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Cadot R, Gery P, Lenief V, Nicolas JF, Vocanson M, Tauber M. Exploring recent advances in drugs severe cutaneous adverse reactions immunopathology. Allergy 2024. [PMID: 39295209 DOI: 10.1111/all.16316] [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: 06/26/2024] [Revised: 08/13/2024] [Accepted: 09/03/2024] [Indexed: 09/21/2024]
Abstract
Severe cutaneous adverse reactions to drugs (SCARs) are rare but life-threatening delayed allergies. While they primarily affect the skin, they can also affect internal organs. Accordingly, they present with diverse clinical symptoms that vary not only between SCARs subtypes but also among patients. Despite the availability of topical and systemic treatments, these only address the symptoms and not the cause. To develop more effective therapies, it is necessary to elucidate the complexity of the pathophysiology of SCARs in relation to their severity. In line with the new type IV hypersensitivity reactions nomenclature proposed by the European Academy of Allergy and Clinical Immunology (EAACI), this review highlights the current insights into the intricate immune mechanisms engaged, the interplay between the culprit drug and genetic predisposition in drug presentation mechanisms, but also how external factors, such as viruses, are implicated in SCARs. Their relevance to the development of targeted medicine is also discussed.
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Affiliation(s)
- Romane Cadot
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
| | - Perrine Gery
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
| | - Vanina Lenief
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
| | - Jean-François Nicolas
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
- Allergology and Clinical Immunology Department, Lyon Sud University Hospital, Pierre Bénite, France
| | - Marc Vocanson
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
| | - Marie Tauber
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
- Allergology and Clinical Immunology Department, Lyon Sud University Hospital, Pierre Bénite, France
- Reference center for toxic bullous dermatitis and severe cutaneous adverse reactions, Hospices Civils de Lyon, Lyon, France
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2
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Armstrong A, Tang Y, Mukherjee N, Zhang N, Huang G. Into the storm: the imbalance in the yin-yang immune response as the commonality of cytokine storm syndromes. Front Immunol 2024; 15:1448201. [PMID: 39318634 PMCID: PMC11420043 DOI: 10.3389/fimmu.2024.1448201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 08/22/2024] [Indexed: 09/26/2024] Open
Abstract
There is a continuous cycle of activation and contraction in the immune response against pathogens and other threats to human health in life. This intrinsic yin-yang of the immune response ensures that inflammatory processes can be appropriately controlled once that threat has been resolved, preventing unnecessary tissue and organ damage. Various factors may contribute to a state of perpetual immune activation, leading to a failure to undergo immune contraction and development of cytokine storm syndromes. A literature review was performed to consider how the trajectory of the immune response in certain individuals leads to cytokine storm, hyperinflammation, and multiorgan damage seen in cytokine storm syndromes. The goal of this review is to evaluate how underlying factors contribute to cytokine storm syndromes, as well as the symptomatology, pathology, and long-term implications of these conditions. Although the recognition of cytokine storm syndromes allows for universal treatment with steroids, this therapy shows limitations for symptom resolution and survival. By identifying cytokine storm syndromes as a continuum of disease, this will allow for a thorough evaluation of disease pathogenesis, consideration of targeted therapies, and eventual restoration of the balance in the yin-yang immune response.
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Affiliation(s)
- Amy Armstrong
- Department of Cell Systems and Anatomy, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Department of Microbiology, Immunology, and Molecular Genetics, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Yuting Tang
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Neelam Mukherjee
- Department of Microbiology, Immunology, and Molecular Genetics, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Department of Urology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Nu Zhang
- Department of Microbiology, Immunology, and Molecular Genetics, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Gang Huang
- Department of Cell Systems and Anatomy, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Department of Microbiology, Immunology, and Molecular Genetics, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Department of Pathology & Laboratory Medicine, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
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3
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Bao C, Tong Z, Xu Q, Xiao Z, Cheng B, Gong T, Ji C. Phloroglucinol-Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome with Subsequent Fulminant Type 1 Diabetes (FT1D): A Rare Case and Literature Review. Case Rep Dermatol Med 2024; 2024:1018971. [PMID: 39280124 PMCID: PMC11398957 DOI: 10.1155/2024/1018971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 08/12/2024] [Accepted: 08/23/2024] [Indexed: 09/18/2024] Open
Abstract
This study reported a woman with drug reaction with eosinophilia and systemic symptom (DRESS) syndrome induced by phloroglucinol who developed fulminant type 1 diabetes as sequelae. The literature review emphasized the necessity of at least seven months of follow-up for better management of DRESS syndrome.
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Affiliation(s)
- Chengbei Bao
- Department of Dermatology The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350000, Fujian, China
- Fujian Dermatology and Venereology Research Institute The First Affiliated Hospital Fujian Medical University, Fuzhou, China
- Key Laboratory of Skin Cancer of Fujian Higher Education Institutions The First Affiliated Hospital Fujian Medical University, Fuzhou 350000, China
| | - Zequn Tong
- Department of Dermatology The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350000, Fujian, China
- Fujian Dermatology and Venereology Research Institute The First Affiliated Hospital Fujian Medical University, Fuzhou, China
- Key Laboratory of Skin Cancer of Fujian Higher Education Institutions The First Affiliated Hospital Fujian Medical University, Fuzhou 350000, China
| | - Qiuyun Xu
- Department of Dermatology The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350000, Fujian, China
- Fujian Dermatology and Venereology Research Institute The First Affiliated Hospital Fujian Medical University, Fuzhou, China
- Key Laboratory of Skin Cancer of Fujian Higher Education Institutions The First Affiliated Hospital Fujian Medical University, Fuzhou 350000, China
| | - Zhixun Xiao
- Department of Dermatology The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350000, Fujian, China
- Fujian Dermatology and Venereology Research Institute The First Affiliated Hospital Fujian Medical University, Fuzhou, China
- Key Laboratory of Skin Cancer of Fujian Higher Education Institutions The First Affiliated Hospital Fujian Medical University, Fuzhou 350000, China
| | - Bo Cheng
- Department of Dermatology The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350000, Fujian, China
- Fujian Dermatology and Venereology Research Institute The First Affiliated Hospital Fujian Medical University, Fuzhou, China
- Key Laboratory of Skin Cancer of Fujian Higher Education Institutions The First Affiliated Hospital Fujian Medical University, Fuzhou 350000, China
| | - Ting Gong
- Department of Dermatology The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350000, Fujian, China
- Central Laboratory The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350000, Fujian, China
| | - Chao Ji
- Department of Dermatology The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350000, Fujian, China
- Fujian Dermatology and Venereology Research Institute The First Affiliated Hospital Fujian Medical University, Fuzhou, China
- Key Laboratory of Skin Cancer of Fujian Higher Education Institutions The First Affiliated Hospital Fujian Medical University, Fuzhou 350000, China
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4
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Green EA, Fogarty K, Ishmael FT. Penicillin Allergy: Mechanisms, Diagnosis, and Management. Med Clin North Am 2024; 108:671-685. [PMID: 38816110 DOI: 10.1016/j.mcna.2023.08.009] [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] [Indexed: 06/01/2024]
Abstract
Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.
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Affiliation(s)
- Estelle A Green
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Kelan Fogarty
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Faoud T Ishmael
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA; Mount Nittany Health, 1850 East Park Avenue, State College, PA 16803, USA.
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5
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Wei BM, Fox LP, Kaffenberger BH, Korman AM, Micheletti RG, Mostaghimi A, Noe MH, Rosenbach M, Shinkai K, Kwah JH, Phillips EJ, Bolognia JL, Damsky W, Nelson CA. Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part I. Epidemiology, pathogenesis, clinicopathological features, and prognosis. J Am Acad Dermatol 2024; 90:885-908. [PMID: 37516359 DOI: 10.1016/j.jaad.2023.02.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/11/2023] [Accepted: 02/26/2023] [Indexed: 07/31/2023]
Abstract
Drug-induced hypersensitivity syndrome (DiHS), also known as drug reaction with eosinophilia and systemic symptoms (DRESS), is a severe cutaneous adverse reaction (SCAR) characterized by an exanthem, fever, and hematologic and visceral organ involvement. Anticonvulsants, antibiotics, and allopurinol are the most common triggers. The pathogenesis involves a complex interplay between drugs, viruses, and the immune system primarily mediated by T-cells. DiHS/DRESS typically presents with a morbilliform eruption 2-6 weeks after drug exposure, and is associated with significant morbidity, mortality, and risk of relapse. Long-term sequelae primarily relate to organ dysfunction and autoimmune diseases. Part I of this continuing medical education activity on DiHS/DRESS provides an update on epidemiology, novel insights into pathogenesis, and a description of clinicopathological features and prognosis.
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Affiliation(s)
- Brian M Wei
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | | | - Abraham M Korman
- Department of Dermatology, The Ohio State University, Columbus, Ohio
| | - Robert G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arash Mostaghimi
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Megan H Noe
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, California
| | - Jason H Kwah
- Department of Medicine, Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jean L Bolognia
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut; Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Caroline A Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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Roser LA, Luckhardt S, Ziegler N, Thomas D, Wagner PV, Damm G, Scheffschick A, Hewitt P, Parnham MJ, Schiffmann S. Immuno-inflammatory in vitro hepatotoxicity models to assess side effects of biologicals exemplified by aldesleukin. Front Immunol 2023; 14:1275368. [PMID: 38045689 PMCID: PMC10693457 DOI: 10.3389/fimmu.2023.1275368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction Hepatotoxicity induced by immunotherapeutics is an appearing cause for immune-mediated drug-induced liver injury. Such immuno-toxic mechanisms are difficult to assess using current preclinical models and the incidence is too low to detect in clinical trials. As hepatotoxicity is a frequent reason for post-authorisation drug withdrawal, there is an urgent need for immuno-inflammatory in vitro models to assess the hepatotoxic potential of immuno-modulatory drug candidates. We developed several immuno-inflammatory hepatotoxicity test systems based on recombinant human interleukin-2 (aldesleukin). Methods Co-culture models of primary human CD8+ T cells or NK cells with the hepatocyte cell line HepaRG were established and validated with primary human hepatocytes (PHHs). Subsequently, the HepaRG model was refined by increasing complexity by inclusion of monocyte-derived macrophages (MdMs). The main readouts were cytotoxicity, inflammatory mediator release, surface marker expression and specific hepatocyte functions. Results We identified CD8+ T cells as possible mediators of aldesleukin-mediated hepatotoxicity, with MdMs being implicated in increased aldesleukin-induced inflammatory effects. In co-cultures of CD8+ T cells with MdMs and HepaRG cells, cytotoxicity was induced at intermediate/high aldesleukin concentrations and perforin was upregulated. A pro-inflammatory milieu was created measured by interleukin-6 (IL-6), c-reactive protein (CRP), interferon gamma (IFN-γ), and monocyte chemoattractant protein-1 (MCP-1) increase. NK cells responded to aldesleukin, however, only minor aldesleukin-induced cytotoxic effects were measured in co-cultures. Results obtained with HepaRG cells and with PHHs were comparable, especially regarding cytotoxicity, but high inter-donor variations limited meaningfulness of the PHH model. Discussion The in vitro test systems developed contribute to the understanding of potential key mechanisms in aldesleukin-mediated hepatotoxicity. In addition, they may aid assessment of immune-mediated hepatotoxicity during the development of novel immunotherapeutics.
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Affiliation(s)
- Luise A. Roser
- Department of Preclinical Research, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Frankfurt am Main, Germany
| | - Sonja Luckhardt
- Department of Preclinical Research, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Frankfurt am Main, Germany
| | - Nicole Ziegler
- Department of Preclinical Research, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Frankfurt am Main, Germany
| | - Dominique Thomas
- Department of Preclinical Research, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Frankfurt am Main, Germany
- pharmazentrum frankfurt/ZAFES, Department of Clinical Pharmacology, Goethe-University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Pia Viktoria Wagner
- Department of Preclinical Research, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Frankfurt am Main, Germany
| | - Georg Damm
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Hospital, Leipzig University, Leipzig, Germany
| | - Andrea Scheffschick
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Hospital, Leipzig University, Leipzig, Germany
| | - Philip Hewitt
- Chemical and Preclinical Safety, Merck Healthcare KGaA, Darmstadt, Germany
| | - Michael J. Parnham
- Department of Preclinical Research, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Frankfurt am Main, Germany
| | - Susanne Schiffmann
- Department of Preclinical Research, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Frankfurt am Main, Germany
- pharmazentrum frankfurt/ZAFES, Department of Clinical Pharmacology, Goethe-University Hospital Frankfurt, Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence Immune-Mediated Diseases (CIMD), Frankfurt am Main, Germany
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Dagnon da Silva M, Domingues SM, Oluic S, Radovanovic M, Kodela P, Nordin T, Paulson MR, Joksimović B, Adetimehin O, Singh D, Madrid C, Cardozo M, Baralic M, Dumic I. Renal Manifestations of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome: A Systematic Review of 71 Cases. J Clin Med 2023; 12:4576. [PMID: 37510691 PMCID: PMC10380880 DOI: 10.3390/jcm12144576] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/30/2023] Open
Abstract
Unlike other adverse drug reactions, visceral organ involvement is a prominent feature of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and correlates with mortality. The aim of this study was to systematically review cases published in PubMed-indexed, peer-reviewed journals in which patients had renal injury during the episode of DRESS syndrome (DS). We found 71 cases, of which 67 were adults and 56% were males. Female sex was associated with higher mortality. Chronic kidney disease (CKD) was present in 14% of patients who developed acute kidney injury (AKI) during DS. In 21% of cases, the kidneys were the only visceral organ involved, while 54% of patients had both liver and kidney involvement. Eosinophilia was absent in 24% of patients. The most common classes of medication associated with renal injury in DS were antibiotics in 34%, xanthine oxidase inhibitors in 15%, and anticonvulsants in 11%. Among antibiotics, vancomycin was the most common culprit in 68% of patients. AKI was the most common renal manifestation reported in 96% of cases, while isolated proteinuria or hematuria was present in only 4% of cases. In cases with AKI, 88% had isolated increase in creatinine and decrease in glomerular filtration (GFR), 27% had AKI concomitantly with proteinuria, 18% had oliguria, and 13% had concomitant AKI with hematuria. Anuria was the rarest manifestation, occurring in only 4% of patients with DS. Temporary renal replacement therapy was needed in 30% of cases, and all but one patient fully recovered renal function. Mortality of DS in this cohort was 13%, which is higher than previously reported. Medication class, latency period, or pre-existing CKD were not found to be associated with higher mortality. More research, particularly prospective studies, is needed to better recognize the risks associated with renal injury in patients with DS. The development of disease-specific biomarkers would also be useful so DS with renal involvement can be easier distinguished from other eosinophilic diseases that might affect the kidney.
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Affiliation(s)
| | | | - Stevan Oluic
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL 60402, USA
| | - Milan Radovanovic
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | | | - Terri Nordin
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Family Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Margaret R Paulson
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Bojan Joksimović
- Faculty of Medicine Foca, University of East Sarajevo, 73300 Foca, The Republic of Srpska, Bosnia and Herzegovina
| | - Omobolanle Adetimehin
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Devender Singh
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Nephrology, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Cristian Madrid
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Milena Cardozo
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Marko Baralic
- Department of Nephrology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Igor Dumic
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
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Awad A, Goh MS, Trubiano JA. Drug Reaction With Eosinophilia and Systemic Symptoms: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1856-1868. [PMID: 36893848 DOI: 10.1016/j.jaip.2023.02.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/30/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a potentially life-threatening drug reaction; recognizing the diversity of its clinical presentations, implicated drugs, and management modalities can aid in diagnosis and reduce morbidity and mortality. OBJECTIVE To review the clinical features, drug causes, and treatments deployed in DRESS. METHODS This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to review publications relating to DRESS published between 1979 and 2021. Only publications with a RegiSCAR score of 4 or greater were included (indicating "probable" or "definite" DRESS). The PRISMA guidelines were used for data extraction and the Newcastle-Ottawa scale for quality assessment (Pierson DJ. Respir Care 2009;54:1372-8). The main outcomes included implicated drugs, patient demographics, clinical manifestations, treatment, and sequelae for each included publication. RESULTS A total of 1124 publications were reviewed, and 131 met the inclusion criteria, amounting to 151 cases of DRESS. The most implicated drug classes were antibiotics, anticonvulsants, and anti-inflammatories, although up to 55 drugs were implicated. Cutaneous manifestations were present in 99% of cases, with a median onset of 24 days and maculopapular rash the most common morphology. Common systemic features were fever, eosinophilia, lymphadenopathy, and liver involvement. Facial edema was present in 67 cases (44%). Systemic corticosteroids were the mainstay of DRESS-specific treatment. A total of 13 cases (9%) resulted in mortality. CONCLUSION DRESS diagnosis should be considered in the presence of a cutaneous eruption, fever, eosinophilia, liver involvement, and lymphadenopathy. The class of implicated drug may influence outcome, as allopurinol was associated with 23% of cases that resulted in death (3 cases). Given potential DRESS complications and mortality, it is important that DRESS is recognized early so that any suspect drugs are ceased promptly.
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Affiliation(s)
- Andrew Awad
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Hospital, Heidelberg, VIC, Australia.
| | - Michelle S Goh
- Department of Dermatology, Austin Health, Heidelberg, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Hospital, Heidelberg, VIC, Australia; Department of Infectious Diseases, University of Melbourne, Parkville, VIC, Australia
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9
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Pathania V, Sinha A, Sood A, Kinra P, Das P, Sinha P, Shankar P. DRESS, the maverick among SCARS: A case series-based review of literature. Med J Armed Forces India 2023; 79:328-336. [PMID: 37193529 PMCID: PMC10182279 DOI: 10.1016/j.mjafi.2020.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/27/2020] [Indexed: 12/17/2022] Open
Abstract
DRESS is a potentially life-threatening severe cutaneous adverse reaction (SCAR). Historically, it was most frequently linked with phenytoin and was initially described as phenytoin hypersensitivity syndrome; however, it was later found to be caused by various other medications, with the commonest been aromatic anticonvulsants, allopurinol and sulfonamides. The severity of this entity is related to systemic involvement, which can result in multiorgan failure and death. The diagnosis of DRESS, especially in the early stages, remains challenging and elusive due to its heterogeneous clinical presentation and the complex course of the disease with different patterns depending on the causal drug. The most important step in the management of DRESS is early diagnosis and immediate cessation of the suspected offending drug along with oral steroids or immunosuppressants to control the disease. We describe the varying presentation and management of six adults with DRESS from a tertiary care hospital, observed over a two-year period with a brief review of the literature.
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Affiliation(s)
- Vikas Pathania
- Classified Specialist (Dermatology), Command Hospital (Southern Command), Pune, India
| | - Anwita Sinha
- Graded Specialist (Dermatology), Military Hospital Kirkee, Pune, India
| | - Aradhana Sood
- Senior Advisor (Dermatology), Base Hospital, Lucknow, India
| | - Prateek Kinra
- Professor, Dept of Pathology, Armed Forces Medical College, Pune, India
| | - Pankaj Das
- Graded Specialist (Dermatology), Base Hospital, Delhi Cantt, India
| | - Preema Sinha
- Senior Adviser & Professor (Dermatology), Base Hospital, Lucknow, India
| | - Prerna Shankar
- Officer Commanding, Station Health Organization, Pune, India
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10
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Hypersensibilités médicamenteuses médiées par l’éosinophile (DRESS syndrome) : de la physiopathologie à l’expression clinique. REVUE FRANÇAISE D'ALLERGOLOGIE 2023. [DOI: 10.1016/j.reval.2023.103301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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11
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Green EA, Fogarty K, Ishmael FT. Penicillin Allergy. Prim Care 2023; 50:221-235. [PMID: 37105603 DOI: 10.1016/j.pop.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.
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Affiliation(s)
- Estelle A Green
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Kelan Fogarty
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Faoud T Ishmael
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA; Mount Nittany Health, 1850 East Park Avenue, State College, PA 16803, USA.
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12
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Rubin L, Talmon A, Ribak Y, Kessler A, Martin Y, Haran TK, Shamriz O, Adini I, Tal Y. Novel targeted inhibition of the IL-5 axis for drug reaction with eosinophilia and systemic symptoms syndrome. Front Immunol 2023; 14:1134178. [PMID: 37187735 PMCID: PMC10175640 DOI: 10.3389/fimmu.2023.1134178] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
Background The drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome represents a severe hypersensitivity reaction. Up-to-date treatment is based on withdrawal of medication, supportive care, and immunosuppression using high-dose corticosteroid (CS) therapy. However, evidence-based data are lacking regarding second-line therapy for steroid-resistant or steroid-dependent patients. Objectives We hypothesize that the interleukin (IL)-5 axis plays a critical role in the pathophysiology of DRESS; hence, inhibition of this signaling pathway could offer a potential therapy for steroid-dependent and/or steroid-resistant cases, and it may offer an alternative to CS therapy in certain patients more prone to CS toxicity. Methods Herein, we collected worldwide data on DRESS cases treated with biological agents targeting the IL-5 axis. We reviewed all cases indexed in PubMed up to October 2022 and performed a total analysis including our center experience with two additional novel cases. Results A review of the literature yielded 14 patients with DRESS who were treated with biological agents targeting the IL-5 axis as well as our two new cases. Reported patients are characterized by a female-to-male ratio of 1:1 and a mean age of 51.8 (17-87) years. The DRESS-inducing drugs, as expected from the prospective RegiSCAR study, were mostly antibiotics (7/16), as follows: vancomycin, trimethoprim-sulfamethoxazole, ciprofloxacin, piperacillin-tazobactam, and cefepime. DRESS patients were treated with anti-IL-5 agents (mepolizumab and reslizumab) or anti-IL-5 receptor (IL-5R) biologics (benralizumab). All patients have clinically improved under anti-IL-5/IL-5R biologics. Multiple doses of mepolizumab were needed to achieve clinical resolution, whereas a single dose of benralizumab was often sufficient. Relapse was noted in one patient receiving benralizumab treatment. One patient receiving benralizumab had a fatal outcome, although mortality was probably related to massive bleeding and cardiac arrest due to coronavirus disease 2019 (COVID-19) infection. Conclusion Current treatment guidelines for DRESS are based on case reports and expert opinion. Understanding the central role of eosinophils in DRESS pathogenicity emphasizes the need for future implementation of IL-5 axis blockade as steroid-sparing agents, potential therapy to steroid-resistant cases, and perhaps an alternative to CS treatment in certain DRESS patients more prone to CS toxicity.
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Affiliation(s)
- Limor Rubin
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aviv Talmon
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yaarit Ribak
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Asa Kessler
- Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yossi Martin
- Psychiatric Department, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tal Keidar Haran
- Department of Pathology, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Oded Shamriz
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Lautenberg Center for Immunology and Cancer Research, Institute of Medical Research Israel-Canada, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- *Correspondence: Oded Shamriz, ; Yuval Tal,
| | - Irit Adini
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Yuval Tal
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- *Correspondence: Oded Shamriz, ; Yuval Tal,
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13
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Muacevic A, Adler JR. A Case of Primary Epstein-Barr Virus Infection Masquerading As Drug Reaction With Eosinophilia and Systemic Symptoms. Cureus 2023; 15:e33782. [PMID: 36819351 PMCID: PMC9928221 DOI: 10.7759/cureus.33782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 01/16/2023] Open
Abstract
In this case report, we discuss the diagnostic dilemma presented by a patient admitted for elevated liver enzymes and rash, who had a history of recent amoxicillin use. This presentation initially appeared to fit the criteria for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. However, histologic evaluation determined the rash was consistent with Miliaria rubra rather than the lymphocytic infiltrate of DRESS. This necessitated broad diagnostic testing to determine the underlying etiology of the patient's syndrome. Serology subsequently demonstrated primary Epstein-Barr Virus (EBV) infection, which explained her acute liver injury. Her eosinophilia was potentially related to an allergic reaction to surgical tape but was never definitely diagnosed. This case demonstrates the importance of maintaining a wide differential even when clinical diagnostic criteria are apparently met.
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14
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Clark A, St. Clair B. Severe Cutaneous Adverse Reactions Associated With High-Dose Lamotrigine for Mood Disorders: A Case Series. Innov Pharm 2022; 13:10.24926/iip.v13i2.4541. [PMID: 36654707 PMCID: PMC9836753 DOI: 10.24926/iip.v13i2.4541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Drug-induced Eosinophilia and Systemic Symptoms (DRESS), Stevens-Johnson Syndrome (SJS), and Toxic Epidermal Necrolysis (TEN) are rare but life-threatening immune-mediated drug reactions known as Severe Cutaneous Adverse Reactions (SCARs). These severe drug reactions have been associated with many commonly prescribed medications, including sulfonamides, allopurinol, carbamazepine, and several antiepileptic drugs including lamotrigine.1 Although the risk of these adverse events is recognized by many medical providers, the risk may be overlooked when prescribing lamotrigine for mood disorders. Review of the literature and the experience of these cases suggest that the risk of lamotrigine-associated SCARs is increased when starting lamotrigine at high initial doses. Here we present and discuss two cases of SCARs attributed to high-dose lamotrigine prescribed for mood disorders. A third patient also presented with a SCAR related to high-dose lamotrigine prescribed for a mood disorder during this time but was lost to follow-up and was not reachable. All three patients presented to our hospital system from 2019-2020. Due to this clinical experience, we recommend that pharmacists and prescribers alike be alerted of the risk of severe cutaneous drug reactions when lamotrigine is prescribed, particularly at initial doses greater than 25 mg.
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Affiliation(s)
- Abigale Clark
- Kansas City University of Medicine and Biosciences;,Corresponding author: Abigale Clark, BA Kansas City University of Medicine and Biosciences Phone: (870) 275-2780;
| | - Blake St. Clair
- Department of Dermatology, University of Arkansas for Medical Sciences
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15
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Weir C, Li J, Fulton R, Fernando SL. Development and initial validation of a modified lymphocyte transformation test (LTT) assay in patients with DRESS and AGEP. ALLERGY, ASTHMA & CLINICAL IMMUNOLOGY 2022; 18:90. [PMID: 36210462 PMCID: PMC9548132 DOI: 10.1186/s13223-022-00729-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022]
Abstract
Background The lymphocyte transformation test (LTT) is an in vitro assay used to diagnose drug induced hypersensitivity reactions by detecting the activation and expansion of drug-specific memory T cells to the suspected implicated drug. Traditionally radiolabelled thymidine (3H-thymidine) has been used but requires the handling and disposal of radioactive materials. Objective To examine safe alternatives to 3H-thymidine, test assay modifications for improved assay sensitivity and evaluate the modified LTT in patients with DRESS and AGEP. Methods Four proliferation detection assays (BRDU, CyQUANT™, MTT and XTT) were screened for LTT sensitivity. XTT the most sensitive and practical was selected for further evaluation Modifications like autologous serum (AS) and regulatory T cell depletion (T-REG) were tested for improved assay sensitivity. Finally, an initial evaluation of the XTT–LTT was performed in 8 patients with DRESS and 2 with AGEP including cytokine testing. Results Of the non-radioactive alternatives we tested, XTT a colorimetric assay was the most sensitive and practical to move to evaluation. The addition of AS increased background signal. Depletion of T-REGs improved sensitivity but cell sorting time and risk of contamination limited benefit. Of eight patients diagnosed with DRESS and 2 with AGEP tested with XTT–LTT assay results showed our assay matched clinical findings of implicated drugs in 8/10 patients when using a stimulation index (SI) ≥ 2 and 8/10 with analysis by ANOVA. All ten patients were correctly diagnosed by either analysis. Conclusion XTT appears to be a safe, viable alternative to 3H-thymidine, with high sensitivity and allowing direct cytokine quantification on specific patient cells.
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16
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Song G, Cheng MQ, Li R, Zhang CQ, Sun P. Drug-induced hypersensitivity syndrome with high procalcitonin levels due to piperacillin/tazobactam and meropenem: A case report. Front Med (Lausanne) 2022; 9:951714. [PMID: 36267625 PMCID: PMC9577609 DOI: 10.3389/fmed.2022.951714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare and life-threatening adverse drug reaction. It is characterized by a long latency period with rash, hematological abnormalities, and visceral damage. Clinical manifestations of DRESS vary. Thus, accurate clinical diagnosis and identification are essential to ensure timely treatment commencement for improving prognosis and speeding up recovery. We report the case of a 66-year-old male patient with a drug reaction induced by a beta-lactam antibiotic, piperacillin/tazobactam (Pip/Taz). This resulted in the manifestation of both eosinophilic and systemic symptoms. Ten days after the Pip/Taz treatment commencement, the patient developed hyperthermia and elevated serum procalcitonin (PCT), leading to a misdiagnosis of an exacerbated infection. Meropenem treatment was then started. However, after 72 h, the patient developed a generalized rash, eosinophilia, hematological abnormalities, and visceral damage. Moreover, PCT levels were significantly elevated. All these symptoms were associated with DRESS. The sensitizing drug was discontinued, and glucocorticoids were administered, resulting in gradual subsiding of symptoms and decreases in serum PCT levels. Clinicians should be aware that elevated PCT serum levels may be a diagnostic biomarker for DRESS, which requires specific treatment. Furthermore, studies are warranted to further evaluate and elucidate the role of PCT in response to DRESS.
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Affiliation(s)
- Gao Song
- Department of Pharmacy, The Puer People's Hospital of Yunna City, Puer, China
| | - Meng-Qun Cheng
- Department of Reproductive Medicine, The Puer People's Hospital of Yunna City, Puer, China,*Correspondence: Meng-Qun Cheng
| | - Rong Li
- Department of Pharmacy, The Puer People's Hospital of Yunna City, Puer, China
| | - Cai-Qiong Zhang
- Department of Pharmacy, The Puer People's Hospital of Yunna City, Puer, China
| | - Ping Sun
- Department of Science Education, The Puer People's Hospital of Yunna City, Puer, China
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17
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Drug rash with eosinophilia and systemic symptoms syndrome masquerading as a lymphoproliferative disorder in a young adult on immunosuppressive therapy for rheumatoid arthritis: a case report. J Med Case Rep 2022; 16:336. [PMID: 36059007 PMCID: PMC9442981 DOI: 10.1186/s13256-022-03526-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background This case reveals a novel presentation of drug rash with eosinophilia and systemic symptoms syndrome that mimics a lymphoproliferative disorder. The heterogeneous clinical presentation of drug rash with eosinophilia and systemic symptoms syndrome gives rise to a broad differential diagnosis that includes a multitude of infectious, inflammatory, and autoimmune conditions. This patient was diagnosed with drug rash with eosinophilia and systemic symptoms syndrome 4 weeks after starting sulfasalazine and 5 weeks after starting hydroxychloroquine for rheumatoid arthritis. Both of these medications have been shown to cause drug rash with eosinophilia and systemic symptoms syndrome, albeit more rarely in the context of hydroxychloroquine. This patient’s history, physical examination, and workup illuminate a case of drug rash with eosinophilia and systemic symptoms syndrome that masquerades as a lymphoproliferative disorder despite its adherence to the RegiSCAR criteria. Case presentation A 22-year-old African-American female with an atopic history and rheumatoid arthritis presented for evaluation of a rash, unremitting fevers, and syncope. She was found to have drug rash with eosinophilia and systemic symptoms syndrome. A syncope workup was unremarkable. Computed tomography of the chest/abdomen/pelvis confirmed extensive lymphadenopathy and revealed a small right pleural effusion (Fig. 5). These imaging findings accompanied by fevers and a rash in the setting of eosinophilia, leukocytosis, and transaminitis led to the clinical suspicion for drug rash with eosinophilia and systemic symptoms syndrome. Steroids were subsequently initiated. Broad-spectrum antibiotic therapy was implemented to cover for possible skin/soft tissue infection due to initial paradoxical worsening after discontinuation of the culprit drugs. Lymph node biopsy ruled out a lymphoproliferative disorder and instead demonstrated necrotizing lymphadenitis. An extensive infectious and autoimmune workup was noncontributory. Clinical improvement was visualized, antibiotics were discontinued, and she was discharged on a steroid taper. Conclusion This case reflects how drug rash with eosinophilia and systemic symptoms syndrome can masquerade as a lymphoproliferative disorder. Additionally, it highlights the extent to which rapid identification and treatment optimized the patient’s outcome. It calls into question how immunogenetics may factor into a patient’s susceptibility to acquire drug rash with eosinophilia and systemic symptoms syndrome. This case is unique because of the early onset of visceral organ involvement, the type of internal organ involvement, the hematopoietic features, and the lymphadenopathy associated with a disease-modifying antirheumatic drug.
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18
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Chen DH, Zhou HR, Zhang YG, Shen GY, Xu C, Guan CL. Drug hypersensitivity syndrome induced by sulfasalazine: A case report. Medicine (Baltimore) 2022; 101:e30060. [PMID: 35984191 PMCID: PMC9388030 DOI: 10.1097/md.0000000000030060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Drug hypersensitivity syndrome (DHS) induced by sulfasalazine is a serious systemic delayed adverse drug reaction, which is associated with significant morbidity and mortality. PATIENT CONCERNS A 52-year-old man was hospitalized for developing a rash after 3 weeks of sulfasalazine treatment for ulcerative colitis (UC). DIAGNOSIS The patient was diagnosed with DHS based on his drug history, clinical manifestations, and laboratory test results. INTERVENTIONS The patient was administered intravenous glucocorticoids. The patient's condition improved after treatment with human immunoglobulin and antihistamines. OUTCOMES Combination therapy of glucocorticoid and gamma globulin, the whole-body pruritus disappeared, and no new rash appeared. The whole-body rash subsided or turned dark red. CONCLUSION This article describes the diagnosis and treatment process of a case of sulfasalazine-induced DHS and reviews the relevant literature to improve clinician understanding and avoid misdiagnosis and missed diagnosis.
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Affiliation(s)
- Dong-Hui Chen
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Hai-Rong Zhou
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Yong-Gang Zhang
- Department of Clinical Laboratory, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Guan-Yuan Shen
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Chong Xu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
- * Correspondence: Chun-Li Guan and Chong Xu, Department of General Practice, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, China (e-mail: , )
| | - Chun-Li Guan
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
- * Correspondence: Chun-Li Guan and Chong Xu, Department of General Practice, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, China (e-mail: , )
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19
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Binstadt BA, Nigrovic PA. The Conundrum of Lung Disease and Drug Hypersensitivity-like Reactions in Systemic Juvenile Idiopathic Arthritis. Arthritis Rheumatol 2022; 74:1122-1131. [PMID: 35413159 PMCID: PMC9367674 DOI: 10.1002/art.42137] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/23/2022] [Accepted: 04/06/2022] [Indexed: 12/14/2022]
Abstract
An unusual form of lung disease has begun to affect some children with systemic juvenile idiopathic arthritis (JIA), coincident with increasing utilization of interleukin-1 (IL-1) and IL-6 antagonists. Many children with systemic JIA-associated lung disease (SJIA-LD) have a history of clinical and laboratory features resembling drug reaction with eosinophilia and systemic symptoms (DRESS), a presentation now convincingly associated with HLA-DRB1*15. Treatment of DRESS typically requires drug discontinuation, a daunting prospect for clinicians and families who rely upon these agents. Here we review SJIA-LD and its associated DRESS-like phenotype. We suggest an alternative explanation, the cytokine plasticity hypothesis, proposing that IL-1 and IL-6 blockers modulate the milieu in which T cells develop, leading to a pathologic immune response triggered through exposure to common microbes, or to other exogenous or endogenous antigens, rather than to the drugs themselves. This hypothesis differs from DRESS in mechanism but also in clinical implications, predicting that control of pathogenic T cells could permit continued use of IL-1 and IL-6 antagonists in some individuals. The spectrum posed by these two hypotheses provides a conceptual framework that will guide investigation into the pathogenesis of SJIA-LD and may open up new therapeutic avenues for patients with systemic JIA.
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Affiliation(s)
| | - Peter A. Nigrovic
- Boston Children's Hospital and Brigham and Women's HospitalBostonMassachusetts
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20
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Magdy E, Shafik S, Saadany BEL. Platelet rich fibrin a new approach in management of persistent oral ulcers in blistering skin diseases. Wound Repair Regen 2022; 30:491-497. [PMID: 35589608 DOI: 10.1111/wrr.13020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 03/18/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Eman Magdy
- Lecturer of Oral medicine, diagnosis and periodontology, Faculty of Dentistry, Beni-Suef University, Beni-Suef, Egypt
| | - Sherif Shafik
- Lecturer of Oral and Maxillofacial Radiology, Faculty of Dentistry, The British University in Egypt, Cairo, Egypt
| | - Basma E L Saadany
- Lecturer of Oral Medicine and Periodontology Department, Faculty of Dentistry, Cairo University, Cairo, Egypt
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21
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Gaur P, Zaffran I, George T, Alekberli FR, Ben-Zimra M, Levi-Schaffer F. The regulatory role of eosinophils in viral, bacterial, and fungal infections. Clin Exp Immunol 2022; 209:72-82. [PMID: 35467728 PMCID: PMC9307229 DOI: 10.1093/cei/uxac038] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/15/2022] [Accepted: 04/24/2022] [Indexed: 12/14/2022] Open
Abstract
Eosinophils are innate immune cells typically associated with allergic and parasitic diseases. However, in recent years, eosinophils have also been ascribed a role in keeping homeostasis and in fighting several infectious diseases. Indeed, these cells circulate as mature cells in the blood and can be quickly recruited to the infected tissue. Moreover, eosinophils have all the necessary cellular equipment such as pattern recognition receptors (PRRs), pro-inflammatory cytokines, anti-bacterial proteins, and DNA traps to fight pathogens and promote an efficient immune response. This review summarizes some of the updated information on the role of eosinophils' direct and indirect mediated interactions with pathogens.
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Affiliation(s)
- Pratibha Gaur
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Ilan Zaffran
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Tresa George
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Fidan Rahimli Alekberli
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Micha Ben-Zimra
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Francesca Levi-Schaffer
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Israel
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22
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Maverakis E, Ji‐Xu A, Brüggen M. Targeting interleukin-5 with benralizumab: a novel treatment for drug rash with eosinophilia and systemic symptoms (DRESS). Allergy 2022; 77:2287-2289. [PMID: 35285038 DOI: 10.1111/all.15283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Emanual Maverakis
- Department of Dermatology University of California, Davis, School of Medicine Sacramento CA USA
| | - Antonio Ji‐Xu
- Department of Dermatology University of California, Davis, School of Medicine Sacramento CA USA
| | - Marie‐Charlotte Brüggen
- Department of Dermatology University Hospital Zurich Zurich Switzerland
- Christine Kühne Center for Allergy Research and Education CK‐CARE Davos Switzerland
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23
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Chen G, Deutsch GH, Schulert G, Zheng H, Jang S, Trapnell B, Lee P, Macaubas C, Ho K, Schneider C, Saper VE, de Jesus AA, Krasnow M, Grom A, Goldbach-Mansky R, Khatri P, Mellins ED, Canna SW. Serum proteome analysis of systemic JIA and related lung disease identifies distinct inflammatory programs and biomarkers. Arthritis Rheumatol 2022; 74:1271-1283. [PMID: 35189047 DOI: 10.1002/art.42099] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 01/16/2022] [Accepted: 02/15/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Recent observations in systemic Juvenile Idiopathic Arthritis (sJIA) suggest an increasing incidence of high-mortality interstitial lung disease (sJIA-LD) often characterized by a variant of pulmonary alveolar proteinosis (PAP). Co-occurrence of macrophage activation syndrome (MAS) and PAP in sJIA suggested a shared pathology, but sJIA-LD patients also commonly experience features of drug reaction such as atypical rashes and eosinophilia. We sought to investigate immunopathology and identify biomarkers in sJIA, MAS, and sJIA-LD. METHODS We used SOMAscan to measure >1300 analytes in sera from healthy controls and patients with sJIA, MAS, sJIA-LD and other related diseases. We verified selected findings by ELISA and lung immunostaining. Because the proteome of a sample may reflect multiple states (sJIA, MAS, sJIA-LD), we used regression modeling to identify subsets of altered proteins associated with each state. We tested key findings in a validation cohort. RESULTS Proteome alterations in active sJIA and MAS overlapped substantially, including known sJIA biomarkers like SAA and S100A9, and novel elevations of heat shock proteins and glycolytic enzymes. IL-18 was elevated in all sJIA groups, particularly MAS and sJIA-LD. We also identified an MAS-independent sJIA-LD signature notable for elevated ICAM5, MMP7, and allergic/eosinophilic chemokines, which have been previously associated with lung damage. Immunohistochemistry localized ICAM5 and MMP7 in sJIA-LD lung. ICAM5's ability to distinguish sJIA-LD from sJIA/MAS was independently validated. CONCLUSION Serum proteins support an sJIA-to-MAS continuum, help distinguish sJIA, sJIA/MAS, and sJIA-LD and suggest etiologic hypotheses. Select biomarkers, such as ICAM5, could aid in early detection and management of sJIA-LD.
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Affiliation(s)
- Guangbo Chen
- Institute for Immunity, Transplantation and Infection, School of Medicine, Stanford University, Stanford, CA, USA
| | - Gail H Deutsch
- Pathology, Seattle Children's Hospital and University of Washington Medical Center, Seattle, WA, USA
| | - Grant Schulert
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hong Zheng
- Institute for Immunity, Transplantation and Infection, School of Medicine, Stanford University, Stanford, CA, USA.,Center for Biomedical Informatics Research, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - SoRi Jang
- Biochemistry, Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Bruce Trapnell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Pui Lee
- Pediatric Rheumatology, Boston Children's Hospital and Harvard School of Medicine, Boston, MA, USA
| | - Claudia Macaubas
- Pediatrics, Program in Immunology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Katherine Ho
- Institute for Immunity, Transplantation and Infection, School of Medicine, Stanford University, Stanford, CA, USA.,Center for Biomedical Informatics Research, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Corinne Schneider
- Pediatrics, UPMC Children's Hospital & University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vivian E Saper
- Pediatrics, School of Medicine, Stanford University, Stanford, California, USA
| | - Adriana Almeida de Jesus
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Mark Krasnow
- Biochemistry, Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Alexei Grom
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Purvesh Khatri
- Institute for Immunity, Transplantation and Infection, School of Medicine, Stanford University, Stanford, CA, USA.,Center for Biomedical Informatics Research, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Elizabeth D Mellins
- Pediatrics, Program in Immunology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Scott W Canna
- Pediatrics, UPMC Children's Hospital & University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Ray JC, Allen P, Bacsi A, Bosco JJ, Chen L, Eller M, Kua H, Lim LL, Matharu MS, Monif M, Ruttledge M, Stark RJ, Hutton EJ. Inflammatory complications of CGRP monoclonal antibodies: a case series. J Headache Pain 2021; 22:121. [PMID: 34625019 PMCID: PMC8501661 DOI: 10.1186/s10194-021-01330-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/16/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Calcitonin gene-related peptide (CGRP) is expressed throughout the body and is a known mediator of migraine, exerting this biological effect through activation of trigeminovascular, meningeal and associated neuronal pathways located in close proximity to the central nervous system. Monoclonal antibodies (mAb) targeting the CGRP pathway are an effective new preventive treatment for migraine, with a generally favourable adverse event profile. Pre-clinical evidence supports an anti-inflammatory/immunoregulatory role for CGRP in other organ systems, and therefore inhibition of the normal action of this peptide may promote a pro-inflammatory response. CASES We present a case series of eight patients with new or significantly worsened inflammatory pathology in close temporal association with the commencement of CGRP mAb therapy. CONCLUSION This case series provides novel insights on the potential molecular mechanisms and side-effects of CGRP antagonism in migraine and supports clinical vigilance in patient care going forward.
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Affiliation(s)
- Jason C Ray
- Department of Neurology, Alfred Hospital, Commercial Melbourne 3004, Melbourne, Australia. .,Department of Neurology, Austin Health, 145 Studley Road, 3084, Heidelberg, Germany. .,Department of Neuroscience, Monash University, Vic, Melbourne, 3004, Australia.
| | - Penelope Allen
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia.,Department of Surgery (Ophthalmology), University of Melbourne, Parkville, Australia
| | - Ann Bacsi
- Integrated Specialist Medical Care, Sydney, Australia
| | - Julian J Bosco
- Department of Allergy, asthma and clinical immunology, Alfred Hospital, Commercial Road 3004, Melbourne, Australia.,Central Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Luke Chen
- Department of Neuroscience, Monash University, Vic, Melbourne, 3004, Australia.,Otoneurology Diagnostic Unit, Alfred Hospital, Commercial Rd 3004, Melbourne, VIC, Australia
| | - Michael Eller
- Department of Neurology, Monash Medical Centre, Vic, Melbourne, Australia.,School of Clinical Sciences, Monash University, Vic, Melbourne, Australia
| | - Hock Kua
- Department of Pathology, Monash Medical Centre, Vic, Melbourne, Australia
| | - Lyndell L Lim
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia.,Department of Surgery (Ophthalmology), University of Melbourne, Parkville, Australia
| | - Manjit S Matharu
- University College London (UCL) Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, University College London, Gower Street WC1E 6BT, London, UK
| | - Mastura Monif
- Department of Neuroscience, Monash University, Vic, Melbourne, 3004, Australia.,Department of Neurology, Royal Melbourne Hospital, Vic, Parkville, 3050, Australia.,MS and Neuroimmunology Department, Alfred Hospital, Vic, Melbourne, 3004, Australia
| | - Martin Ruttledge
- Consultant Neurologist & Headache Clinical Lead, Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - Richard J Stark
- Department of Neurology, Alfred Hospital, Commercial Melbourne 3004, Melbourne, Australia.,Department of Neuroscience, Monash University, Vic, Melbourne, 3004, Australia
| | - Elspeth J Hutton
- Department of Neurology, Alfred Hospital, Commercial Melbourne 3004, Melbourne, Australia.,Department of Neuroscience, Monash University, Vic, Melbourne, 3004, Australia
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Su T, Xiong W, Xu Y, Lu Y. Allopurinol-induced drug reaction with eosinophilia and systemic symptoms syndrome associated with reactivation of Epstein-Barr virus leading to secondary hemophagocytic lymphohistiocytosis in an HLA-B*5801-negative patient. Indian J Dermatol Venereol Leprol 2021; 87:545-548. [PMID: 34219434 DOI: 10.25259/ijdvl_925_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/01/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Ting Su
- Department of Dermatology The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wenjie Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yang Xu
- Department of Dermatology The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Lu
- Department of Dermatology The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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26
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Radonjic-Hoesli S, Brüggen MC, Feldmeyer L, Simon HU, Simon D. Eosinophils in skin diseases. Semin Immunopathol 2021; 43:393-409. [PMID: 34097126 PMCID: PMC8241748 DOI: 10.1007/s00281-021-00868-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/06/2021] [Indexed: 02/06/2023]
Abstract
Eosinophil infiltration is a common finding in a broad spectrum of skin diseases, despite the fact that the skin is devoid of eosinophils under physiologic conditions. Although cutaneous eosinophilia is reactive, cytokine-mediated in most cases, diseases with an intrinsic mutation-mediated clonal expansion of eosinophils can also manifest on the skin. As eosinophils are involved in host defense, regulate immune responses, generate pruritus, induce remodeling and fibrosis, and can cause tissue damage, they have the capacity to actively contribute to the pathogenesis of diseases. Recent research provided deeper insights in the mechanisms, e.g., bacterial and viral clearance, blister formation, recruitment of cytotoxic T cells, and generation of pruritus, by which eosinophils might come into action. This review aims at providing an overview on the clinical presentations of eosinophil-associated dermatoses and the current understanding of their pathogenic role in these diseases. Further, we discuss the effects of therapies targeting eosinophils.
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Affiliation(s)
- Susanne Radonjic-Hoesli
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie-Charlotte Brüggen
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Department of Dermatology, Hochgebirgsklinik Davos, Davos, Switzerland
| | - Laurence Feldmeyer
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
- Department of Clinical Immunology and Allergology, Sechenov University, Moscow, Russia
- Laboratory of Molecular Immunology, Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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27
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Perwitasari DA, Febriana SA, Tristiana RS. Quality of Life of Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) and Stevens-Johnson Syndrome (SJS) and/or Toxic Epidermal Necrolysis (TEN) Patients. Patient Prefer Adherence 2021; 15:329-335. [PMID: 33623374 PMCID: PMC7894792 DOI: 10.2147/ppa.s285256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 01/19/2021] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Drug Reaction With Eosinophilia and Systemic Symptom (DRESS), Stevens-Johnson Syndrome (SJS), and Toxic Epidermal Necrolysis (TEN) are acute hypersensitivity reactions with the potential to reduce the quality of life of exposed individuals. This study aims to determine the quality of life of patients suffering from DRESS, SJS, SJS/TEN. PATIENTS AND METHODS A cross-sectional approach was used to get the quality of life data from DRESS, SJS, and/or TEN patients at Dr. Sardjito general hospital, Yogyakarta. The utility index and VAS score differences of EQ-5D-5L were analyzed based on the diagnosis. RESULTS We recruited 58 patients. Most of the patients were female (63%). The mean value of utility index was 0.61, 0.08 and 0.03 for DRESS, SJS and SJS/TEN patients, respectively (p value <0.01). Furthermore, the mean of VAS score was 73.36, 57.93 and 50.00 for DRESS, SJS and SJS/TEN patients, respectively (p value <0.01). CONCLUSION In general, the quality of life of DRESS patients is better than the quality of life of SJS and/or TEN patients.
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Affiliation(s)
| | - Sri Awalia Febriana
- Department of Dermatology and Venereology, Universitas Gadjah Mada, Yogyakarta, Indonesia
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28
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Amirthalingam P, Mohammed O, Osman AB, Alatawi A, Mirghani H, Elseed Mohamed WH. Overlapping of Steven-Johnson syndrome and the drug rash with eosinophilia and systemic symptoms during the treatment of carbamazepine. EGYPTIAN JOURNAL OF DERMATOLOGY AND VENEROLOGY 2021; 41:115. [DOI: 10.4103/ejdv.ejdv_25_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/01/2024]
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29
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Benralizumab for severe DRESS in two COVID-19 patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:481-483.e2. [PMID: 33039646 PMCID: PMC7543785 DOI: 10.1016/j.jaip.2020.09.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 12/17/2022]
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30
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Vrinceanu D, Dumitru M, Stefan A, Neagos A, Musat G, Nica EA. Severe DRESS syndrome after carbamazepine intake in a case with multiple addictions: A case report. Exp Ther Med 2020; 20:2377-2380. [PMID: 32765718 DOI: 10.3892/etm.2020.8894] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/21/2020] [Indexed: 12/19/2022] Open
Abstract
A case is presented of a male with drug rash with eosinophilia and systemic symptoms (DRESS) syndrome induced by carbamazepine intake. The patient presented all the elements of DRESS syndrome: Skin reaction, fever, enlargement of the lymph nodes, increased eosinophils and lymphocytes, with associated organ dysfunctions. The patient was admitted with acute laryngeal edema and imminence of respiratory insufficiency. The escalation of symptoms for this syndrome is typical, even after the administering of the the culprit medicine has ceased. However, in this case, the most difficult aspect was the complex treatment scheme prior to admission. All medical compounds involved in the background treatment were substituted with other substances in order to control the immune response. Current knowledge regarding DRESS is reviewed and possible influence of various etiologies over the present case are discussed. Clinicians should be aware of this rare situation with life-threatening potential. We benefited from the advantage of reuniting the knowledge of a complex team of experts from various tertiary emergency units in Romania.
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Affiliation(s)
- Daniela Vrinceanu
- ENT Department, Bucharest Emergency University Hospital, 010271 Bucharest, Romania
| | - Mihai Dumitru
- Department of Anatomy, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Adrian Stefan
- ENT Department, Bucharest Emergency University Hospital, 010271 Bucharest, Romania
| | - Adriana Neagos
- ENT Department, Târgu Mureş University of Medicine and Pharmacy, 540139 Târgu Mureş, Romania
| | - Gabriela Musat
- ENT Department, 'Sânta Maria' Clinical Hospital, 011172 Bucharest, Romania
| | - Elena Adriana Nica
- Department of Anesthesia and ICU, Bucharest Emergency University Hospital, 020021 Bucharest, Romania
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31
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Kim D, Kobayashi T, Voisin B, Jo JH, Sakamoto K, Jin SP, Kelly M, Pasieka HB, Naff JL, Meyerle JH, Ikpeama ID, Fahle GA, Davis FP, Rosenzweig SD, Alejo JC, Pittaluga S, Kong HH, Freeman AF, Nagao K. Targeted therapy guided by single-cell transcriptomic analysis in drug-induced hypersensitivity syndrome: a case report. Nat Med 2020; 26:236-243. [PMID: 31959990 PMCID: PMC7105105 DOI: 10.1038/s41591-019-0733-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 12/06/2019] [Indexed: 12/17/2022]
Abstract
Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DiHS/DRESS) is a potentially fatal multiorgan inflammatory disease associated with herpesvirus reactivation and subsequent onset of autoimmune diseases1-4. Pathophysiology remains elusive and therapeutic options are limited. Cases refractory to corticosteroid therapy pose a clinical challenge1,5 and approximately 30% of patients with DiHS/DRESS develop complications, including infections and inflammatory and autoimmune diseases1,2,5. Progress in single-cell RNA sequencing (scRNA-seq) provides an opportunity to dissect human disease pathophysiology at unprecedented resolutions6, particularly in diseases lacking animal models, such as DiHS/DRESS. We performed scRNA-seq on skin and blood from a patient with refractory DiHS/DRESS, identifying the JAK-STAT signaling pathway as a potential target. We further showed that central memory CD4+ T cells were enriched with DNA from human herpesvirus 6b. Intervention via tofacitinib enabled disease control and tapering of other immunosuppressive agents. Tofacitinib, as well as antiviral agents, suppressed culprit-induced T cell proliferation in vitro, further supporting the roles of the JAK-STAT pathway and herpesviruses in mediating the adverse drug reaction. Thus, scRNA-seq analyses guided successful therapeutic intervention in the patient with refractory DiHS/DRESS. scRNA-seq may improve our understanding of complicated human disease pathophysiology and provide an alternative approach in personalized medicine.
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Affiliation(s)
- Doyoung Kim
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tetsuro Kobayashi
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
| | - Benjamin Voisin
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
| | - Jay-Hyun Jo
- Cutaneous Microbiome and Inflammation Section, Dermatology Branch, NIAMS, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Keiko Sakamoto
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
| | - Seon-Pil Jin
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
| | - Michael Kelly
- Cancer Research Technology Program, Single-Cell Analysis Facility, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Helena B Pasieka
- Department of Dermatology, MedStar Washington Hospital Center & Georgetown University Hospital, Washington, DC, USA
| | - Jessica L Naff
- Department of Dermatology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jon H Meyerle
- Department of Dermatology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ijeoma D Ikpeama
- Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD, USA
| | - Gary A Fahle
- Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD, USA
| | - Fred P Davis
- Molecular Immunology and Inflammation Branch, NIAMS, NIH, Bethesda, MD, USA
| | - Sergio D Rosenzweig
- Immunology Service, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD, USA
| | - Julie C Alejo
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Stefania Pittaluga
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Heidi H Kong
- Cutaneous Microbiome and Inflammation Section, Dermatology Branch, NIAMS, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Keisuke Nagao
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA.
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32
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Schwere Hautreaktionen: klinisches Bild, Epidemiologie, Ätiologie, Pathogenese und Therapie. ALLERGO JOURNAL 2019. [DOI: 10.1007/s15007-019-1973-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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33
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Paulmann M, Mockenhaupt M. Severe skin reactions: clinical picture, epidemiology, etiology, pathogenesis, and treatment. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s40629-019-00111-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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34
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Zhu B, Wu J, Chen G, Yang Y, Yi C. Fulminant Type 1 Diabetes Mellitus Caused by Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS): A Case Report and Review of the Literature. Front Endocrinol (Lausanne) 2019; 10:474. [PMID: 31379742 PMCID: PMC6646467 DOI: 10.3389/fendo.2019.00474] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 07/01/2019] [Indexed: 12/14/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DIHS) is a rare, severe cutaneous adverse drug reaction characterized by fever, skin rashes, lymphadenopathy, leukocytosis with eosinophilia, and/or atypical lymphocytosis, and multiple visceral organ involvement. Moreover, patients with DRESS are at risk of developing autoimmune diseases including thyroiditis, diabetes mellitus (DM), and systemic lupus erythematosus (SLE), etc. several weeks or months after the initial resolution. We described a 9-month boy who was admitted to our hospital because of severe pneumonia and developed DRESS 3 weeks later. After the withdrawal of suspicious drug and administration of systemic corticosteroids, the patient's condition improved gradually. Nevertheless, hyperglycemia was detected 20 days after the initial onset of DRESS, and subsequent fulminant type 1 diabetes mellitus (F1DM) was diagnosed requiring continuous intravenous insulin infusion. After 13 months of follow-up, the blood glucose levels are now well-controlled. Literature research in PubMed for diabetes mellitus associated with DRESS showed 16 articles and 27 related case reports. Of 27 patients with DM related to DRESS, 11 were male, 16 were female. The mean age was 46 years. The duration from the onset of DRESS to the development of DM was 21 days on average. F1DM was diagnosed in 21 patients, T1DM was confirmed in 5 patients, and T2DM was only defined in 1 patient. Glutamic acid decarboxylase antibodies (GAD) were detected in 4 cases. Of 22 cases in which virus examination was carried out, evidence of virus reactivation was established in 16 cases (72.7%). Of patients with F1DM, 16 (88.9%) cases were evidenced by reactivation of herpes virus. A high frequency of HLA genotype and haplotype were found in 11 cases. DM was concomitant with acute pancreatitis in 3 patients and thyroiditis in 2 patients. No patients died from the disease. This work aims to raise awareness of long-term autoimmune sequelae in patients with DRESS.
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崔 宁, 朱 雪. [Lamotrigine induced hypersensitivity syndrome in children: a case report]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:356-358. [PMID: 30996382 PMCID: PMC7441192 DOI: 10.19723/j.issn.1671-167x.2019.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Indexed: 06/09/2023]
Abstract
Drug induced hypersensitivity syndrome (DIHS) is often manifested as severe systemic drug trans-reactions characterized by acute and extensive skin lesions (mostly measles-like rash), fever, enlargement of lymph nodes, multiple organ involvement (hepatitis, nephritis, and pneumonia), eosinophilia and mononucleosis,within 2-6 weeks of the application of sensitizing drugs. In the early stage of the lesion, macular papules or erythema multiforme were common, and in severe cases, exfoliative dermatitis, Stevens-Johnson syndrome and toxic epidermal necrolysis were also common. Most of them developed after taking allergic drugs for 2-6 weeks (average: 3 weeks). Symptoms persisted after discontinuation of allergic drugs. It takes more than one month to alleviate, which may endanger life in severe cases. Documents report that the most common drugs causing DIHS are phenytoin sodium, carbamazepine and phenobarbital aromatic drugs. However, it was reported that phenobarbital sodium was the most common anticonvulsant among allergenic drugs in children, followed by antipyretics, analgesics and antibiotics, which may be related to the spectrum of childhood diseases and the particularity of the drug. Lamotrigine has been reported to cause DIHS in adults in China, but less in children. In order to improve the understanding of clinical diagnosis and treatment of DIHS in children, reduce misdiagnosis, missed diagnosis, and untimely treatment, and prevent the aggravation of the disease, we studied the case of a 4-year-old 7-month-old girl who presented with systemic erythematous papules, fever, hepatosplenomegaly, marked increase of white blood cells, marked decrease of anemia and platelets, abnormal liver function and coagulation routine after taking lamotrigine for one month due to epilepsy seizures. Now, according to the DIHS diagnostic criteria established by Registration of Severe Cutaneous Adverse Reactions Drug Review Group in 2007, plasma exchange was immediately given to replace the toxic metabolites in hemorrhagic plasma, and methylprednisolone was given intravenously for three days. At the same time, after symptomatic supportive treatments, such as loratadine and albumin, the condition gradually improved without recurrence. Through a case report of Drug reaction with eosinophilia and systemic symptoms in a child caused by lamotrigine, we can strengthen our understanding and improve the level of diagnosis and treatment of drug hypersensitivity syndrome in children. Lamotrigine can cause DIHS in children, which is very dangerous. Early diagnosis and early withdrawal of allergenic drugs, plasma exchange and glucocorticoid therapy are the key to treatment.
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Affiliation(s)
- 宁迅 崔
- />苏州大学附属儿童医院新生儿科, 江苏苏州 215025Department of Neonatology, Children’s Hospital of Soochow University, Suzhou 215025, Jiangsu, China
| | - 雪萍 朱
- />苏州大学附属儿童医院新生儿科, 江苏苏州 215025Department of Neonatology, Children’s Hospital of Soochow University, Suzhou 215025, Jiangsu, China
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Cochran BP, Kimbrough EO, Pagán RJ. 62-Year-Old Man With Fever and Pruritic Rash. Mayo Clin Proc 2018; 93:1654-1658. [PMID: 30269943 DOI: 10.1016/j.mayocp.2018.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/26/2018] [Accepted: 01/31/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Benjamin P Cochran
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - ErinMarie O Kimbrough
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Ricardo J Pagán
- Advisor to residents and Consultant in Internal Medicine, Mayo Clinic, Jacksonville, FL.
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37
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Leiferman KM, Peters MS. Eosinophil-Related Disease and the Skin. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1462-1482.e6. [DOI: 10.1016/j.jaip.2018.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/04/2018] [Accepted: 06/04/2018] [Indexed: 02/06/2023]
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38
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Roufosse F. Targeting the Interleukin-5 Pathway for Treatment of Eosinophilic Conditions Other than Asthma. Front Med (Lausanne) 2018; 5:49. [PMID: 29682504 PMCID: PMC5897501 DOI: 10.3389/fmed.2018.00049] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/09/2018] [Indexed: 01/01/2023] Open
Abstract
Improved understanding of the contribution of eosinophils to various chronic inflammatory conditions, most notably allergic asthma, has encouraged development of monoclonal antibodies specifically targeting mediators and surface receptors involved in eosinophil expansion and activation. The pivotal role of interleukin-5 (IL-5) in eosinophil biology, its high specificity for this leukocyte subset, and its involvement in the majority of eosinophilic conditions make it a very enticing target for treatment of eosinophil-mediated disorders. Two types of antibodies have been developed to target eosinophils: antibodies against IL-5 (mepolizumab and reslizumab), and an antibody against the IL-5-receptor-alpha-chain (IL-5Rα) (benralizumab). Both types of antibodies prevent IL-5 from engaging its receptor and in addition, anti-IL-5Rα antibodies induce target-cell lysis. They have been shown to reduce circulating eosinophil counts rapidly in humans with various disorders. Herein, a brief overview of the role of IL-5 in eosinophil biology will be presented, followed by a description of the development and characteristics of antibodies targeting IL-5 or its receptor. Results of clinical trials evaluating the efficacy and safety of these new antibodies in diseases (other than eosinophilic asthma) with prominent tissue eosinophilia are reviewed, followed by safety considerations and potential future applications.
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Affiliation(s)
- Florence Roufosse
- Hôpital Erasme, Department of Internal Medicine, Université Libre de Bruxelles, Brussels, Belgium
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