DRESS syndrome: a case report and literature review

Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome: A Case Report From South India

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome usually presents two to six weeks after treatment with a drug implicated in this disorder. However, in some cases, it can present more than eight weeks after the initiation of an implicated medication. This is a type 4 drug hypersensitivity reaction in which any internal organ may be involved. While the liver is commonly involved, cardiac involvement is not unheard of. Comorbidities and multiorgan involvement may obscure the diagnosis, and Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) criteria are a useful diagnostic aid. It is best treated by withdrawing the offending agent and administering systemic steroids. Oxidative stress is high in DRESS syndrome. Hepatoprotection is a priority in all patients and yields a better prognosis.

Fatal Itching and Failing Liver: A Case Report and Literature Review of Rare, Atypical DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) Syndrome

DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) syndrome is a rare, life-threatening, hypersensitivity reaction. The prolonged course and non-specific symptoms of the condition make diagnosis challenging. We present a case of DRESS syndrome that was misdiagnosed as urticaria. Investigations revealed deranged liver and kidney functions and abnormal blood count. The presented case emphasizes the need to have a high suspicion for DRESS syndrome in patients who present with jaundice, generalized rash, acute renal failure, and acute liver failure.

Hepatic Safety of Febuxostat and Allopurinol for Gout Patients: A Systematic Review of Randomized Controlled Trial

Purpose

This study aims to systematically review the hepatic safety of febuxostat and allopurinol in adult gout patients.

Methods

We searched for information using the following databases: PubMed, Cochrane Library, and Scopus. The inclusion criteria were to review all randomized controlled trials (RCT) that compared allopurinol and febuxostat for adult gout patients that had an assessment of liver function outcomes. Non-English studies on case reports, case series, reviews, and abstracts only were excluded. We extracted information from the studies to answer the research question, ie, study design, publication year, population, sample size, patient characterization, duration, Jadad score, and liver function outcomes.

Results

We screened 512 publications from the databases and identified 11 studies that met the inclusion criteria. Ten out of 11 included studies were double-blind RCTs. In the majority of the included studies, no statistically significant differences were observed in terms of hepatic safety data between febuxostat and allopurinol. However, in studies where allopurinol titration was used, it posed a challenge to maintain blinding. Notably, consistent adverse events related to liver function findings were observed across all reviewed RCTs. These abnormal liver function test results sometimes led to study withdrawal based on the investigators' assessment. Nevertheless, the investigators classified most liver function test elevations as mild to moderate in severity.

Conclusion

Our analysis concluded that adult gout patients enrolled in the included RCTs exhibited similar hepatic safety profiles for both febuxostat and allopurinol treatment. Liver function abnormalities were identified in all RCTs included in this systematic review. Consequently, it is important for the product labeling information of both allopurinol and febuxostat to present and describe the current safety data to guide healthcare practitioners when prescribing these medications to patients. Pharmacovigilance and post-marketing pharmacoepidemiology data are essential in establishing the comprehensive safety profile.

COVID-19 Vaccine: A Common Suspect but Rare Culprit in Drug Rash With Eosinophilia and Systemic Symptoms (DRESS) Syndrome

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a rare drug reaction that commonly presents with rash, fever, lymphadenopathy, eosinophilia, and multiorgan involvement. We present a case of this syndrome in a 31-year-old male who presented with a diffuse erythematous morbilliform rash with high fever and elevated liver enzymes. Upon history taking, the patient reported acute onset of multiple seizures that required intubation and ICU admission six weeks prior, which started 24 hours after receiving the Johnson and Johnson Janssen coronavirus disease 2019 (COVID-19) vaccine. During that hospitalization, he was given antiseizure medications Keppra (levetiracetam) and Dilantin (phenytoin), which he was eventually discharged home with. During our encounter with the patient, Dermatology was consulted and recommended punch skin biopsy, which revealed spongiotic dermatitis with subcorneal pustules along with superficial perivascular and mixed lymphocytic and neutrophilic infiltrate with dermal edema and rare eosinophils. Given these findings in conjunction with the patient's fever, elevated liver function, and cervical lymphadenopathy, the rash was consistent with DRESS syndrome or a pustular drug eruption likely secondary to phenytoin or levetiracetam. This case was eventually resolved with treatment with oral and topical corticosteroids and close outpatient follow-up with Dermatology. Prompt diagnosis and treatment of DRESS syndrome are therefore critical as the mortality rate can be as high as 10% in the setting of liver failure.

A typical presentation of moxifloxacin-induced DRESS syndrome with pulmonary involvement: a case report and review of the literature

Background

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a kind of hypersensitivity drug reaction involving the skin and multiple internal organ systems. Moxifloxacin has rarely been reported to be a drug that is associated with DRESS syndrome. Lungs are less frequently involved in DRESS syndrome, but their involvements may herald more serious clinical processes. We present a rare typical case of moxifloxacin-induced DRESS syndrome with lungs involved. Valuable clinical data such as changes in the pulmonary imaging and pulmonary function tests was recorded. This case is important for the differential diagnosis of DRESS syndrome with lungs involved by providing clinical manifestations, CT imaging, pulmonary function tests, and biopsy pathological characteristics. The changes in pulmonary imaging and pulmonary function tests may help us understand the mechanism of DRESS syndrome further.

Case presentation

We report a case of a 47-year-old woman who was treated with oral moxifloxacin for community-acquired pneumonia. The patient subsequently developed a cough, fever, liver injury, skin rash, hematologic abnormalities, and shortness of breath (SOB) followed by pharyngeal herpes and peripheral neuritis. These symptoms, clinical lab index, and CT scan of the lungs improved after the withdrawal of moxifloxacin. The probability of moxifloxacin-induced DRESS syndrome was rated as “Definite”, with 7 scores graded by RegiSCAR. A literature search was also performed with “fluoroquinolones,” “moxifloxacin,” “ciprofloxacin,” “levofloxacin,” “delafloxacin,” and “DRESS” or “drug-induced hypersensitivity syndrome (DIHS)” as the keywords that were put into PubMed. The overall pulmonary involvement was approximately 9.1% (1/11). It is a rare reported case of DRESS syndrome with pulmonary involvement induced by moxifloxacin. We summarized detailed clinical data, including pulmonary imaging and pulmonary function changes.

Conclusion

This is a rare reported case of DRESS syndrome with pulmonary involvement induced by moxifloxacin. Prompt recognition and correct diagnosis can promote appropriate treatment and accelerate recovery. This case is important for us as a reference in the differential diagnosis of DRESS syndrome and helps us further understand the mechanism of DRESS syndrome.

DRESS characteristics according to the causative medication

BACKGROUND

To date, no study has identified a clear relationship between drug and a specific clinical presentation of DRESS.

OBJECTIVES

To investigate the particularities of DRESS and analyze the variation of DRESS pattern according to culprit drugs.

METHODS

We analyzed cases of DRESS notified to the Department of Clinical Pharmacology at the University Hospital of Monastir over a 15-year period. The statistical study was performed using the comparative and multivariate analysis.

RESULTS

DRESS was mostly induced by anticonvulsive agents (27%) followed by allopurinol (26.3%) and antibiotics (24%): For anticonvulsive agents, the occurrence of lymphadenopathy was higher, renal involvement was rare and mild, and positive skin tests were more frequent. The allopurinol group was associated with the patient's older age and a lower incidence of lymphadenopathy and kidney injury. For antibiotics, eosinophilia rate was lower, time to recovery was shorter, and RegiSCAR score was low. The multivariate analysis showed a link of allopurinol with severe renal impairment, antibiotics with short latency period and low RegiSCAR score, and anticonvulsants with high propensity of positive skin test.

CONCLUSION

We report the largest African and south Mediterranean cohort of DRESS and evaluated the usefulness of skin tests in identifying the culprit drug. The prominent finding was that latency period and renal involvement may independently differ according to culprit drugs.

Drug Reaction With Eosinophilia and Systemic Symptom (DRESS) Following Rifampicin Treatment: A Case Report

Drug reaction with eosinophilia and systemic symptoms (DRESS) is an idiosyncratic severe cutaneous adverse reaction (SCAR) characterized by a skin rash with systemic involvement (e.g., hematological, solid organ abnormalities). Various medications, most commonly anticonvulsants (carbamazepine, phenytoin), antibiotics (vancomycin, amoxicillin), and sulfa drugs (dapsone, sulfasalazine), have been implicated. We report a case of a 75-year-old man with pulmonary tuberculosis under anti-tubercular treatment (ATT Category 1 as per the national guidelines of Nepal) presenting with rash, fever, liver dysfunction, and eosinophilia, a combination of features suggestive of DRESS. According to the national tuberculosis (TB) survey of 2018-2019, over 117,000 people in Nepal were living with TB, including 69,000 newly diagnosed people. In third-world countries, such as Nepal, with a high TB prevalence, and the Southeast Asian region (with a huge percentage of the global burden of ‎TB‎ incidence), the risk of life-threatening adverse drug reactions during ATT is high. However, a good response is seen if it is recognized early and on stopping ATT and receiving a course of steroids and emollients.

A Unique Case Of Tenofovir-Induced DRESS Syndrome Associated With Raynaud's Of The Tongue

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a potentially fatal severe adverse reaction to medications. Numerous drugs have been implicated, with carbamazepine and allopurinol being the most common. Tenofovir-induced DRESS is extremely rare. We report a case of a 65-year-old male patient with a diffuse exfoliative maculopapular rash across his entire body of five weeks of duration. The patient also had icteric sclera, abnormal liver enzymes and Raynaud’s of the tongue, nose and the left fifth finger. After discontinuation of tenofovir, the case resolved over a span of ten days. A high index of suspicion is crucial along with the prompt withdrawal of the offending medication for a good outcome.

Case report: atypical presentation of vancomycin induced DRESS syndrome: a case report and review of the literature

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.

Vancomycin-associated drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: masquerading under the guise of sepsis

A patient presented with what appeared to be severe urosepsis. After admission and antibiotic administration, a newly developed rash and subsequent facial swelling appeared to be a reaction to penicillin class antibiotics. However, despite changing class of therapy with continued antimicrobial coverage, end organ damage continued, the rash worsened and facial oedema developed. Drug reaction with eosinophilia and systemic symptoms was ultimately diagnosed and was consistent with clinical and histopathological findings, as well as meeting all criteria for scoring systems. The patient was started on intravenous methylprednisolone 125 mg per 8 hours with rapid improvement of rash, swelling and end organ damage. Initial challenge to decrease dose failed, but the patient was ultimately able to be discharged on an extended taper.

Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)

OBJECTIVE

To review the hypersensitivity reaction to drugs known as drug reaction with eosinophilia and systemic symptoms (DRESS syndrome), based on a case report. We also intend to discuss the difficulty and importance of disease recognition, since none of the changes is pathognomonic of this disease and failure to identify it may have disastrous consequences for the patient.

METHOD

To describe this case report, in addition to the information collected for clinical assessment, a literature review was performed in the PubMed and Bireme databases in order to retrieve the latest information published in literature on DRESS syndrome.

RESULTS

The case of a 20-year old patient is reported. After anamnesis, physical examination and laboratory tests a diagnosis of DRESS syndrome was performed, characterized by rash, hematologic alterations, lymphadenopathy and lesions in target organ. This is a rare syndrome, whose frequency varies according to the drug used and the immune status of the patient, being more often associated with the use of anticonvulsants.

CONCLUSION

The approach and discussion of the topic are of paramount importance, in view of the potential lethality of this treatable syndrome. Recognizing the occurrence of DRESS syndrome and starting treatment as soon as possible is crucial to reduce the risk of mortality and improve prognosis.

Severe dermatologic reactions with bendamustine: a case series

Cutaneous drug reactions make up the largest proportion of adverse events in the medical field. Causality, in particular, is difficult to determine, and therefore, preventing recurrent reactions can be challenging. Bendamustine was initially thought to be a well-tolerated chemotherapy agent with few side effects aside from bone marrow suppression. However, the incidence of cutaneous reactions reported is rising. We describe three such reactions in relation to bendamustine administration in hopes of adding to the awareness of such side effects.