Drug reaction with eosinophilia and systemic symptoms (DRESS) and its relation with autoimmunity in a reference center in Mexico

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Focus on the Pathophysiological and Diagnostic Role of Viruses

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a heterogeneous, multiorgan and potentially life-threatening drug-hypersensitivity reaction (DHR) that occurs several days or weeks after drug initiation or discontinuation. DHRs constitute an emerging issue for public health, due to population aging, growing multi-organ morbidity, and subsequent enhanced drug prescriptions. DRESS has more consistently been associated with anticonvulsants, allopurinol and antibiotics, such as sulphonamides and vancomycin, although new drugs are increasingly reported as culprit agents. Reactivation of latent infectious agents such as viruses (especially Herpesviridae) plays a key role in prompting and sustaining aberrant T-cell and eosinophil responses to drugs and pathogens, ultimately causing organ damage. However, the boundaries of the impact of viral agents in the pathophysiology of DRESS are still ill-defined. Along with growing awareness of the multifaceted aspects of immune perturbation caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the ongoing SARS-CoV-2-related disease (COVID-19) pandemic, novel interest has been sparked towards DRESS and the potential interactions among antiviral and anti-drug inflammatory responses. In this review, we summarised the most recent evidence on pathophysiological mechanisms, diagnostic approaches, and clinical management of DRESS with the aim of increasing awareness on this syndrome and possibly suggesting clues for future research in this field.

Late sequelae of drug reaction with eosinophilia and systemic symptoms (DRESS) cause thyroid dysfunction and thyroiditis: review of literature

Drug reaction with eosinophilia and systemic symptoms (DRESS) is one of the severe cutaneous adverse drug reactions (SCARs) with high mortality rate and variable long term sequelae, especially in thyroid dysfunction and thyroiditis. In this article, we review clinical course, culprit drugs, onset of diagnosis, and type of thyroid dysfunction in DRESS patients. There were a total of 51 cases including 12 children (aged less than 18 years old) and 39 adults from our review. The most common thyroid dysfunction was Hashimoto's thyroiditis (41/51=80.4%) including anti-thyroid antibody positive (29/51=56.9%), possible/compatible with Hashimoto's thyroiditis (12/51=23.5%) both in the children (n=12) and adult (n=39), Graves' disease/hyperthyroidism (7/51=13.7%) and non-specific hypothyroidism (3/51=5.9%), respectively. The most common culprit drugs and onset of thyroid dysfunction after DRESS diagnosis in children aged less than 18 years include antiepileptic drugs (phenytoin, phenobarbital, carbamazepine) (range 0-8 months, median 2 months) and sulfa groups (sulfasalazine, sulfamethoxazole, sulfonamide) (range 1-4 months, median 2 months). Data of prevalence, type, and clinical course of thyroid dysfunction from DRESS is important for clinicians to recognize for monitoring its sequelae and provide plans for treatment.

Drug Reaction with Eosinophilia and Systemic Symptoms (DReSS)/Drug-Induced Hypersensitivity Syndrome (DiHS)-Readdressing the DReSS

Drug reaction with eosinophilia and systemic symptoms (DReSS), also known as drug-induced hypersensitivity syndrome (DiHS), is a severe, systemic, T cell mediated drug reaction with combinations of cutaneous, hematologic, and internal organ involvement. Pathogenesis of DReSS is multi-factorial, involving drug-exposure, genetic predisposition through specific human leukocyte antigen (HLA) alleles and metabolism defects, viral reactivation, and immune dysregulation. Clinical features of this condition are delayed, stepwise, and heterogenous, making this syndrome challenging to recognize and diagnose. Two sets of validated diagnostic criteria exist that can be employed to diagnose DReSS/DiHS. Methods to improve early recognition of DReSS and predict disease severity has been a recent area of research focus. In vitro and in vivo tests can be employed to confirm the diagnosis and help identify culprit drugs. The mainstay treatment of DReSS is prompt withdrawal of the culprit drug, supportive treatment, and immunosuppression depending on the severity of disease. We present a comprehensive review on the most recent research and literature on DReSS, with emphasis on pathogenesis, clinical features, diagnosis, confirmatory testing modalities, and treatment. Additionally, this summary aims to highlight the differing viewpoints on this severe disease and broaden our perspective on the condition known as DReSS.

Autoimmune Diseases, End Organ Dysfunction and Adverse Drug Reaction Following Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): A Retrospective Cohort Study

Context:

Autoimmune diseases, organ dysfunction and new drug allergies are mentioned as long-term complications after DRESS. There is scarcity of data on this from the country.

Aims:

To determine the frequency of autoimmune diseases, organ dysfunction, and new drug allergies after the resolution of DRESS.

Settings and Design:

This retrospective cohort study was carried out among patients who received treatment for DRESS in a tertiary referral center.

Materials and Methods:

In this retrospective cohort study, DRESS patients who received inpatient care in the dermatology department of our tertiary referral center from August 2014 to February 2017 were included. We excluded patients aged 12 years or below and those who had not completed minimum two years after the resolution of DRESS as on December 2019. We collected information on new onset autoimmune disease, end organ damage and new drug allergies detected after the resolution of DRESS through a telephonic interview. Those who consented were evaluated in our department.

Results:

We could contact 40/50 (80%) identified individuals and all of them consented for telephonic interview. 17 patients gave consent for revaluation in our department. There were 22 females and 18 males. 17 had definite and 23 had probable DRESS. The frequency of detection of a new disease and a new drug allergy after DRESS was 10% (4/40) and 7.5% (3/40), respectively. We noted three (7.5%) autoimmune diseases (rheumatoid arthritis 1, alopecia areata 1, chronic autoimmune urticaria 1) and one end organ damage (chronic kidney disease) among the study participants.

Limitations:

Small sample size and retrospective study design were the limitations.

Conclusions:

Prospective studies with large sample size are needed to delineate the link between DRESS and autoimmunity, end organ damage, and new drug allergies.

Allopurinol-induced severe cutaneous adverse drug reactions: Risk minimization measures in Malaysia

PURPOSE

To describe risk minimization measures (RMMs) implemented in Malaysia for allopurinol-induced severe cutaneous adverse drug reactions (SCARs) and examine their impact using real-world data on allopurinol usage and adverse drug reaction (ADR) reports associated with allopurinol.

METHODS

Data on allopurinol ADR reports (2000-2018) were extracted from the Malaysian ADR database. We identified RMMs implemented between 2000 and 2018 from the minutes of relevant meetings and the national pharmacovigilance newsletter. We obtained allopurinol utilization data (2004-2018) from the Pharmaceutical Services Programme. To determine the impact of RMMs on ADR reporting, we considered ADR reports received within 1 year of RMM implementation. We used the Pearson χ² test to examine the relation between the implementation of RMMs and allopurinol ADR reports.

RESULTS

The 16 RMMs for allopurinol-related SCARs implemented in Malaysia involved nine risk communications, four prescriber or patient educational material, and three health system innovations. Allopurinol utilization decreased by 21.5% from 2004 to 2018. ADR reporting rates for all drugs (n = 144 507) and allopurinol (n = 1747) increased. ADR reports involving off-label use decreased by 6% from 2011. SCARs cases remained between 20% and 50%. RMMs implemented showed statistically significant reduction in ADR reports involving off-label use for August 2014 [χ² _{(1, N = 258)} = 5.32, P = .021] and October 2016 [χ² _{(1, N = 349)} = 3.85, P = .0499].

CONCLUSIONS

RMMs to promote the appropriate use of allopurinol and prescriber education have a positive impact. We need further measures to reduce the incidence and severity of allopurinol-induced SCARs, such as patient education and more research into pharmacogenetic screening.

Severe cutaneous adverse reaction associated with antiseizure medications: Diagnosis, management, and prevention

Severe cutaneous adverse reactions (SCARs) are potentially life-threatening, with considerable morbidity and mortality. They are nonimmediate hypersensitivity reactions that occur in specifically predisposed patients with delayed T-cell-mediated hypersensitivity reaction. Antiseizure medications (ASMs) are among the drugs that can induce SCAR. Increased awareness of SCAR among clinicians treating patients with ASMs is critically important for early recognition of symptoms, prompt identification and removal of the causal drug, and early intervention to reduce SCAR-related acute and long-term morbidity and mortality. The diagnosis, management, and prevention of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) are reviewed, along with the current understanding of the pathomechanisms and role of genetics in SCAR development. Supportive care and immunomodulating treatments for SCAR are discussed.

Drug reaction with eosinophilia and systemic symptoms: A single center descriptive observational study

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse cutaneous drug reaction with mortality up to 10%. It is a rare condition with risk varying between 1 in 1000 and 1 in 10 000 drug exposures. The aim of the study was to describe clinical features, management and drugs responsible for causing DRESS. The study was retrospective, observational study. The data of patients admitted to hospital with diagnosis of DRESS during study period (March 2018 to February 2020), were retrieved and analyzed. The descriptive data of patients were summarized. The continuous variables were summarized as mean ± SD and/or median, depending on the skewness of the data. The categorical variables were expressed as absolute numbers, frequency, and proportions (%). The data was tabulated and analyzed in Microsoft Excel 2019 version. A total of 20 patients who met inclusion criteria (probable or definite DRESS as per RegiSCAR criteria) were included in the study. The mean age of the patients was 41.2 ± 15.7 years. The average latency period was 26.45 ± 5.65 days (range: 7-60). The commonest culprit drugs were dapsone and phenytoin, each in five (25%) patients. Commonest morphology of rash was morbilliform in 13 (65%) patients. One patient with targetoid rash had multi-organ involvement. Facial edema, periorbital edema, and conjunctival injection were seen in 17 (85%), seven (35%), and six (30%) cases, respectively. Eosinophilia was present in 18 (90%) patients with mean (±SD) value of 1976 ± 840 cells/μl. Liver was the commonest internal organ involved in 14 (70%) patients and kidney in three (15%) patients. The initial dose of prednisolone for treatment varied from 0.75 to 2 mg/kg/day. The mean duration of steroid treatment was 64 ± 21 days. Two patients were treated with intravenous methylprednisolone and one with intravenous immunoglobulin. Two patients (10%) had recurrence of adverse drug reaction >6 months after completion of initial treatment and two (10%) developed autoimmune thyroiditis during follow-up. Small sample size and retrospective nature of the study were main limitations. Selection bias is a possibility as study was carried out in tertiary care center. Tests for incriminating culprit drugs such as patch test, intradermal test, and lymphocyte transformation test were not performed. DRESS is a rare disease that can be diagnosed early with high index of suspicion and treated successfully with steroids. The internal organ involvement is common in DRESS and requires a thorough evaluation.

Drug Reaction with Eosinophilia and Systemic Symptoms (DReSS): How Far Have We Come?

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.