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Sittiwattanawong P, Kantikosum K, Charoenchaipiyakul K, Pootongkam S, Asawanonda P, Kerr SJ, Thantiworasit P, Sodsai P, Hirankarn N, Klaewsongkram J, Rerknimitr P. In-vivo and ex-vivo tests for culprit drugs identification in severe cutaneous adverse drugs reactions. J Dermatol 2024. [PMID: 38605448 DOI: 10.1111/1346-8138.17207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
Drug causality assessment in severe cutaneous adverse reactions (SCARs) remains challenging. We investigated the usefulness of in-vivo drug patch tests (PT), ex-vivo interferon (IFN)-γ enzyme-linked immunospot (ELISpot) assay, and lymphocyte transformation test (LTT) in 30 SCARs patients within the past 36 months. Drug PT yielded a 20% positivity rate (n = 6), while IFN-γ ELISpot and LTT showed positive rates of 56.67% (n = 17) and 41.38% (n = 12), respectively. Combining the three tests resulted in an overall positive rate of 66.67% (n = 20) of cases. IFN-γ ELISpot offered additional positivity, especially with oxypurinol. Employing a combined diagnostic approach may enhance the chances of obtaining a positive result.
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Affiliation(s)
- P Sittiwattanawong
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Center of Excellence for Skin and Allergy Research, Chulalongkorn University, Bangkok, Thailand
| | - K Kantikosum
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Center of Excellence for Skin and Allergy Research, Chulalongkorn University, Bangkok, Thailand
| | - K Charoenchaipiyakul
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Center of Excellence for Skin and Allergy Research, Chulalongkorn University, Bangkok, Thailand
| | - S Pootongkam
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Center of Excellence for Skin and Allergy Research, Chulalongkorn University, Bangkok, Thailand
| | - P Asawanonda
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Center of Excellence for Skin and Allergy Research, Chulalongkorn University, Bangkok, Thailand
| | - S J Kerr
- Center for Excellence in Biostatistics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - P Thantiworasit
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Center of Excellence for Skin and Allergy Research, Chulalongkorn University, Bangkok, Thailand
| | - P Sodsai
- Division of Immunology, Department of Microbiology, Faculty of Medicine, Center of Excellence in Immunology and Immune-Mediated Diseases, Chulalongkorn University, Bangkok, Thailand
| | - N Hirankarn
- Division of Immunology, Department of Microbiology, Faculty of Medicine, Center of Excellence in Immunology and Immune-Mediated Diseases, Chulalongkorn University, Bangkok, Thailand
| | - J Klaewsongkram
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Center of Excellence for Skin and Allergy Research, Chulalongkorn University, Bangkok, Thailand
| | - P Rerknimitr
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Center of Excellence for Skin and Allergy Research, Chulalongkorn University, Bangkok, Thailand
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Pinyopornpanish K, Pinyopornpanish K, Pinyopornpanish K, Benjanuwattra J, Teepapan P, Chungcharoenpanich A, Laisuan W. Omeprazole Induced Rapid Drug Reaction with Eosinophilia, Systemic Symptoms, and Cross-Reactivity in Delayed-Type Hypersensitivity Associated with Proton-Pump Inhibitors: A Case Report and Literature Review. Case Reports Immunol 2024; 2024:1317971. [PMID: 38213955 PMCID: PMC10781523 DOI: 10.1155/2024/1317971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/13/2024] Open
Abstract
Background Omeprazole, a proton pump inhibitor (PPI), is a widely used and generally safe agent for treating acid-related gastrointestinal conditions. However, drug reaction with eosinophilia and systemic symptoms (DRESSs) syndrome has been reported. Objectives To report a case of omeprazole-induced rapid DRESS syndrome and to review the literature. Methods Descriptive analysis of one new case and a case series from literature review. Results We report a case of 82-year-old woman presenting with rapid-onset of DRESS syndrome. The condition was initially suspected to be caused by antibiotic, but the definite diagnosis was eventually omeprazole-induced DRESS syndrome as suggested by the enzyme-linked immune absorbent spot (ELISpot) assay along with the clinical picture. Previous literatures regarding cases of PPI-induced DRESS syndrome were pooled for descriptive analysis. Among 21 PPI cases pooled, esomeprazole was the most commonly implicated PPI (52.4%), followed by pantoprazole (19.1%), and omeprazole along with lansoprazole (both 14.3%). The issue of cross-reactivities amongst PPIs remains uncertain. Nonetheless, in situations in which a PPIs are deemed necessary, a prudent approach could be considering a switch to an alternative agent with distinct chemical structure. Conclusion PPI is commonly used safely as an agent for acid-related gastrointestinal conditions. However, PPI-induced rapid DRESS syndrome can occur, particularly with prior exposure history. ELISpot is an in vitro test, useful in identifying the culprit agent in patients with delayed-type hypersensitivity reaction.
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Affiliation(s)
- Kanokkarn Pinyopornpanish
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Department of Medicine, Chiangmai University Hospital, Chiangmai, Thailand
| | | | | | - Juthipong Benjanuwattra
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Putthapon Teepapan
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Apinya Chungcharoenpanich
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wannada Laisuan
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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3
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Chongpison Y, Sriswasdi S, Buranapraditkun S, Thantiworasit P, Rerknimitr P, Mongkolpathumrat P, Chularojanamontri L, Srinoulprasert Y, Rerkpattanapipat T, Chanprapaph K, Disphanurat W, Chakkavittumrong P, Tovanabutra N, Srisuttiyakorn C, Sukasem C, Tuchinda P, Pongcharoen P, Klaewsongkram J. IFN-γ ELISpot-enabled machine learning for culprit drug identification in nonimmediate drug hypersensitivity. J Allergy Clin Immunol 2024; 153:193-202. [PMID: 37678574 DOI: 10.1016/j.jaci.2023.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Diagnosing drug-induced allergy, especially nonimmediate phenotypes, is challenging. Incorrect classifications have unwanted consequences. OBJECTIVE We sought to evaluate the diagnostic utility of IFN-γ ELISpot and clinical parameters in predicting drug-induced nonimmediate hypersensitivity using machine learning. METHODS The study recruited 393 patients. A positive patch test or drug provocation test (DPT) was used to define positive drug hypersensitivity. Various clinical factors were considered in developing random forest (RF) and logistic regression (LR) models. Performances were compared against the IFN-γ ELISpot-only model. RESULTS Among the 102 patients who had 164 DPTs, most patients had severe cutaneous adverse reactions (35/102, 34.3%) and maculopapular exanthems (33/102, 32.4%). Common suspected drugs were antituberculosis drugs (46/164, 28.1%) and β-lactams (42/164, 25.6%). Mean (SD) age of patients with DPT was 52.7 (20.8) years. IFN-γ ELISpot, fixed drug eruption, Naranjo categories, and nonsteroidal anti-inflammatory drugs were the most important features in all developed models. The RF and LR models had higher discriminating abilities. An IFN-γ ELISpot cutoff value of 16.0 spot-forming cells/106 PBMCs achieved 94.8% specificity and 57.1% sensitivity. Depending on clinical needs, optimal cutoff values for RF and LR models can be chosen to achieve either high specificity (0.41 for 96.1% specificity and 0.52 for 97.4% specificity, respectively) or high sensitivity (0.26 for 78.6% sensitivity and 0.37 for 71.4% sensitivity, respectively). CONCLUSIONS IFN-γ ELISpot assay was valuable in identifying culprit drugs, whether used individually or incorporated in a prediction model. Performances of RF and LR models were comparable. Additional test datasets with DPT would be helpful to validate the model further.
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Affiliation(s)
- Yuda Chongpison
- Biostatistics Excellence Centre, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sira Sriswasdi
- Center of Excellence in Computational Molecular Biology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center for Artificial Intelligence in Medicine, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Supranee Buranapraditkun
- Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pattarawat Thantiworasit
- Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pawinee Rerknimitr
- Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Division of Dermatology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pungjai Mongkolpathumrat
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Leena Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ticha Rerkpattanapipat
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wareeporn Disphanurat
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Panlop Chakkavittumrong
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Napatra Tovanabutra
- Division of Dermatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chutika Srisuttiyakorn
- Division of Dermatology, Department of Medicine, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Pharmacogenomics and Precision Medicine Clinic, Bumrungrad Genomic Medicine Institute, Bumrungrad International Hospital, Bangkok, Thailand
| | - Papapit Tuchinda
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Padcha Pongcharoen
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Jettanong Klaewsongkram
- Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
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Rodríguez-Pérez R, de las Vecillas L, Cabañas R, Bellón T. Tools for Etiologic Diagnosis of Drug-Induced Allergic Conditions. Int J Mol Sci 2023; 24:12577. [PMID: 37628756 PMCID: PMC10454098 DOI: 10.3390/ijms241612577] [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: 06/06/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023] Open
Abstract
Drug hypersensitivity reactions are a serious concern in clinical practice because they can be severe and result in lifelong sequelae. An accurate diagnosis and identification of the culprit drug is essential to prevent future reactions as well as for the identification of safe treatment alternatives. Nonetheless, the diagnosis can be challenging. In vivo and in vitro tests can be helpful, although none are conclusive; therefore, the tests are not usually performed in isolation but as part of a diagnostic algorithm. In addition, some in vitro tests are only available in research laboratories, and standardization has not been fully accomplished. Collaborating research is needed to improve drug hypersensitivity reaction diagnosis. In this review, we update the current available in vivo and in vitro tools with their pros and cons and propose an algorithm to integrate them into clinical practice.
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Affiliation(s)
- Rosa Rodríguez-Pérez
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
| | - Leticia de las Vecillas
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- Allergy Department, La Paz University Hospital, Paseo Castellana 261, 28046 Madrid, Spain
- PIELenRed Consortium, 28046 Madrid, Spain
| | - Rosario Cabañas
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- Allergy Department, La Paz University Hospital, Paseo Castellana 261, 28046 Madrid, Spain
- PIELenRed Consortium, 28046 Madrid, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER U754), 28046 Madrid, Spain
| | - Teresa Bellón
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- PIELenRed Consortium, 28046 Madrid, Spain
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Fernández-Lozano C, Solano Solares E, Elías-Sáenz I, Pérez-Allegue I, Fernández-Guarino M, Fernández-Nieto D, Díaz Montalvo L, González-de-Olano D, de Andrés A, Martínez-Botas J, de la Hoz Caballer B. Value of the Lymphocyte Transformation Test for the Diagnosis of Drug-Induced Hypersensitivity Reactions in Hospitalized Patients with Severe COVID-19. Int J Mol Sci 2023; 24:11543. [PMID: 37511302 PMCID: PMC10380365 DOI: 10.3390/ijms241411543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
In the first wave of COVID-19, up to 20% of patients had skin lesions with variable characteristics. There is no clear evidence of the involvement of the SARS-CoV-2 virus in all cases; some of these lesions may be secondary to drug hypersensitivity. To analyze the possible cause of the skin lesions, we performed a complete allergology study on 11 patients. One year after recovery from COVID-19, we performed a lymphocyte transformation test (LTT) and Th1/Th2 cytokine secretion assays for PBMCs. We included five nonallergic patients treated with the same drugs without lesions. Except for one patient who had an immediate reaction to azithromycin, all patients had a positive LTT result for at least one of the drugs tested (azithromycin, clavulanic acid, hydroxychloroquine, lopinavir, and ritonavir). None of the nonallergic patients had a positive LTT result. We found mixed Th1/Th2 cytokine secretion (IL-4, IL-5, IL-13, and IFN-γ) in patients with skin lesions corresponding to mixed drug hypersensitivity type IVa and IVb. In all cases, we identified a candidate drug as the culprit for skin lesions during SARS-CoV-2 infection, although only three patients had a positive drug challenge. Therefore, it would be reasonable to recommend avoiding the drug in question in all cases.
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Affiliation(s)
- Carlos Fernández-Lozano
- Biochemistry-Research Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - Emilio Solano Solares
- Allergy Service, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - Isabel Elías-Sáenz
- Allergy Service, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - Isabel Pérez-Allegue
- Allergy Service, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - Monserrat Fernández-Guarino
- Dermatology Service, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - Diego Fernández-Nieto
- Dermatology Service, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - Laura Díaz Montalvo
- Allergy Service, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - David González-de-Olano
- Allergy Service, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - Ana de Andrés
- Immunology Service, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - Javier Martínez-Botas
- Biochemistry-Research Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
| | - Belén de la Hoz Caballer
- Allergy Service, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Carretera de Colmenar Km 9, 28034 Madrid, Spain
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Beta-lactam hypersensitivity diagnosis in ambulatory and hospitalized settings require different approaches. Ann Allergy Asthma Immunol 2023; 130:84-92.e1. [PMID: 36122888 DOI: 10.1016/j.anai.2022.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Data on beta-lactam hypersensitivity (BLH) are mainly focused on immediate or mild nonimmediate reactions in the ambulatory setting, but limited in patients with concurrent illness and moderate-to-severe nonimmediate reactions in the hospitalized setting. OBJECTIVE To investigate the entire spectrum of BLH in Thai tertiary hospital. METHODS Clinical characteristics of 357 patients with suspected BLH were evaluated in a 7-year period. Culprit drug identification was performed in 335 patients by combined skin testing, in vitro testing, or drug provocation tests. RESULTS The predominant BLH presentations were non-immunoglobulin (Ig)E-mediated reactions with severe cutaneous adverse reactions of 18.9%, and BLH status was definitively confirmed in 18.1%. The most common verified culprits were cephalosporins (34.8%), particularly in hypersensitivity type IV reactions. Natural penicillins were the main implicated drugs in 48.5% of ambulatory patients. In contrast, cephalosporins and carbapenems were the main implicated drugs in hospitalized patients. Non-IgE-mediated anaphylaxis and serum sickness-like reaction remained diagnostically challenged. New generations of beta-lactams, hospitalized patients, recent allergic history, and underlying malignancies or autoimmune diseases were associated with increased BLH risk. CONCLUSION At present, cephalosporins are the leading causes of BLH, particularly in non-IgE-mediated reactions. More research on the verification of non-IgE hypersensitivity reactions from new generations of beta-lactams should be better emphasized. CLINICAL TRIAL REGISTRATION The registry was approved by the Ethics and Research Committee of the Faculty of Medicine, Chulalongkorn University, and listed on ClinicalTrials.gov (Identifier: NCT01667055; https://www. CLINICALTRIALS gov/ct2/show/NCT01667055).
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 144] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Copaescu AM, Ben-Shoshan M, Trubiano JA. Tools to improve the diagnosis and management of T-cell mediated adverse drug reactions. Front Med (Lausanne) 2022; 9:923991. [PMID: 36313986 PMCID: PMC9606226 DOI: 10.3389/fmed.2022.923991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022] Open
Abstract
Delayed drug T-cell immune-mediated hypersensitivity reactions have a large clinical heterogeneity varying from mild maculopapular exanthema (MPE) to severe cutaneous adverse reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and severe skin necrosis and blistering as seen in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Given the knowledge gaps related to the immunopathogenesis of these conditions, the absence of validated diagnostic tools and the significant associated morbidity and mortality, patients with SCARs often have limited drug choices. We performed a comprehensive review aiming to evaluate in vivo diagnostic tools such as delayed intradermal skin and patch testing and ex vivo/in vitro research assays such as the lymphocyte transformation test (LTT) and the enzyme-linked ImmunoSpot (ELISpot) assay. We searched through PubMed using the terms “drug allergy,” “in vivo” and “ex vivo” for original papers in the last 10 years. A detailed meticulous approach adapted to the various clinical phenotypes is recommended for the diagnostic and management of delayed drug hypersensitivity reactions. This review highlights the current diagnostic tools for the delayed drug hypersensitivity phenotypes.
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Affiliation(s)
- Ana Maria Copaescu
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia,Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), Montreal, QC, Canada,The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), Montreal, QC, Canada,*Correspondence: Ana Maria Copaescu,
| | - Moshe Ben-Shoshan
- The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), Montreal, QC, Canada,Division of Allergy, Immunology and Dermatology, Montreal Children’s Hospital, McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Jason A. Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia,Department of Oncology, Sir Peter MacCallum Cancer Centre, The University of Melbourne, Parkville, VIC, Australia,Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Management of Drug-Induced Epidermal Necrolysis (DEN) in Pediatric Patients: Moving from Drug-Induced Stevens-Johnson Syndrome, Overlap and Toxic Epidermal Necrolysis to a Single Unifying Diagnosis of DEN. Paediatr Drugs 2022; 24:307-319. [PMID: 35676614 DOI: 10.1007/s40272-022-00515-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
Pediatric Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threating blistering diseases triggered by medications that affect the skin and mucosae. Drug-induced epidermal necrolysis is a better term for medication-triggered cases because there is a spectrum of disease severity that otherwise is divided into the separate entities of SJS, overlap SJS/TEN, and TEN. This manuscript reviews the management of drug-induced epidermal necrolysis (DEN), including diagnosis, investigations to exclude differential diagnoses, and treatment. Diagnosis of DEN relies on clinical features and a detailed medication history. The primary differential diagnosis is reactive infectious mucocutaneous eruption, which can be clinically distinguished by its disproportionate mucous membrane involvement relative to (sparse or absent) skin lesions. Identification and discontinuation of culprit medications is the mainstay of treatment of DEN. Early initiation of immunomodulatory therapy may prevent progression, reducing maximal disease severity and the risk of sequelae. A checklist approach to detailed management of DEN is proposed.
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10
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Glässner A, Dubrall D, Weinhold L, Schmid M, Sachs B. Lymphocyte Transformation Test for drug allergy detection: when does it work? Ann Allergy Asthma Immunol 2022; 129:497-506.e3. [PMID: 35732204 DOI: 10.1016/j.anai.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The lymphocyte transformation test (LTT) is an in vitro test system for the detection of a sensitization in the context of allergies to drugs. Its reported sensitivity varies largely and seems to be affected by different parameters. In review articles, the average LTT performance was often calculated by combining overall mean sensitivities of various published studies, but without considering different patient characteristics or varying patient numbers per publication. OBJECTIVE This meta-analysis aims to investigate the impact of different patient-specific and methodical parameters on the sensitivity of the LTT based on data on the level of the individual patient extracted from single studies. METHODS We performed an advanced literature search in Pubmed and screened the identified publications according to previously defined inclusion criteria. In total, individual patient data from 721 patients were extracted from 30 studies. Random-effects meta-regression analyses were performed. RESULTS The analysis indicate that the ELISA-based read-out is more sensitive compared to the classical radioactivity method (ELISA: 80% vs. radioactivity: 66%;p=0.084). Interestingly, DRESS/DHISS is associated with a higher probability of a positive LTT test result compared to other investigated clinical phenotypes ("DRESS/DHISS" vs. "bullous reaction"; OR: 2.52;p-value=0.003). Our analysis also revealed an impact of the time to testing period after the occurrence of the allergic event ("<2 weeks" vs. "2 weeks-2 months"; OR: 2.12;p-value=0.034). CONCLUSION The read-out method and relevant clinical parameters affect the sensitivity of the LTT. These findings are based on a meta-analysis providing a higher level of evidence than a single study or previous reviews not considering individual patient data.
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Affiliation(s)
- Andreas Glässner
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany.
| | - Diana Dubrall
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany; Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Leonie Weinhold
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Bernhardt Sachs
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany; Department for Dermatology and Allergy, University Hospital Aachen, Aachen, Germany
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11
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Tempark T, John S, Rerknimitr P, Satapornpong P, Sukasem C. Drug-Induced Severe Cutaneous Adverse Reactions: Insights Into Clinical Presentation, Immunopathogenesis, Diagnostic Methods, Treatment, and Pharmacogenomics. Front Pharmacol 2022; 13:832048. [PMID: 35517811 PMCID: PMC9065683 DOI: 10.3389/fphar.2022.832048] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/01/2022] [Indexed: 12/19/2022] Open
Abstract
SCARs are rare and life-threatening hypersensitivity reactions. In general, the increased duration of hospital stays and the associated cost burden are common issues, and in the worst-case scenario, they can result in mortality. SCARs are delayed T cell-mediated hypersensitivity reactions. Recovery can take from 2 weeks to many months after dechallenging the culprit drugs. Genetic polymorphism of the HLA genes may change the selection and presentation of antigens, allowing toxic drug metabolites to initiate immunological reactions. However, each SCARs has a different onset latency period, clinical features, or morphological pattern. This explains that, other than HLA mutations, other immuno-pathogenesis may be involved in drug-induced severe cutaneous reactions. This review will discuss the clinical morphology of various SCARs, various immune pathogenesis models, diagnostic criteria, treatments, the association of various drug-induced reactions and susceptible alleles in different populations, and the successful implementation of pharmacogenomics in Thailand for the prevention of SCARs.
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Affiliation(s)
- Therdpong Tempark
- Division of Dermatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,The Pediatrics-Thai Severe Cutaneous Adverse Drug Reaction (Ped-Thai-SCAR) Research Group, Bangkok, Thailand
| | - Shobana John
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | - Pawinee Rerknimitr
- The Thai Severe Cutaneous Adverse Drug Reaction (Thai-SCAR) Research Group, Bangkok, Thailand.,Division of Dermatology, Department of Medicine, Faculty of Medicine, Skin, and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Patompong Satapornpong
- Division of General Pharmacy Practice, Department of Pharmaceutical Care, College of Pharmacy, Rangsit University, Pathum Thani, Thailand.,Excellence Pharmacogenomics and Precision Medicine Centre, College of Pharmacy, Rangsit University, Pathum Thani, Thailand
| | - Chonlaphat Sukasem
- The Pediatrics-Thai Severe Cutaneous Adverse Drug Reaction (Ped-Thai-SCAR) Research Group, Bangkok, Thailand.,Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand.,The Thai Severe Cutaneous Adverse Drug Reaction (Thai-SCAR) Research Group, Bangkok, Thailand.,Pharmacogenomics and Precision Medicine, The Preventive Genomics & Family Check-up Services Center, Bumrungrad International Hospital, Bangkok, Thailand.,MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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12
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Klaewsongkram J, Buranapraditkun S, Thantiworasit P, Rerknimitr P, Tuchinda P, Chularojanamontri L, Rerkpattanapipat T, Chanprapaph K, Disphanurat W, Chakkavittumrong P, Tovanabutra N, Srisuttiyakorn C, Srinoulprasert Y, Sukasem C, Chongpison Y. The Role of In Vitro Detection of Drug-Specific Mediator-Releasing Cells to Diagnose Different Phenotypes of Severe Cutaneous Adverse Reactions. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2021; 13:896-907. [PMID: 34734507 PMCID: PMC8569031 DOI: 10.4168/aair.2021.13.6.896] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/28/2021] [Accepted: 05/12/2021] [Indexed: 12/19/2022]
Abstract
PROPOSE The purpose of this study was to investigate panels of enzyme-linked immunospot assays (ELISpot) to detect drug-specific mediator releasing cells for confirming culprit drugs in severe cutaneous adverse reactions (SCARs). METHODS Frequencies of drug-induced interleukin-22 (IL-22)-, interferon-gamma (IFN-γ)-, and granzyme-B (GrB)-releasing cells were measured by incubating peripheral blood mononuclear cells (PBMCs) from SCAR patients with the culprit drugs. Potential immunoadjuvants were supplemented to enhance drug-induced mediator responses. RESULTS Twenty-seven patients, including 9 acute generalized exanthematous pustulosis (AGEP), 10 drug reactions with eosinophilia and systemic symptoms, and 8 Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) were recruited. The average frequencies of drug-induced IL-22-, IFN-γ-, and GrB-releasing cells were 35.5±16.3, 33.0±7.1, and 164.8±43.1 cells/million PBMCs, respectively. The sensitivity of combined IFN-γ/IL-22/GrB ELISpot was higher than that of IFN-γ ELISpot alone for culprit drug detection in all SCAR subjects (77.8% vs 51.9%, P < 0.01). The measurement of drug-induced IL-22- and IFN-γ releasing cells confirmed the culprit drugs in 77.8% of AGEP. The measurement of drug-induced IFN-γ- and GrB-releasing cells confirmed the culprit drugs in 62.5% of SJS/TEN. Alpha-galactosylceramide supplementation significantly increased the frequencies of drug-induced IFN-γ releasing cells. CONCLUSION The measurement of drug-induced IFN-γ-releasing cells is the key for identifying culprit drugs. The additional measurement of drug-induced IL-22-releasing cells enhances ELISpot sensitivity to identify drug-induced AGEP, while the measurement of drug-induced GrB-releasing cells could have a role in SJS/TEN. ELISpot sensitivity might be improved by supplementary alpha-galactosylceramide. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02574988.
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Affiliation(s)
- Jettanong Klaewsongkram
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - Supranee Buranapraditkun
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Pattarawat Thantiworasit
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Pawinee Rerknimitr
- King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of Dermatology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Papapit Tuchinda
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Leena Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ticha Rerkpattanapipat
- Allergy Immunology and Rheumatology Division, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wareeporn Disphanurat
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Panlop Chakkavittumrong
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Napatra Tovanabutra
- Dermatologic Division, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chutika Srisuttiyakorn
- Division of Dermatology, Department of Medicine, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Yuda Chongpison
- Center for Excellence in Biostatistics, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
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13
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Glutathione Whitening Pills Induced Toxic Epidermal Necrolysis: An Unusual Case Confirmed by Enzyme-Linked Immunospot Assay and Liquid Chromatography-Mass Spectrometry. Dermatitis 2021; 32:e115-e117. [PMID: 34608063 DOI: 10.1097/der.0000000000000782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Identifying the Culprit Drug in Severe Cutaneous Adverse Reactions (SCARs). CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00291-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Delabeling Delayed Drug Hypersensitivity: How Far Can You Safely Go? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2878-2895.e6. [PMID: 33039012 DOI: 10.1016/j.jaip.2020.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022]
Abstract
Delayed immune-mediated adverse drug reactions (IM-ADRs) are defined as reactions occurring more than 6 hours after dosing. They include heterogeneous clinical phenotypes that are typically T-cell-mediated reactions with distinct mechanisms across a wide spectrum of severity from benign exanthems through to life-threatening cutaneous or organ-specific diseases. For mild reactions such as benign exanthem, considerations for delabeling are similar to immediate reactions and may include a graded or single-dose drug challenge with or without preceding skin or patch testing. Evaluation of challenging cases such as the patient who is on multiple drugs at the time a severe delayed IM-ADR occurs should prioritize clinical ascertainment of the most likely phenotype and implicated drug(s). Although not widely available and validated, procedures such as patch testing, delayed intradermal skin testing, and laboratory-based functional drug assays or genetic (human leukocyte antigen) testing may provide valuable information to further help risk stratify patients and identify the likely implicated and/or cross-reactive drug(s). The decision to use a drug challenge as a diagnostic or delabeling tool in a patient with a severe delayed IM-ADR should weigh the risk-benefit ratio, balancing the severity and priority for the treatment of the underlying, and the availability of alternative efficacious and safe treatments.
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16
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Fatangare A, Glässner A, Sachs B, Sickmann A. Future perspectives on in-vitro diagnosis of drug allergy by the lymphocyte transformation test. J Immunol Methods 2021; 495:113072. [PMID: 34000289 DOI: 10.1016/j.jim.2021.113072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/22/2021] [Accepted: 05/12/2021] [Indexed: 11/26/2022]
Abstract
This article aims to envisage future perspectives of the lymphocyte transformation test (LTT). We describe the select innovative techniques, which can be integrated at different stages of the LTT to potentially improve the sensitivity, specificity, or practicability of the LTT. We first focus upon the cell sorting techniques comprising immunomagnetic cell separation and flow cytometry, which can be implemented prior and after the LTT culturing step to concentrate and quantify specific immune cell types. Further, we elaborate upon three important omics techniques such as transcriptomics, proteomics, and metabolomics, which can be integrated downstream of the LTT to analyze molecular changes in specific immune cells following drug induced activation and proliferation. We also develop visions, how state of the art techniques used in other scientific fields, can be transferred and applied in the context of in-vitro detection of drug allergy.
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Affiliation(s)
- Amol Fatangare
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany
| | - Andreas Glässner
- Federal Institute for Drugs and Medical Devices, Research Division, Bonn, Germany
| | - Bernhardt Sachs
- Federal Institute for Drugs and Medical Devices, Research Division, Bonn, Germany; Department for Dermatology and Allergology, University Hospital Aachen, Germany
| | - Albert Sickmann
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany; Medizinische Fakultät, Medizinisches Proteom-Center (MPC), Ruhr-Universität Bochum, 44801 Bochum, Germany; Department of Chemistry, College of Physical Sciences, University of Aberdeen, Aberdeen, AB243FX, Scotland, UK.
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17
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Porebski G, Piotrowicz-Wojcik K, Spiewak R. ELISpot assay as a diagnostic tool in drug hypersensitivity reactions. J Immunol Methods 2021; 495:113062. [PMID: 33940020 DOI: 10.1016/j.jim.2021.113062] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 12/17/2022]
Abstract
In patients with drug hypersensitivity reactions, confirmation of causality frequently facilitates decision on a continuation or withdrawal of a given treatment. Unfortunately, identification of the culprit drug often proves difficult. In vivo methods possess well-known disadvantages like low sensitivity of skin tests or the risk of relapse during drug provocation tests. Therefore, laboratory assays are of great interest as they may improve causal diagnosis without putting patients at risk. In this article, the mechanistic principles and methodological issues of the enzyme-linked immunospot (ELISpot) assay were recapped the context of drug hypersensitivity reactions. A review of ELISpot application in causal diagnosis of drug hypersensitivity was based on literature search. The main findings are: (i) ELISpot assay has a good performance in the detection of drug-specific response. (ii) ELISpot results seem to be not substantially impacted by the type of drug or phenotype of the reaction. (iii) Testing within 30 days since the episode of drug hypersensitivity reaction shows a better performance than in later recovery phase. (iv) Data from pediatric population are too scarce to draw any conclusions. (v) Differences in laboratory protocols and in criteria used in the assessment of ELISpot plates along with the issue of the technical feasibility and reproducibility may limit the use of this assay in the routine diagnostic of drug hypersensitivity reactions.
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Affiliation(s)
- Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland.
| | - Katarzyna Piotrowicz-Wojcik
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Radoslaw Spiewak
- Department of Experimental Dermatology and Cosmetology, Jagiellonian University Medical College, Krakow, Poland
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18
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Copaescu A, Gibson A, Li Y, Trubiano JA, Phillips EJ. An Updated Review of the Diagnostic Methods in Delayed Drug Hypersensitivity. Front Pharmacol 2021; 11:573573. [PMID: 33597867 PMCID: PMC7883592 DOI: 10.3389/fphar.2020.573573] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/23/2020] [Indexed: 12/19/2022] Open
Abstract
Delayed drug hypersensitivity reactions are clinically diverse reactions that vary from isolated benign skin conditions that remit quickly with no or symptomatic treatment, drug discontinuation or even continued drug treatment, to the other extreme of severe cutaneous adverse reactions (SCARs) that are associated with presumed life-long memory T-cell responses, significant acute and long-term morbidity and mortality. Diagnostic "in clinic" approaches to delayed hypersensitivity reactions have included patch testing (PT), delayed intradermal testing (IDT) and drug challenges for milder reactions. Patch and IDT are, in general, performed no sooner than 4-6 weeks after resolution of the acute reaction at the maximum non-irritating concentrations. Functional in vitro and ex vivo assays have largely remained the province of research laboratories and include lymphocyte transformation test (LTT) and cytokine release enzyme linked ImmunoSpot (ELISpot) assay, an emerging diagnostic tool which uses cytokine release, typically IFN-γ, after the patient's peripheral blood mononuclear cells are stimulated with the suspected drug(s). Genetic markers such as human leukocyte antigen have shown recent promise for both pre-prescription screening as well as pre-emptive and diagnostic testing strategies.
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Affiliation(s)
- Ana Copaescu
- Department of Infectious Diseases, Austin Health, Center for Antibiotic Allergy and Research, Heidelberg, VIC, Australia
| | - Andrew Gibson
- Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia.,Clinical Immunology and Allergy, McGill University Health Center, Montréal, Canada
| | - Yueran Li
- Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Center for Antibiotic Allergy and Research, Heidelberg, VIC, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Center, The University of Melbourne, Parkville, VIC, Australia.,Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, VIC, Australia.,The National Center for Infections in Cancer, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia.,Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, United States
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19
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Abstract
PURPOSE OF REVIEW To provide updates on recent advances in the diagnosis and management of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. RECENT FINDINGS The number of identified HLA allele associations with DRESS continues to grow. There is increasing evidence indicating viral infection, reactivation, and cross-reactivity may play key roles in disease. Translational work illuminated JAK/STAT activation in recalcitrant disease. There is expanding recognition of rapid-onset DRESS resulting from specific drugs. SUMMARY DRESS is a severe form of adverse drug reaction with potential for significant morbidity and mortality. Recent research advances may improve clinical care. HLA screening can now be performed to prevent disease in susceptible patients and may help identify culprit drugs in the near future. Viral testing should be performed on every patient, and if positive, patients potentially treated with antiviral therapy. JAK inhibitors may be an effective treatment option for DRESS. Early onset of disease relative to drug exposure should not exclude the diagnosis of DRESS.
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20
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Jin HJ, Kang DY, Nam YH, Ye YM, Koh YI, Hur GY, Kim SH, Yang MS, Kim S, Jeong YY, Kim MH, Choi JH, Kang HR, Jo EJ, Park HK. Severe Cutaneous Adverse Reactions to Anti-tuberculosis Drugs in Korean Patients. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2021; 13:245-255. [PMID: 33474859 PMCID: PMC7840880 DOI: 10.4168/aair.2021.13.2.245] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/08/2020] [Accepted: 07/30/2020] [Indexed: 12/18/2022]
Abstract
Purpose Anti-tuberculosis drugs (ATDs) can cause severe cutaneous adverse reactions (SCARs) such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS). Underlying tuberculous infection and co-administration of multiple drugs may contribute to the complexity of ATD-related SCARs. This study aimed to investigate the clinical characteristics and outcomes of ATD-related SCARs. Methods We analyzed ATD-related SCAR cases in 2010-2015, selected from a web-based Database of the Korean Registry of SCAR. Results Among 783, 53 patients with ATD-induced SCARs were enrolled, including 12 with SJS/TEN (22.6%) and 41 with DRESS (77.4%). When comparing the ATD and non-ATD groups, the prevalence of DRESS patients was higher in the ATD group than in the non-ATD group (77.4% vs. 45.8%, P < 0.001). Among patients with ATD-related SCARs, those with SJS/TEN were significantly older, had higher intensive care unit admissions, and had higher mortality than those with DRESS (70.5 vs. 50.0 years, P < 0.001; 41.7% vs. 6.1%, P = 0.010; and 33.3% vs. 2.5%, P = 0.003, respectively). ATDs were challenged in 14 cases. The ATD associated most often with SCAR cases was rifampin (81.8%), followed by isoniazid (66.7%), ethambutol (50.0%), pyrazinamide (33.3%). Six patients (42.9%) had hypersensitivity reactions to 2 or more drugs. Conclusions DRESS was more common among the ATD-related SCAR cases. Although treatment with most ATDs carries the risk of SCAR development, the use of rifampin was most frequently involved in the occurrence of SCARs. Multiple hypersensitivity was frequently observed in ATD-related SCARs.
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Affiliation(s)
- Hyun Jung Jin
- Department of Internal Medicine, Medical School of Yeungnam University, Daegu, Korea
| | - Dong Yoon Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
| | - Young Hee Nam
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Young Il Koh
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Gyu Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sae Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Min Suk Yang
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Sujeong Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yi Yeong Jeong
- Department of Internal Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Min Hye Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Jeong Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hwaseong and Allergy and Clinical Immunology Research Center, Hallym University College of Medicine, Chuncheon, Korea
| | - Hye Ryun Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Jung Jo
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Hye Kyung Park
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea.
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21
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Srinoulprasert Y, Rerkpattanapipat T, Sompornrattanaphan M, Wongsa C, Kanistanon D. Clinical value of in vitro tests for the management of severe drug hypersensitivity reactions. Asia Pac Allergy 2020; 10:e44. [PMID: 33178569 PMCID: PMC7610079 DOI: 10.5415/apallergy.2020.10.e44] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/29/2020] [Indexed: 12/14/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) occasionally present with severe cutaneous adverse reactions (SCARs) which result in a high risk of morbidity and mortality. Although SCARs are rare, the occurrence could lead to a significant increase in healthcare and economic burden, especially when more than one possible culprit drug is implicated. Therefore, the accurate identification of the culprit drug(s) is important for correct labeling and subsequent patient education and avoidance. To date, clinical evaluation using causality assessment has limitations because the assessment may be inaccurate due to the overlapping timelines when multiple drugs are initiated/continued. Moreover, drug provocation tests (DPTs) which is the gold standard in diagnosis, are contraindicated, and in vivo skin tests may also be associated with risks of triggering SCAR. The European Network for Drug Allergy recommended that in vitro tests, if available, should be performed before any in vivo tests. Basophil activation tests and lymphocyte transformation tests, could serve as reliable in vitro tests for both immediate and delayed-type DHR. Many academic medical centers with affiliated laboratory services offer these tests in the diagnostic evaluation of SCARs in clinical practice. This not only complements identification of the culprit drug(s), but may also be used to test for potentially non cross-reactive alternatives, hence avoiding DPTs. In this review, we summarize the roles of in vitro tests in identifying the culprit drug(s) in SCARs, issues with utilization and interpretation of test results, and our experience in clinical practice.
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Affiliation(s)
- Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ticha Rerkpattanapipat
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Mongkhon Sompornrattanaphan
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chamard Wongsa
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Duangjit Kanistanon
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Abstract
Stevens–Johnson syndrome and toxic epidermal necrolysis are rare severe blistering skin reactions triggered by medications or infections. Over the last 5 to 10 years, a number of important publications have advanced understanding of these diseases and their response to treatment. Importantly, a subset of patients with disease triggered by infection has been identified as having Mycoplasma pneumoniae–induced rash and mucositis, suggesting a reconsideration of the diagnostic paradigm. We present an update on pediatric Stevens–Johnson syndrome and toxic epidermal necrolysis in the broader context of cutaneous adverse drug reactions and focus on challenges and recent advances in diagnosis, management, and prevention.
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Affiliation(s)
- Michele Ramien
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, 28 Oki Dr NW, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jennifer L Goldman
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA.,Division of Pediatric Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
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23
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Faridnia R, Kalani H, Hezarjaribi HZ, Denny PW, Rafie A, Fakhar M, Virgilio S. Apoptotic blebs from Leishmania major-infected macrophages as a new approach for cutaneous leishmaniasis vaccination. Microb Pathog 2020; 147:104406. [PMID: 32738284 DOI: 10.1016/j.micpath.2020.104406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 11/25/2022]
Abstract
We focused on apoptotic blebs from Leishmania major-infected macrophages as a vaccine for cutaneous leishmaniasis. Apoptosis was induced in L. major-infected J774A.1 cells in order to prepare apoptotic blebs. Test groups of BALB/c mice were immunized with these at doses of 1 × 106, 5 × 106 or 1 × 107 blebs. An immunization control group received Leishmania lysate antigens. The results showed that as the number of apoptotic bodies increased, the lymphocyte proliferation index increased, and this was proportional to IFN-γ level in the test groups. Additionally, the difference of IFN-γ, IL-4, IFN-γ/IL-4 ratio, or total IgG (p < 0.0001) in all groups was statistically significant compared to the negative control group. The highest IFN-γ (514.0 ± 40.92 pg/mL) and IFN-γ/IL-4 ratio (2.94 ± 0.22) were observed in the group that received 1 × 107 apoptotic blebs. The highest levels of IL-4 (244.6 ± 38.8 pg/mL) and total IgG (5626 ± 377 μg/mL) were observed in the immunization control group. Reflecting these data, no lesions were observed in any of the groups vaccinated with apoptotic blebs after 12 weeks. In summary, the use of apoptotic blebs from L. major-infected macrophages is protective against the challenge with L. major in this animal model.
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Affiliation(s)
- Roghiyeh Faridnia
- Student Research Committee, Pediatric Infectious Diseases Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hamed Kalani
- Infectious Diseases Research Center, Golestan University of Medical Sciences, Gorgan, Iran.
| | - Hajar Ziaei Hezarjaribi
- Toxoplasmosis Research Center, Communicable Diseases Institute, Department of Parasitology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Paul W Denny
- Department of Biosciences and Centre for Global Infectious Disease, Durham University, Stockton Road, Durham, DH1 3LE, United Kingdom
| | - Alireza Rafie
- Molecular and Cell Biology Research Center, Department of Immunology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahdi Fakhar
- Toxoplasmosis Research Center, Communicable Diseases Institute, Department of Parasitology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran; Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Stela Virgilio
- Department of Cell and Molecular Biology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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Zhang X, Lu WS, Qin XM. Cytokines/Chemokines: Novel Biomarkers Associated with Severe Cutaneous Adverse Reactions. J Interferon Cytokine Res 2020; 40:172-181. [PMID: 32195616 DOI: 10.1089/jir.2019.0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although the incidence of severe cutaneous adverse reactions (SCARs) is very low, if it is not diagnosed and treated in time, it can not only cause skin and mucous membrane involvement, but can also cause multiple organ failure and even death. The diagnostic criteria and treatment guidelines for severe drug eruptions have not been unified. Many medical centers have used human leukocyte antigen alleles to diagnose SCARs. Some prospective studies have shown that susceptibility gene testing can prevent SCARs as early as possible, but the widespread implementation of its technology is limited by being ethnically specific. With the unique advantages of cytokine detection technology, cytokines are increasingly important for the diagnosis and treatment of SCARs. Related cytokines/chemokines involved in the pathogenesis, adjuvant diagnosis, and treatment of SCARs are discussed.
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Affiliation(s)
- Xiang Zhang
- Department of Dermatology, The Second Affiliated Hospital, WanNan Medical College, Wuhu, China
| | - Wen-Shen Lu
- Department of Dermatology, Affiliated Provincial Hospital, University of Science and Technology of China, Hefei, China
| | - Xiao-Ming Qin
- Department of Dermatology, The Second Affiliated Hospital, WanNan Medical College, Wuhu, China
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Drug Reaction with Eosinophilia and Systemic Symptoms (DReSS): How Far Have We Come? Am J Clin Dermatol 2019; 20:217-236. [PMID: 30652265 DOI: 10.1007/s40257-018-00416-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DReSS), also known as drug-induced hypersensitivity syndrome (DiHS), is an uncommon severe adverse reaction to medications. It is important to recognize it as it is potentially fatal and can cause significant morbidity. From the first reports of drug reactions related to certain anticonvulsants characterized by fever, liver enzyme elevation, and skin changes, our continuously growing understanding of this entity has allowed us to describe its physiopathology and clinical features even further. The relationship of genetic factors, viral activation, and specific drug exposure is now known to play a role in this disease. There is still not a widely accepted marker for DReSS/DiHS, but the spectrum of clinical and laboratory features has now been better outlined. The mainstay of treatment is the use of systemic corticosteroids, but other options such as intravenous immunoglobulin, cyclosporine, mycophenolate mofetil, rituximab, and cyclophosphamide have been described. We present a comprehensive review of the literature on DReSS/DiHS, focusing on its history, etiopathogenesis, diagnosis, therapeutic approach, and outcome.
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Samuelov L, Nathan A, Slutsky E, Fruchter D, Gat A, Sprecher E, Goldberg I. Nested case–control study investigating the diagnostic role of tissue eosinophilia in adverse cutaneous drug reactions. J Eur Acad Dermatol Venereol 2019; 33:1152-1157. [DOI: 10.1111/jdv.15509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 01/18/2019] [Indexed: 12/21/2022]
Affiliation(s)
- L. Samuelov
- Department of Dermatology Tel Aviv Sourasky Medical Center Affiliated with Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - A. Nathan
- Department of Dermatology Tel Aviv Sourasky Medical Center Affiliated with Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - E. Slutsky
- Department of Dermatology Tel Aviv Sourasky Medical Center Affiliated with Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - D. Fruchter
- Department of Dermatology Tel Aviv Sourasky Medical Center Affiliated with Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - A. Gat
- Institute of Pathology Tel Aviv Sourasky Medical Center Affiliated with Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - E. Sprecher
- Department of Dermatology Tel Aviv Sourasky Medical Center Affiliated with Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - I. Goldberg
- Department of Dermatology Tel Aviv Sourasky Medical Center Affiliated with Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
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