1016/j.dmpk.2016.11.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/08/2016] [Accepted: 11/09/2016] [Indexed: 12/17/2022]
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Mosedale M, Watkins PB. Drug-induced liver injury: Advances in mechanistic understanding that will inform risk management. Clin Pharmacol Ther 2017; 101:469-480. [PMID: 27861792 DOI: 10.1002/cpt.564] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/26/2016] [Accepted: 11/06/2016] [Indexed: 12/11/2022]
Abstract
Drug-induced liver injury (DILI) is a major public health problem. Intrinsic (dose-dependent) DILI associated with acetaminophen overdose is the number one cause of acute liver failure in the US. However, the most problematic type of DILI impacting drug development is idiosyncratic, occurring only very rarely among treated patients and often only after several weeks or months of treatment with the offending drug. Recent advances in our understanding of the pathogenesis of DILI suggest that three mechanisms may underlie most hepatocyte effects in response to both intrinsic and idiosyncratic DILI drugs: mitochondrial dysfunction, oxidative stress, and alterations in bile acid homeostasis. However, in some cases hepatocyte stress promotes an immune response that results in clinically important idiosyncratic DILI. This review discusses recent advances in our understanding of the pathogenesis of both intrinsic and idiosyncratic DILI as well as emerging tools and techniques that will likely improve DILI risk identification and management.
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Affiliation(s)
- M Mosedale
- Institute for Drug Safety Sciences, University of North Carolina at Chapel Hill, Research Triangle Park, North Carolina, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - P B Watkins
- Institute for Drug Safety Sciences, University of North Carolina at Chapel Hill, Research Triangle Park, North Carolina, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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Ogese MO, Ahmed S, Alferivic A, Betts CJ, Dickinson A, Faulkner L, French N, Gibson A, Hirschfield GM, Kammüller M, Meng X, Martin SF, Musette P, Norris A, Pirmohamed M, Park BK, Purcell AW, Spraggs CF, Whritenour J, Naisbitt DJ. New Approaches to Investigate Drug-Induced Hypersensitivity. Chem Res Toxicol 2016; 30:239-259. [DOI: 10.1021/acs.chemrestox.6b00333] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Monday O. Ogese
- Pathology Sciences, Drug Safety and Metabolism, AstraZeneca R&D, Darwin Building 310, Cambridge Science Park, Milton Road, Cambridge CB4 0WG, U.K
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
| | - Shaheda Ahmed
- Alcyomics
Ltd c/o Haematological Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne NE2 4HH, U.K
| | - Ana Alferivic
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
| | - Catherine J. Betts
- Pathology Sciences, Drug Safety and Metabolism, AstraZeneca R&D, Darwin Building 310, Cambridge Science Park, Milton Road, Cambridge CB4 0WG, U.K
| | - Anne Dickinson
- Alcyomics
Ltd c/o Haematological Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne NE2 4HH, U.K
| | - Lee Faulkner
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
| | - Neil French
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
| | - Andrew Gibson
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
| | - Gideon M. Hirschfield
- Centre for Liver Research, NIHR Birmingham Liver Biomedical
Research Unit, Institute of Immunology and Immunotherapy, University of Birmingham, Edgbaston, Birmingham B15 2TT, U.K
| | - Michael Kammüller
- Novartis Institutes for Biomedical Research, Klybeckstrasse 141, CH-4057 Basel, Switzerland
| | - Xiaoli Meng
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
| | - Stefan F. Martin
- Department of Dermatology and Venereology,
Allergy Research Group, University of Freiburg, Hauptstraße 7, 79104 Freiburg, Germany
| | - Philippe Musette
- Department of Dermatology and INSERM, University of Rouen, 905 Rouen, France
| | - Alan Norris
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
| | - Munir Pirmohamed
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
- The Wolfson Centre
for Personalised Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
| | - B. Kevin Park
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
| | - Anthony W. Purcell
- Infection and Immunity
Program and Department of Biochemistry and Molecular Biology, Biomedicine
Discovery Institute, Monash University, Clayton, Victoria 3800, Australia
| | - Colin F. Spraggs
- Medicines
Research Centre, GlaxoSmithKline, Gunnels Wood Road, Stevenage SG1 2NY, U.K
| | - Jessica Whritenour
- Drug Safety Research and Development, Pfizer, Eastern Point Road, Groton, Connecticut 06340, United States
| | - Dean J. Naisbitt
- MRC Centre for Drug Safety Science, Department of Molecular
and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, U.K
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Yang CW, Chen YC, Cho YT, Chu CY. The Role of Viral Reactivation in Drug Reaction with Eosinophilia and Systemic Symptoms and Other Cutaneous Adverse Drug Reactions (cADRs). CURRENT DERMATOLOGY REPORTS 2016. [DOI: 10.1007/s13671-016-0124-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Thompson RA, Isin EM, Ogese MO, Mettetal JT, Williams DP. Reactive Metabolites: Current and Emerging Risk and Hazard Assessments. Chem Res Toxicol 2016; 29:505-33. [DOI: 10.1021/acs.chemrestox.5b00410] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Richard A. Thompson
- DMPK, Respiratory, Inflammation & Autoimmunity iMed, AstraZeneca R&D, 431 83 Mölndal, Sweden
| | - Emre M. Isin
- DMPK, Cardiovascular & Metabolic Diseases iMed, AstraZeneca R&D, 431 83 Mölndal, Sweden
| | - Monday O. Ogese
- Translational Safety, Drug Safety and Metabolism, AstraZeneca R&D, Darwin Building 310, Cambridge Science Park, Milton Rd, Cambridge CB4 0FZ, United Kingdom
| | - Jerome T. Mettetal
- Translational Safety, Drug Safety and Metabolism, AstraZeneca R&D, 35 Gatehouse Dr, Waltham, Massachusetts 02451, United States
| | - Dominic P. Williams
- Translational Safety, Drug Safety and Metabolism, AstraZeneca R&D, Darwin Building 310, Cambridge Science Park, Milton Rd, Cambridge CB4 0FZ, United Kingdom
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Tailor A, Faulkner L, Naisbitt DJ, Park BK. The chemical, genetic and immunological basis of idiosyncratic drug–induced liver injury. Hum Exp Toxicol 2015; 34:1310-7. [DOI: 10.1177/0960327115606529] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Idiosyncratic drug reactions can be extremely severe and are not accounted for by the regular pharmacology of a drug. Thus, the mechanism of idiosyncratic drug–induced liver injury (iDILI), a phenomenon that occurs with many drugs including β-lactams, anti-tuberculosis drugs and non-steroidal anti-inflammatories, has been difficult to determine and remains a pressing issue for patients and drug companies. Evidence has shown that iDILI is multifactorial and multifaceted, which suggests that multiple cellular mechanisms may be involved. However, a common initiating event has been proposed to be the formation of reactive drug metabolites and covalently bound adducts. Although the fate of these metabolites are unclear, recent evidence has shown a possible link between iDILI and the adaptive immune system. This review highlights the role of reactive metabolites, the recent genetic innovations which have provided molecular targets for iDILI, and the current literature which suggests an immunological basis for iDILI.
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Affiliation(s)
- A Tailor
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Sherrington Building, Ashton Street, Liverpool, England
| | - L Faulkner
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Sherrington Building, Ashton Street, Liverpool, England
| | - DJ Naisbitt
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Sherrington Building, Ashton Street, Liverpool, England
| | - BK Park
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Sherrington Building, Ashton Street, Liverpool, England
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Yang F, Gu B, Zhang L, Xuan J, Luo H, Zhou P, Zhu Q, Yan S, Chen SA, Cao Z, Xu J, Xing Q, Luo X. HLA-B*13:01 is associated with salazosulfapyridine-induced drug rash with eosinophilia and systemic symptoms in Chinese Han population. Pharmacogenomics 2015; 15:1461-9. [PMID: 25303297 DOI: 10.2217/pgs.14.69] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Salazosulfapyridine (SASP) frequently causes several adverse reactions, such as drug rash with eosinophilia and systemic symptoms (DRESS). This study aims to assess whether there is an association between SASP-induced DRESS and HLA-A, -B and -C alleles in the Chinese Han population. SUBJECTS & METHODS We performed an association study of six subjects with SASP-induced DRESS, 30 SASP-tolerant patients and 283 general subjects from the human MHC database, all of whom are Han Chinese. RESULTS The frequency of the SASP-induced DRESS patients carrying the HLA-B*13:01 allele is 66.67% (4/6). It is significantly higher compared with the general Chinese Han population (15.19%, 43/283; odds ratio: 11.16; p = 0.007) or with the SASP-tolerant patients (13.33%, 4/30; odds ratio: 13.00; p = 0.004). CONCLUSION These findings show for the first time that in the Chinese Han population, HLA-B*13:01 is associated with SASP-induced DRESS. HLA-B*13:01 might serve as a potential genetic marker for reducing the prevalence of SASP-induced DRESS.
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Affiliation(s)
- Fanping Yang
- Huashan Hospital, Fudan University, Shanghai, China
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Jörg-Walther L, Schnyder B, Helbling A, Helsing K, Schüller A, Wochner A, Pichler W. Flare-up reactions in severe drug hypersensitivity: infection or ongoing T-cell hyperresponsiveness. Clin Case Rep 2015; 3:798-801. [PMID: 26509009 PMCID: PMC4614642 DOI: 10.1002/ccr3.346] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 07/14/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022] Open
Abstract
“Flare-up” reactions are late manifestations of severe T-cell-mediated drug hypersensitivity reactions. Management is anti-inflammatory treatment and avoiding unnecessary medicines. Symptoms like fever, lymph node swelling, and blood count abnormalities may lead to confusion with bacterial infections. For prompt recognition it is important to keep the differential diagnosis in mind.
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Affiliation(s)
- Lukas Jörg-Walther
- Department of Rheumatology, Immunology and Allergology, Inselspital, University Hospital of Bern Bern, Switzerland
| | - Benno Schnyder
- Department of Rheumatology, Immunology and Allergology, Inselspital, University Hospital of Bern Bern, Switzerland
| | - Arthur Helbling
- Department of Rheumatology, Immunology and Allergology, Inselspital, University Hospital of Bern Bern, Switzerland
| | - Karin Helsing
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital of Bern Bern, Switzerland
| | - Alexandra Schüller
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital of Bern Bern, Switzerland
| | - Annette Wochner
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital of Bern Bern, Switzerland
| | - Werner Pichler
- ADR-AC GmbH, Adverse Drug Reactions, Analysis and Consulting Bern, Switzerland
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Kim SH, Naisbitt DJ. Update on Advances in Research on Idiosyncratic Drug-Induced Liver Injury. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2015; 8:3-11. [PMID: 26540496 PMCID: PMC4695405 DOI: 10.4168/aair.2016.8.1.3] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 04/13/2015] [Indexed: 12/12/2022]
Abstract
Drug-induced liver injury (DILI) is a major concern for public health, as well as for drug development in the pharmaceutical industry, since it can cause liver failure and lead to drug withdrawal from the market and black box warnings. Thus, it is important to identify biomarkers for early prediction to increase our understanding of mechanisms underlying DILI that will ultimately aid in the exploration of novel therapeutic strategies to prevent or manage DILI. DILI can be subdivided into 'intrinsic' and 'idiosyncratic' categories, although the validity of this classification remains controversial. Idiosyncratic DILI occurs in a minority of susceptible individuals with a prolonged latency, while intrinsic DILI results from drug-induced direct hepatotoxicity over the course of a few days. The rare occurrence of idiosyncratic DILI requires multicenter collaborative investigations and phenotype standardization. Recent progress in research on idiosyncratic DILI is based on key developments in 3 areas: (1) newly developed high-throughput genotyping across the whole genome allowing for the identification of genetic susceptibility markers, (2) new mechanistic concepts on the pathogenesis of DILI revealing a key role of drug-responsive T lymphocytes in the immunological response, and (3) broad multidisciplinary approaches using different platform "-omics" technologies that have identified novel biomarkers for the prediction of DILI. An association of a specific human leukocyte antigen (HLA) allele with DILI has been reported for several drugs. HLA-restricted T-cell immune responses have also been investigated using lymphocytes and T-cell clones isolated from patients. A microRNA, miR-122, has been discovered as a promising biomarker for the early prediction of DILI. In this review, we summarize recent advances in research on idiosyncratic DILI with an understanding of the key role of adaptive immune systems.
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Affiliation(s)
- Seung Hyun Kim
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Dean J Naisbitt
- MRC Centre for Drug Safety Science, Department of Clinical and Molecular Pharmacology, Sherrington Building, Ashton Street, The University of Liverpool, Liverpool, L69 3 GE, England.
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Yang F, Yang Y, Zhu Q, Chen SA, Fu X, Yan S, Meng C, Ma L, Sun X, Xu J, Luo X, Xing Q. Research on Susceptible Genes and Immunological Pathogenesis of Cutaneous Adverse Drug Reactions in Chinese Hans. J Investig Dermatol Symp Proc 2015; 17:29-31. [PMID: 26067314 DOI: 10.1038/jidsymp.2015.6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Cutaneous adverse drug reactions (cADRs) include mild maculopapular exanthems (MPE), Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP). We used HLA high-resolution genotyping and genome wide association analysis (GWAS) to identify the genetic markers for cADRs induced by common culprit drugs in Han Chinese population. To further understand the immunopathogenesis of cADRs, and with the goal of developing treatment strategies, we compared the expression of cytoxic cytokines between the patients with cADRs and normal controls. Our data suggested that the carbamazepine induced SJS/TEN, allopurinol induced CADRs, methazolamide induced SJS/TEN and SASP induced DRESS were respectively strongly associated with HLA-B*15:02, HLA-B*58:01, HLA-B*59:01 and HLA-B*13:01. In addition, increased expression of cytotoxic cytokines in sera and tissues of cADRs patients were found, compared with healthy controls. Our findings may shed light on prediction and prevention of cADRs, provide clues to pathogenesis, and guide treatment strategies of these reactions.
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Affiliation(s)
- Fangping Yang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Ying Yang
- Children's Hospital & Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Qinyuan Zhu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Sheng-An Chen
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaodan Fu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Sijia Yan
- Children's Hospital & Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Chunjie Meng
- Children's Hospital & Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Li Ma
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xinfen Sun
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jinhua Xu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoqun Luo
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qinghe Xing
- Children's Hospital & Institutes of Biomedical Sciences, Fudan University, Shanghai, China
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Lai R, Xiang X, Mo R, Bao R, Wang P, Guo S, Zhao G, Gui H, Wang H, Bao S, Xie Q. Protective effect of Th22 cells and intrahepatic IL-22 in drug induced hepatocellular injury. J Hepatol 2015; 63:148-55. [PMID: 25681556 DOI: 10.1016/j.jhep.2015.02.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 02/02/2015] [Accepted: 02/03/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Th22 cells regulate host immunity against pathogenic invasion, including protecting host against chronic hepatitis B; however, the relationship between drug induced liver injury (DILI) and Th22/Th17 cells is still unclear. We investigated the role of Th22 cells in DILI development. METHODS The frequencies of peripheral Th22/Th17/Th1 cells and intrahepatic IL-22/IL-17 production from DILI, non-DILI liver diseases, and healthy controls were examined. Plasma IL-22/IL-17 and the related cytokines were determined in DILI patients at week 0 (defined as the occurrence of liver injury within 7days), 4 and 24. Multivariable stepwise logistic regression was applied to explore the associations between various factors and recovery of DILI. RESULTS The frequencies of Th22/Th17 cells were significantly higher in DILI onset patients than HC. Significant increase of Th22 cells and the related cytokines levels was observed in DILI with hepatocellular injury type. There was a positive correlation between intrahepatic IL-22 level and liver regeneration. Plasma IL-22 level was higher in DILI patients with improved liver function than unimproved function. Multivariable analysis showed that the odds ratio (OR) of plasma IL-22 at 4weeks was 1.054 [95% confidence interval (CI), 1.012, 1.124]. CONCLUSIONS Increased peripheral and intrahepatic IL-22-secreting cells are detected in DILI. Th22 and its related cytokines might be hepato-protective, which might provide new perspective for understanding the immunopathogenesis of DILI. Plasma IL-22 might be a reliable indicator to evaluate the prognosis of DILI and provide a novel therapeutic target for DILI treatment.
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Affiliation(s)
- Rongtao Lai
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaogang Xiang
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ruidong Mo
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rebecca Bao
- Discipline of Pathology, Bosch Institute and School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
| | - Peng Wang
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Simin Guo
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Gangde Zhao
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Honglian Gui
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hui Wang
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shisan Bao
- Discipline of Pathology, Bosch Institute and School of Medical Sciences, University of Sydney, Sydney, NSW, Australia.
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Naisbitt DJ, Nattrass RG, Ogese MO. In vitro diagnosis of delayed-type drug hypersensitivity: mechanistic aspects and unmet needs. Immunol Allergy Clin North Am 2015; 34:691-705, x. [PMID: 25017686 DOI: 10.1016/j.iac.2014.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Several laboratories use the lymphocyte transformation test for the diagnosis of delayed-type drug hypersensitivity reactions. Recently, the availability of multiple readouts has improved our ability to diagnose reactions. It is important to note that most published studies characterizing the usefulness of diagnostic tests utilize blood samples from well-defined test and control patient groups. The purpose of this article is to briefly summarize the cellular and chemical basis of delayed-type drug hypersensitivity reactions and to review in vitro assays that are available for drug hypersensitivity diagnosis.
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Affiliation(s)
- Dean J Naisbitt
- Department of Clinical and Molecular Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Sherrington Building, Ashton Street, Liverpool L69 3GE, England.
| | - Ryan G Nattrass
- Department of Clinical and Molecular Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Sherrington Building, Ashton Street, Liverpool L69 3GE, England
| | - Monday O Ogese
- Department of Clinical and Molecular Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Sherrington Building, Ashton Street, Liverpool L69 3GE, England
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