Liver enzyme elevation and eosinophilia with atorvastatin: a case of probable DRESS without cutaneous symptoms

Atorvastatin hypersensitivity reaction within 24 hours of first dose

We report a case of atorvastatin-induced hypersensitivity reaction in a 58-year-old male following first exposure to the drug. The patient took one dose of atorvastatin 40 mg and presented to the emergency department (ED) within 24 h with a chief complaint of throat swelling, trouble swallowing, and throat pain. The patient did not have pruritis or skin manifestations. The patient's vital signs were within normal limits. However, the patient had leukocytosis with a white blood cell (WBC) count of 12.68 × 10³/mcL. Eosinophils were within normal limits at 1.6 × 10³/mcL. Bilirubin was slightly elevated at 1.6 mg/dL. The patient was treated with epinephrine, famotidine, and diphenhydramine, and his symptoms began to resolve within 15 min. Statin-induced hypersensitivity reactions could be explained by statins' effects on bradykinin 2 receptors that potentiate vasodilation and leading to angioedema. In the literature, cases of hypersensitivity associated with atorvastatin present after months of cumulative exposure. Therefore, this case is unique in that a reaction developed within 24 h of that first dose.

Advances in Our Understanding of the Interaction of Drugs with T-cells: Implications for the Discovery of Biomarkers in Severe Cutaneous Drug Reactions

Drugs can activate different cells of the immune system and initiate an immune response that can lead to life-threatening diseases collectively known as severe cutaneous adverse reactions (SCARs). Antibiotics, anticonvulsants, and antiretrovirals are involved in the development of SCARs by the activation of αβ naïve T-cells. However, other subsets of lymphocytes known as nonconventional T-cells with a limited T-cell receptor repertoire and innate and adaptative functions also recognize drugs and drug-like molecules, but their role in the pathogenesis of SCARs has only just begun to be explored. Despite 30 years of advances in our understanding of the mechanisms in which drugs interact with T-cells and the pathways for tissue injury seen during T-cell activation, at present, the development of useful clinical biomarkers for SCARs or predictive preclinical in vitro assays that could identify immunogenic moieties during drug discovery is an unmet goal. Therefore, the present review focuses on (i) advances in the understanding of the pathogenesis of SCARs reactions, (ii) a description of the interaction of drugs with conventional and nonconventional T-cells, and (iii) the current state of soluble blood circulating biomarker candidates for SCARs.