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Cruz CV, Rabinovich A, Moscatelli G, Moroni S, González N, Garcia-Bournissen F, Ballering G, Freilij H, Altcheh J. Adverse events associated with benznidazole treatment for Chagas disease in children and adults. Br J Clin Pharmacol 2024. [PMID: 39210623 DOI: 10.1111/bcp.16214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 07/16/2024] [Accepted: 07/19/2024] [Indexed: 09/04/2024] Open
Abstract
AIMS Chagas disease (ChD) affects approximately 7 million people in Latin America, with benznidazole being the most commonly used treatment. METHODS Data from a retrospective cohort study in Argentina, covering January 1980 to July 2019, was reanalysed to identify and characterize benznidazole-related adverse drug reactions (ADRs). RESULTS The study included 518 patients: 449 children and 69 adults (median age in children: 4 years; adults: 25 years; age ranges: 1 month-17.75 years and 18-59 years, respectively). The median benznidazole doses received were 6.6 mg/kg/day for at least 60 days in children and 5.6 mg/kg/day for a median of 31 days in adults. Overall, 29.34% (152/518) of patients developed benznidazole-related ADRs, with an incidence of 25.83% (116/449) in children and 52.17% (36/69) in adults (odds ratio [OR] = 0.32, 95% confidence interval [CI] = 0.19-0.54, P < .001). The incidence rate was 177 cases per 1000 person-years (95% CI = 145-214) in children and 537 per 1000 person-years (95% CI = 360-771) in adults. There were 240 ADRs identified, primarily mild to moderate. Severe ADRs occurred in 1.11% (5/449) of children and 1.45% (1/69) of adults. The skin was the most affected system. A total of 10.23% (53/518) of patients discontinued treatment. More adults than children discontinued treatment (OR = 3.36, 95% CI = 1.7-6.4, P < .001). CONCLUSIONS Although 29.34% of patients experienced ADRs, most were mild to moderate, indicating a manageable safety profile for benznidazole. While optimized dosing schedules and new drugs are needed, avoiding benznidazole solely due to safety concerns is not justified.
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Affiliation(s)
- Cintia Valeria Cruz
- Servicio de Parasitología y Instituto Multidisciplinario de Investigación en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
- Mahidol Oxford Research Unit (MORU), Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andres Rabinovich
- Servicio de Parasitología y Instituto Multidisciplinario de Investigación en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Guillermo Moscatelli
- Servicio de Parasitología y Instituto Multidisciplinario de Investigación en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Samanta Moroni
- Servicio de Parasitología y Instituto Multidisciplinario de Investigación en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Nicolas González
- Servicio de Parasitología y Instituto Multidisciplinario de Investigación en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Facundo Garcia-Bournissen
- Division of Paediatric Clinical Pharmacology, Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Griselda Ballering
- Servicio de Parasitología y Instituto Multidisciplinario de Investigación en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Hector Freilij
- Servicio de Parasitología y Instituto Multidisciplinario de Investigación en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Jaime Altcheh
- Servicio de Parasitología y Instituto Multidisciplinario de Investigación en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
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de Filippis R, Kane JM, Arzenton E, Moretti U, Raschi E, Trifirò G, Barbui C, De Fazio P, Gastaldon C, Schoretsanitis G. Antipsychotic-Related DRESS Syndrome: Analysis of Individual Case Safety Reports of the WHO Pharmacovigilance Database. Drug Saf 2024; 47:745-757. [PMID: 38722481 PMCID: PMC11286650 DOI: 10.1007/s40264-024-01431-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is gaining attention in pharmacovigilance, but its association with antipsychotics, other than clozapine, is still unclear. METHODS We conducted a case/non-case study with disproportionality analysis based on the World Health Organization (WHO) global spontaneous reporting database, VigiBase®. We analyzed individual case safety reports of DRESS syndrome related to antipsychotics compared to (1) all other medications in VigiBase®, (2) carbamazepine (a known positive control), and (3) within classes (typical/atypical) of antipsychotics. We calculated reporting odds ratio (ROR) and Bayesian information component (IC), with 95% confidence intervals (CIs). Disproportionate reporting was prioritized based on clinical importance, according to predefined criteria. Additionally, we compared characteristics of patients reporting with serious/non-serious reactions. RESULTS A total of 1534 reports describing DRESS syndrome for 19 antipsychotics were identified. The ROR for antipsychotics as a class as compared to all other medications was 1.0 (95% CI 0.9-1.1). We found disproportionate reporting for clozapine (ROR 2.3, 95% CI 2.1-2.5; IC 1.2, 95% CI 1.1-1.3), cyamemazine (ROR 2.3, 95% CI 1.5-3.5; IC 1.2, 95% CI 0.5-1.7), and chlorpromazine (ROR 1.5, 95% CI 1.1-2.1; IC 0.6, 95% CI 0.1-1.0). We found 35.7% of cases with co-reported anticonvulsants, and 25% with multiple concurrent antipsychotics in serious compared to 8.6% in non-serious cases (p = 0.03). Fatal cases were 164 (10.7%). CONCLUSIONS Apart from the expected association with clozapine, chlorpromazine and cyamemazine (sharing an aromatic heteropolycyclic molecular structure) emerged with a higher-than-expected reporting of DRESS. Better knowledge of the antipsychotic-related DRESS syndrome should increase clinicians' awareness leading to safer prescribing of antipsychotics.
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Affiliation(s)
- Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, 88100, Catanzaro, Italy.
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Elena Arzenton
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Ugo Moretti
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Gianluca Trifirò
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, 88100, Catanzaro, Italy
| | - Chiara Gastaldon
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
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Li W, Yu Y, Li M, Fang Q, Jin X, Lin H, Xu J. Identification of novel signal of proton pump inhibitor-associated drug reaction with eosinophilia and systemic symptoms: a disproportionality analysis. Int J Clin Pharm 2024:10.1007/s11096-024-01778-y. [PMID: 39042351 DOI: 10.1007/s11096-024-01778-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/07/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are commonly prescribed for treating upper gastrointestinal hemorrhage, eradicating Helicobacter pylori, and stress ulcer prophylaxis, among other digestive system diseases. Recent case reports provided limited evidence of a correlation between PPIs and drug reactions with eosinophilia and systemic symptoms (DRESS). However, there is currently no established association between PPIs and DRESS. AIM This research aimed to identify the associations between PPIs and DRESS using the US Food and Drug Administration Adverse Events Reporting System (FAERS) database. METHOD A retrospective investigation of DRESS associated with six PPIs used FAERS data from Q1 2004 to Q3 2023. Data mining algorithms were used to identify adverse events in the FAERS database that met the following criteria: (1) proportional reporting ratio (PRR) ≥ 2; (2) reporting odds ratio (ROR) > 1; (3) 95% confidence interval (CI) of ROR > 1; (4) Chi-square (χ2) ≥ 4 and case count ≥ 3. RESULTS There were 495 reports of PPI-related DRESS, including pantoprazole (174, 35.2%), omeprazole (103, 20.8%), lansoprazole (103, 20.8%), esomeprazole (101, 20.4%), rabeprazole (8, 1.6%), and dexlansoprazole (6, 1.2%). The results indicated a significant association of three PPIs (pantoprazole, omeprazole, and lansoprazole) with DRESS. The sensitivity analysis demonstrated that only pantoprazole remained significantly associated with DRESS after 10 concomitant drugs had been removed (ROR: 3.00, PRR: 2.99, and information component [IC]: 1.57). CONCLUSION This study identified the signals suggesting a potential association between DRESS and six PPIs. However, more investigation of epidemiological data is required to validate of these conclusions.
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Affiliation(s)
- Wanshu Li
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Yanan Yu
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Minghui Li
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Qing Fang
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Xin Jin
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Hangjuan Lin
- Department of Pharmacy, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China
| | - Jun Xu
- Department of Nursing, Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, 315010, Zhejiang, China.
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Ajon ARS, Camara PTA. Drug Rash With Eosinophilia and Systemic Symptoms (DRESS) Due to Multiple Anti-Epileptic Drug Hypersensitivity. Cureus 2024; 16:e65417. [PMID: 39184707 PMCID: PMC11344962 DOI: 10.7759/cureus.65417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 08/27/2024] Open
Abstract
Drug rash with eosinophilia and systemic symptoms (DRESS) is a rare type of hypersensitivity reaction with an incidence in the general population of one case per 10,000, which may lead to life-threatening complications with a mortality rate of 3.8% to 10%. This condition has been characterized by the following symptoms: skin rash, febrile episodes, lymph node enlargement, and involvement of internal organs, specifically the liver. Common medications associated with these reactions are aromatic anticonvulsants and antibiotics. In this paper, we report a case of a 41-year-old female presenting with head-turning to the right and stiffening of the right upper and lower extremities, with subsequent involvement of the left upper and lower extremities secondary to a left frontal lobe glioma. She had a hypersensitivity reaction to five anticonvulsant medications and was treated with prednisone pulse therapy. This case showed that DRESS syndrome may also manifest with newer non-aromatic anticonvulsants such as levetiracetam and that steroid pulse therapy is effective in resolving the elevated blood parameters as well as skin lesions of patients with DRESS syndrome. The patient's epilepsy responded well to gabapentin without any recurrence of seizure episodes or hypersensitivity reactions.
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Affiliation(s)
- Alyssa Roseni S Ajon
- Department of Adult Neurology, Center for Neurological Sciences, Quirino Memorial Medical Center, Quezon City, PHL
| | - Pia Teresa A Camara
- Department of Adult Neurology, Center for Neurological Sciences, Quirino Memorial Medical Center, Quezon City, PHL
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Tran H, Bhatt G. Atypical Presentation of Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) in a Patient on Pembrolizumab: A Case Report. Cureus 2024; 16:e59804. [PMID: 38846231 PMCID: PMC11155428 DOI: 10.7759/cureus.59804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 06/09/2024] Open
Abstract
Pembrolizumab is an immune checkpoint inhibitor that has been associated with numerous immune-mediated adverse effects. Several of these cutaneous side effects may include bullous pemphigoid, Stevens-Johnson syndrome, and drug reaction with eosinophilia and systemic symptoms (DRESS). Other case reports have reported DRESS as a rare side effect of immune checkpoint inhibitors but due to its variable presentation and similarities with other cutaneous diseases, it has proven to be a diagnostic challenge. In addition, no effective methods have been developed to monitor for such adverse skin reactions in patients on immunotherapy. Here, we report a diagnostic challenging case of pembrolizumab-induced blistering lesions that were initially treated as suspected Herpes zoster and/or bullous pemphigoid but further pathology was consistent with DRESS.
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Affiliation(s)
- Hillary Tran
- Anesthesiology, Lake Erie College of Osteopathic Medicine, Jacksonville, USA
| | - Geetika Bhatt
- Hematology and Medical Oncology, Baptist Health-Jacksonville, Jacksonville, USA
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Chaisrimaneepan N, Pruneda C, Elmassry M, Abdelnabi M. DRESS syndrome without eosinophilia presented with extensive skin rash and acute respiratory failure. Clin Case Rep 2024; 12:e8905. [PMID: 38711841 PMCID: PMC11070480 DOI: 10.1002/ccr3.8905] [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: 02/12/2024] [Revised: 03/28/2024] [Accepted: 04/23/2024] [Indexed: 05/08/2024] Open
Abstract
This case demonstrated the complex pathophysiology of DRESS syndrome presenting with latent human herpes virus infection reactivation due to exposure to sulfasalazine and/or hydroxychloroquine. Patients who do not initially fulfill the diagnostic criteria on admission may evolve and eventually fulfill the criteria. Steroid dose tapering is required to prevent flaring.
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Affiliation(s)
| | - Corley Pruneda
- Dermatology DepartmentTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Marwan Elmassry
- Department of Internal MedicineTexas Tech University Health Science CenterLubbockTexasUSA
| | - Mahmoud Abdelnabi
- Department of Internal MedicineTexas Tech University Health Science CenterLubbockTexasUSA
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Varghese A, Alosious A, Thomas R, Surendran K, Vilapurathu JK. Phenytoin Induced Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome: A Clinical Case Report. J Pharm Pract 2024; 37:225-228. [PMID: 35924976 DOI: 10.1177/08971900221116686] [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: 11/15/2022]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and potentially life-threatening hypersensitivity reaction with cutaneous presentation and internal organ involvement. We herein present a case of phenytoin induced DRESS syndrome in a 56- year-old male who presented with high-grade fever and chills, cough with expectoration and generalized maculopapular rash. Laboratory findings revealed eosinophilia, leukocytosis, thrombocytopenia, transaminitis and elevated inflammatory markers. Further clinical, radiological and histopathological assessments confirmed the diagnosis. Phenytoin was discontinued, and patient was started on intravenous dexamethasone, which was later switched to oral prednisone. Rapid resolution of fever, eosinophilia and progressive improvement in skin rash and liver dysfunction was observed. Our report highlights the importance of prompt recognition of DRESS syndrome and the need for a guideline directed therapy for the management of this adverse drug reaction.
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Affiliation(s)
- Arshamol Varghese
- Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, India
| | - Aaja Alosious
- Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, India
| | - Rimisha Thomas
- Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, India
| | - Kavya Surendran
- Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, India
| | - Jobin K Vilapurathu
- Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, India
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Bahloul E, Trimeche K, Sellami K, Hammami F, Hayder F, Chaabouni R, Amouri M, Masmoudi A, Mseddi M, Boudeya S, Turki H. Characteristics of DRESS Syndrome in the Elderly: A Comparative Study of 55 Patients. Dermatitis 2024; 35:55-60. [PMID: 37669109 DOI: 10.1089/derm.2022.0032] [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: 09/07/2023]
Abstract
Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare drug reaction characterized by a skin rash, eosinophilia, and organ involvement. Objective: Our purpose is to focus on the clinical and epidemiological characteristics of DRESS in the elderly and to identify the incriminated drugs. Methods: This is a retrospective study including patients, hospitalized for DRESS with a RegiSCAR ≥4. The population was divided into 2 groups according to age: 65 years or older (G1) and <65 years (G2). The statistical study was performed using the comparative and multivariate analysis. Results: We included 55 patients (30.9% G1 and 69.1% G2). Skin manifestations were comparable in both groups. Lymphadenopathy was less common in G1 with a statistically significant difference (P = 0.012). Renal impairment was more frequent in the elderly with a statistically significant result (P = 0.005). DRESS in the elderly group was significantly associated with the occurrence of sepsis (P = 0.008). Allopurinol was the most common culprit associated with DRESS in G1 (P = 0.001). Relapses and recurrences were comparable in both groups (P = 0.71). Conclusions: DRESS in the elderly is associated with a high risk of complications, mainly kidney involvement and sepsis. Allopurinol is the most incriminated drug.
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Affiliation(s)
- Emna Bahloul
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Khaoula Trimeche
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Khadija Sellami
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Fatma Hammami
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Faten Hayder
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Rim Chaabouni
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Meriem Amouri
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | | | - Madiha Mseddi
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Sonia Boudeya
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Hamida Turki
- From the Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
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Ansah R, Arkoh EA, Quao BO, Groger M. Lack of Suspicion of Dapsone Hypersensitivity Syndrome in a Leprosy Patient: Case Report with Fatal Outcome. Res Rep Trop Med 2023; 14:135-139. [PMID: 38170098 PMCID: PMC10759403 DOI: 10.2147/rrtm.s434947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
Background Dapsone is an antibiotic used in the management of leprosy. Following the worldwide adoption of the dapsone-containing multidrug therapy for treating leprosy, an upsurge in the reported frequency of dapsone hypersensitivity syndrome (DHS) has been observed. DHS is associated with a high fatality rate among patients from low-resourced settings and patients with syndrome-associated hepatitis. Case Presentation This is a case of a Ghanaian male who, while being treated for leprosy with the multidrug therapy, developed exfoliative dermatitis and signs of liver damage, 6 weeks after treatment initiation. He was managed for dapsone-related exfoliative dermatitis and infectious causes of liver damage were investigated. However, the patient's condition rapidly deteriorated with a fatal outcome despite discontinuation of dapsone. DHS was only considered as a differential diagnosis postmortem. Conclusion This case highlights the importance of having a high index of suspicion for DHS in all patients on dapsone and the need for a thorough workup for all leprosy patients who present with exfoliative dermatitis and signs of liver involvement within the latency period of the syndrome, especially in low resource settings. Furthermore, it stresses the need for prompt and appropriate treatment as DHS can quickly become fatal in such settings.
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Affiliation(s)
- Ruth Ansah
- Center of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and I. Department of Internal Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Benedict Okoe Quao
- Ankaful Leprosy / General Hospital, Ankaful, Central Region, Ghana
- National Leprosy Control Program, Ghana Health Service, Accra, Ghana
| | - Mirjam Groger
- Center of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and I. Department of Internal Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Haward R, Haward R, Sharma JP. Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome Induced by Primary Anti-tubercular Medication: A Case Report. Cureus 2023; 15:e50753. [PMID: 38239535 PMCID: PMC10794811 DOI: 10.7759/cureus.50753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 01/22/2024] Open
Abstract
Drug reaction with eosinophilia and systemic syndrome (DRESS) is a life-threatening hypersensitivity reaction of the skin and visceral organs caused by exposure to certain drugs, often with a latency period of two to eight weeks. A 20-year-old man, previously diagnosed with pulmonary tuberculosis (TB) one month ago and receiving treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE regimen), presented with symptoms including a maculopapular rash, fever, elevated transaminase levels, an increased white blood cell count with eosinophilia, hepatomegaly, and lymphadenopathy. The patient experienced recovery upon cessation of drug use and was administered corticosteroids and supportive therapeutic interventions. Individuals diagnosed with pulmonary TB who are undergoing treatment with first-line anti-tubercular medications have a heightened susceptibility to DRESS. The timely identification and cessation of the offending agent can effectively mitigate mortality.
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Affiliation(s)
- Raymond Haward
- Internal Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
| | - Rachel Haward
- Internal Medicine, Kurunji Venkatramana Gowda (KVG) Medical College & Hospital, Sullia, IND
| | - Jv Pranav Sharma
- General Surgery, Adesh Medical College and Hospital, Shahbad, IND
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Sohi MK, Towne D, Mogallapu R, Chalia A, Ang-Rabanes M. A Case of Olanzapine-Induced Cutaneous Eruption. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941379. [PMID: 37777823 PMCID: PMC10556537 DOI: 10.12659/ajcr.941379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/14/2023] [Accepted: 08/03/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Different medication classes have been implicated in cutaneous eruptions that may lead to significant morbidity and mortality. In drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, the patient may initially present with a cutaneous eruption and hematologic abnormalities which can lead to acute visceral organ involvement if the offending drug is not discontinued. There is also a potential for long-term sequelae such as autoimmune disorders. CASE REPORT A 47-year-old woman with an unknown past medical history and no known drug allergies was admitted to the Behavioral Health Unit, where she was diagnosed with disorganized schizophrenia and started on olanzapine. On day 17 of admission, she developed a diffuse, macular, and erythematous rash on her abdomen, which spread to involve over 50% of her total body surface area. Occipital and posterior auricular lymphadenopathy was present. The patient was treated with prednisone and diphenhydramine. Olanzapine was subsequently discontinued and the patient's rash cleared up. CONCLUSIONS This case report highlights the challenges in diagnosing DRESS syndrome and the potential for antipsychotics to cause DRESS syndrome. DRESS syndrome is a clinical diagnosis augmented by laboratory tests with a wide range of patient presentations. Although there are probability criteria to assist with diagnosis, not all patients will fall exactly into these criteria, which can lead to missed diagnoses and poor patient outcomes. A challenge with DRESS syndrome diagnosis is the latency period between drug initiation and cutaneous eruption. Thus, in differential diagnoses for skin eruptions, temporal associations (minutes, days, weeks) with medications are crucial.
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Affiliation(s)
- Maninder K Sohi
- Eastern Division, West Virginia University School of Medicine, Martinsburg, WV, USA
| | - Devin Towne
- Eastern Region, West Virginia School of Osteopathic Medicine, Martinsburg, WV, USA
| | - Raja Mogallapu
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Martinsburg, WV, USA
| | - Ankit Chalia
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Martinsburg, WV, USA
| | - Michael Ang-Rabanes
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Martinsburg, WV, USA
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Line J, Saville E, Meng X, Naisbitt D. Why drug exposure is frequently associated with T-cell mediated cutaneous hypersensitivity reactions. FRONTIERS IN TOXICOLOGY 2023; 5:1268107. [PMID: 37795379 PMCID: PMC10546197 DOI: 10.3389/ftox.2023.1268107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
Cutaneous hypersensitivity reactions represent the most common manifestation of drug allergy seen in the clinic, with 25% of all adverse drug reactions appearing in the skin. The severity of cutaneous eruptions can vastly differ depending on the cellular mechanisms involved from a minor, self-resolving maculopapular rash to major, life-threatening pathologies such as the T-cell mediated bullous eruptions, i.e., Stevens Johnson syndrome/toxic epidermal necrolysis. It remains a significant question as to why these reactions are so frequently associated with the skin and what factors polarise these reactions towards more serious disease states. The barrier function which the skin performs means it is constantly subject to a barrage of danger signals, creating an environment that favors elicitation. Therefore, a critical question is what drives the expansion of cutaneous lymphocyte antigen positive, skin homing, T-cell sub-populations in draining lymph nodes. One answer could be the heterologous immunity hypothesis whereby tissue resident memory T-cells that express T-cell receptors (TCRs) for pathogen derived antigens cross-react with drug antigen. A significant amount of research has been conducted on skin immunity in the context of contact allergy and the role of tissue specific antigen presenting cells in presenting drug antigen to T-cells, but it is unclear how this relates to epitopes derived from circulation. Studies have shown that the skin is a metabolically active organ, capable of generating reactive drug metabolites. However, we know that drug antigens are displayed systemically so what factors permit tolerance in one part of the body, but reactivity in the skin. Most adverse drug reactions are mild, and skin eruptions tend to be visible to the patient, whereas minor organ injury such as transient transaminase elevation is often not apparent. Systemic hypersensitivity reactions tend to have early cutaneous manifestations, the progression of which is halted by early diagnosis and treatment. It is apparent that the preference for cutaneous involvement of drug hypersensitivity reactions is multi-faceted, therefore this review aims to abridge the findings from literature on the current state of the field and provide insight into the cellular and metabolic mechanisms which may contribute to severe cutaneous adverse reactions.
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Affiliation(s)
| | | | | | - Dean Naisbitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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13
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Cho M, Hostoffer R. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. J Osteopath Med 2023; 123:459-460. [PMID: 37382386 DOI: 10.1515/jom-2023-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Mandy Cho
- Department of Internal Medicine, Summa Health Internal Medicine Residency, Akron, OH, USA
| | - Robert Hostoffer
- Allergy/Immunology Associates, Inc., Mayfield Heights, Cleveland Heights, OH, USA
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Lassoued N, Alaya W, Arfa S, Korbi M, Lassoued I, Amor SB, Zaouali F, Farhat Z, Chelly J, Habib Sfar M. A posteriori diagnosis of DRESS syndrome induced by diazoxide in a patient with an insulinoma: a case report and review of the literature. Front Med (Lausanne) 2023; 10:1196041. [PMID: 37601782 PMCID: PMC10436324 DOI: 10.3389/fmed.2023.1196041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
The Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome can be potentially life-threatening. The diagnosis is sometimes difficult since the clinical manifestations may be incomplete or non-specific. Insulinoma is a rare functioning neuroendocrine tumor (NET) of the pancreas. Medical therapy may be needed when surgery is contraindicated, delayed or refused. Diazoxide is widely used to control hypoglycemia in patients with insulinoma. We report a clinical case of an insulinoma in a 85-year-old patient treated with diazoxide with a fatal outcome due to a delayed diagnosis of a DRESS syndrome. This is the first case of DRESS syndrome reported after using diazoxide for insulinoma treatment in our knowledge.
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Affiliation(s)
- Najoua Lassoued
- Department of Endocrinology, Taher Sfar University Hospital, Mahdia, Tunisia
- University of Monastir, Monastir, Tunisia
| | - Wafa Alaya
- Department of Endocrinology, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Sondos Arfa
- Department of Endocrinology, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Mouna Korbi
- Department of Dermatology, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Ines Lassoued
- Department of Gastroenterology, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Soumaya Ben Amor
- Department of Gastroenterology, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Fatma Zaouali
- Department of Family Medicine, Faculty of Medicine of Monastir, Monastir, Tunisia
| | - Zayneb Farhat
- Department of Family Medicine, Faculty of Medicine of Monastir, Monastir, Tunisia
| | - Jihen Chelly
- Department of Infectious Disease, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Mohamed Habib Sfar
- Department of Endocrinology, Taher Sfar University Hospital, Mahdia, Tunisia
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15
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Manieri E, Dondi A, Neri I, Lanari M. Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome in childhood: a narrative review. Front Med (Lausanne) 2023; 10:1108345. [PMID: 37575981 PMCID: PMC10421667 DOI: 10.3389/fmed.2023.1108345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Despite being rare, the Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a serious, possibly fatal condition that may affect both adults and children who may be also burdened by delayed sequelae. It is an adverse drug reaction characterized by widespread skin involvement, fever, lymphadenopathy, visceral involvement, and laboratory abnormalities (eosinophilia, mononucleosis-like atypical lymphocytes). It is more frequently triggered by anticonvulsants, sulphonamides, or antibiotics, the latter being responsible for up to 30% of pediatric cases. The disease typically develops 2-8 weeks after exposure to the culprit medication, with fever and widespread skin eruption; mild viral prodromes are possible. Unfortunately, diagnosis is challenging due to the absence of a reliable test; however, a score by the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) allows to classify suspect patients into no, possible, probable, or definite DRESS cases. Moreover, rapid-onset DRESS syndrome has been described in recent years. It affects children more often than adults and differs from the most common form because it appears ≤15 days vs. >15 days after starting the drug, it is usually triggered by antibiotics or iodinated contrast media rather than by anticonvulsants and has a higher presence of lymphadenopathy. Differential diagnosis between rapid-onset antibiotic-driven DRESS syndrome, viral exanthems, or other drug eruptions may be challenging, but it is mandatory to define it as early as possible to start adequate treatment and monitor possible complications. The present review reports the latest evidence about the diagnosis and treatment of pediatric DRESS syndrome.
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Affiliation(s)
- Elisa Manieri
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Arianna Dondi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Iria Neri
- Division of Dermatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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16
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Zhu H, Ren V. Immunopathogenic Insights on Preferential Human Herpesvirus-6 Reactivation in Drug Rash With Eosinophilia and Systemic Symptoms: A Scoping Review. J Cutan Med Surg 2023; 27:388-398. [PMID: 37231539 PMCID: PMC10523827 DOI: 10.1177/12034754231177590] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/14/2023] [Accepted: 04/28/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Human herpesvirus-6 (HHV-6) is a ubiquitous lymphotropic betaherpesvirus that can reactivate in drug rash with eosinophilia and systemic symptoms (DRESS). Despite recent publications advancing our understanding of HHV-6 in DRESS, the exact role of HHV-6 in disease pathogenesis remains unclear. METHODS A scoping review with the PubMed query "(HHV 6 AND (drug OR DRESS OR DIHS)) OR (HHV6 AND (drug OR DRESS OR DIHS))" was conducted in accordance with PRISMA guidelines. Articles containing original data on at least one DRESS patient with HHV-6 testing were included. RESULTS Our search returned a total of 373 publications, of which 89 met eligibility criteria. HHV-6 reactivation occurred in 63% of DRESS patients (n = 748), which was significantly more often than other herpesviruses. HHV-6 reactivation was associated with worse outcomes and greater severity in controlled studies. Case reports have demonstrated sometimes fatal HHV-6-related multi-organ involvement. Temporally, HHV-6 reactivation typically occurs 2 to 4 weeks after DRESS onset and has been linked to markers of immunologic signaling, such as OX40 (CD134), an HHV-6 entry receptor. Efficacy of antiviral or immunoglobulin treatment has only been demonstrated anecdotally, and steroid use may affect HHV-6 reactivation. CONCLUSION HHV-6 is implicated in DRESS more than in any other dermatologic condition. It is still unclear whether HHV-6 reactivation is cause or consequence of DRESS dysregulation. Similar pathogenic mechanisms precipitated by HHV-6 in other contexts may be relevant in DRESS. Future randomized controlled studies to assess effects of viral suppression on clinical outcomes is needed.
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Affiliation(s)
- Harrison Zhu
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
- HHV-6 Foundation, Santa Barbara, CA, USA
| | - Vicky Ren
- Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
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17
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Pavón-Romero GF, Parra-Vargas MI, Rosas-Fernández R, Ramírez-Jiménez F, Gutiérrez-Quiroz KV, Terán LM. [DRESS syndrome induced by anti-TB drugs]. REVISTA ALERGIA MÉXICO 2023; 70:55-63. [PMID: 37566768 DOI: 10.29262/ram.v70i2.1151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 04/23/2023] [Indexed: 08/13/2023] Open
Abstract
OBJETIVE To describe the phenotype of DRESS syndrome induced by antituberculosis drugs. METHODS Descriptive study, withdrawn from the review of the records of patients with DRESS syndrome, identified in the interconsultation of the Department of Research in Immunogenetics and Allergy, of the Insti-tuto Nacional de Enfermedades Respiratorias (INER) Ismael Cosío Villegas, among 2014 and 2020. Frequency analysis was performed. The associations between biomarkers and latency are calculated with the χ2 test and log-rank, and the evaluation of the change in the biomarkers with the Wilcoxon test. The value of p < 0.05 is considered statistically significant. For data analysis, the SPSS v.21 program was obtained. RESULTS 15 patients were identified; represented by 0.02% of total cases treated in the Department for so-meimmuno-allergic condition (15/7052); the main symptomatology were: rash (100%), eosinophilia (93%), fe-ver (80%), adenomegaly (60%), kidney damage (40%), liver damage (33%), and latency of 21 days. Liver damage was associated with prolonged latency (p = 0.02). After treatment, the total levels of eosinophils (p < 0.001) and liver and kidney biomarkers (p < 0.04) decreased. DRESS syndrome induced by antituberculosis drugs is not associated with the number of drugs prescribed or with the pattern of resistance of Mycobacterium tuberculosis. CONCLUSIONS DRESS syndrome induced by antituberculosis drugs is an atypical clinical reaction, similar to other types of DRESS syndrome that respond favorably to systemic corticosteroids.
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Affiliation(s)
- Gandhi Fernando Pavón-Romero
- Departamento de Inmunogenética y Alergia, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México
| | - María Itzel Parra-Vargas
- Departamento de Inmunogenética y Alergia, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México
| | - Rodrigo Rosas-Fernández
- Servicio de Pediatría, Hospital General de Playa del Carmen 18, Instituto Mexicano del Seguro Social, Quintana Roo, México
| | - Fernando Ramírez-Jiménez
- Departamento de Inmunogenética y Alergia, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México
| | - Katia Vanessa Gutiérrez-Quiroz
- Departamento de Inmunogenética y Alergia, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México
| | - Luis Manuel Terán
- Departamento de Inmunogenética y Alergia, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México.
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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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19
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Lugito NPH, Kurniawan A, Jayadi NN, Kristiani E. Immune-Mediated Adverse Drug Reactions (IM-ARDs) in the Form of Drug-Induced Immune Thrombocytopenia and Cutaneous Adverse Drug Reactions (CARD) Due to Clindamycin in an Human Immunodeficieny Virus (HIV) Patient. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e938358. [PMID: 36600572 PMCID: PMC9827413 DOI: 10.12659/ajcr.938358] [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: 12/24/2022]
Abstract
BACKGROUND Many drugs have been reported to cause immune-mediated adverse drug reactions (IM-ADRs) in human immunodeficiency virus (HIV) patients; the most common is cutaneous adverse drug reaction (CADR). Immune thrombocytopenia purpura (ITP) is frequent in HIV patients, and it can be caused HIV, opportunistic infections, or drugs. Although drugs can cause immune thrombocytopenia, termed drug-induced immune thrombocytopenia (DIIT), there has been no study on DIIT in HIV patients. CASE REPORT A 33-year-old male patient was admitted to our hospital with pruritic skin lesion over the entire body, which started 7 days before. He was diagnosed with HIV infection, brain toxoplasmosis, and pulmonary tuberculosis 2 weeks before admission, and was given trimethoprim sulphamethoxazole, isoniazid, rifampicin, pyrazinamide, and ethambutol. Clindamycin was added 10 days before admission. Skin examination revealed generalized erythematous macules with palpable petechiae and purpura. The platelet count was 141 000/µL when he was diagnosed with HIV, and it was 2000/µL at the time of admission. Clindamycin was discontinued and he was given steroids and platelet transfusion. The skin lesions improved along with an increased platelet count. He was discharged on the 10th day of admission, with platelet count of 42 000/µL. When he returned to the outpatient clinic on the 15th day, his platelet was 54 000/µL. The skin lesions had resolved completely and become hyperpigmented, and no purpura or petechiae were seen. CONCLUSIONS We present a case of an HIV patient with IM-ADR in the form of DIIT in conjunction with CADR that might have been caused by clindamycin.
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Affiliation(s)
- Nata Pratama Hardjo Lugito
- Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia,Corresponding Author: Nata Pratama Hardjo Lugito, e-mail:
| | - Andree Kurniawan
- Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
| | - Nana Novia Jayadi
- Department of Dermato-Venereology, Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
| | - Erna Kristiani
- Department of Pathological Anatomy, Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
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Amos K, Garcia-Bournissen F, Zhao L, Taheri S. Carbamazepine-induced liver injury in an 11-year-old female: Case report and review of the literature. J Paediatr Child Health 2023; 59:165-168. [PMID: 36069405 DOI: 10.1111/jpc.16200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Kiersten Amos
- Department of Paediatrics, Western University, London, Ontario, Canada
| | | | - Liena Zhao
- Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada
| | - Sepideh Taheri
- Department of Paediatrics, Western University, London, Ontario, Canada
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21
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Del Pozzo-Magaña BR, Rieder MJ, Garcia-Bournissen F, Lazo-Langner A. Drug reaction with Eosinophilia and Systemic Symptoms (DRESS): A Tertiary Care Center Retrospective Study. Br J Clin Pharmacol 2022; 88:4134-4141. [PMID: 35421262 DOI: 10.1111/bcp.15354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, drug-induced severe adverse reaction that usually occurs 3-6 weeks after initial exposure to certain drugs. It affects mainly adults and children to a lesser extent. Clinical features include fever, facial edema, generalized skin rash, lymphadenopathy, hematologic abnormalities, and internal organ involvement. OBJECTIVES To investigate the clinical and laboratory features of patients with DRESS in our center. METHODS We retrospectively describe and analyze 19 cases of DRESS whose diagnosis was based on the RegiSCAR criteria (≥ 6 points) that occurred from January 2009 to December 2019. RESULTS Patients ages ranged from 4-76 years(4 children/15 adults); 10 were female (52.3%). The most common culprit drugs were antibiotics (74%) and anticonvulsants (21%). The most common comorbidities were epilepsy (26%) and hypertension (26%). All patients developed cutaneous manifestations and of those, 58% presented facial edema. LFTs, urea/creatinine and troponin elevation were present in 74%, 32% and 42%, respectively. The median time to develop the skin rash after the drug exposure was 3.7 weeks (IQR2.4-4.2 weeks). Eosinophilia (≥ 0.7 x 10^9/L) was present in 95% of the patients and peaked around 10 days after the skin manifestations. Leukocytosis and reactive lymphocytes were reported in 84% and 26% of all patients respectively. Treatment with systemic steroids was reported in 16 patients. The mean recovery time was 2 weeks (IQR 2-3.5 weeks) and mortality was 5%. CONCLUSIONS DRESS is a serious condition with significant morbidity and mortality, which requires more research for a better understanding.
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Affiliation(s)
| | - Michael J Rieder
- Department of Paediatrics, Clinical Pharmacology, Western University
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22
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Mullan KA, Anderson A, Shi YW, Ding JH, Ng CC, Chen Z, Baum L, Cherny S, Petrovski S, Sham PC, Lim KS, Liao WP, Kwan P. Potential role of regulatory DNA variants in modifying the risk of severe cutaneous reactions induced by aromatic anti-seizure medications. Epilepsia 2022; 63:936-949. [PMID: 35170024 PMCID: PMC9541367 DOI: 10.1111/epi.17182] [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: 06/29/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 11/30/2022]
Abstract
Objective Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse drug reactions. Antiseizure medications (ASMs) with aromatic ring structure, including carbamazepine, are among the most common culprits. Screening for human leukocyte antigen (HLA) allele HLA‐B*15:02 is recommended prior to initiating treatment with carbamazepine in Asians, but this allele has low positive predictive value. Methods We performed whole genome sequencing and analyzed 6 199 696 common variants among 113 aromatic ASM‐induced SJS/TEN cases and 84 tolerant controls of Han Chinese ethnicity. Results In the primary analysis, nine variants reached genome‐wide significance (p < 5e‐08), one in the carbamazepine subanalysis (85 cases vs. 77 controls) and a further eight identified in HLA‐B*15:02‐negative subanalysis (35 cases and 53 controls). Interaction analysis between each novel variant from the primary analysis found that five increased risk irrespective of HLA‐B*15:02 status or zygosity. HLA‐B*15:02‐positive individuals were found to have reduced risk if they also carried a chromosome 12 variant, chr12.9426934 (heterozygotes: relative risk = .71, p = .001; homozygotes: relative risk = .23, p < .001). All significant variants lie within intronic or intergenic regions with poorly understood functional consequence. In silico functional analysis of suggestive variants (p < 5e‐6) identified through the primary and subanalyses (stratified by HLA‐B*15:02 status and drug exposure) suggests that genetic variation within regulatory DNA may contribute to risk indirectly by disrupting the regulation of pathology‐related genes. The genes implicated were specific either to the primary analysis (CD9), HLA‐B*15:02 carriers (DOCK10), noncarriers (ABCA1), carbamazepine exposure (HLA‐E), or phenytoin exposure (CD24). Significance We identified variants that could explain why some carriers of HLA‐B*15:02 tolerate treatment, and why some noncarriers develop ASM‐induced SJS/TEN. Additionally, this analysis suggests that the mixing of HLA‐B*15:02 carrier status in previous studies might have masked variants contributing to susceptibility, and that inheritance of risk for ASM‐induced SJS/TEN is complex, likely involving multiple risk variants.
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Affiliation(s)
- Kerry A Mullan
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Alison Anderson
- Department of Neuroscience, Central Clinical School, Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Yi-Wu Shi
- Institute of Neuroscience and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, China
| | - Jia-Hong Ding
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Ching-Ching Ng
- Genetics and Molecular Biology, Institute of Biological Sciences, Faculty of Science, University of Malaya, Kuala Lumpur, Malaysia
| | - Zhibin Chen
- Department of Neuroscience, Central Clinical School, Alfred Hospital, Monash University, Melbourne, Victoria, Australia.,Departments of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Larry Baum
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Stacey Cherny
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China.,Department of Epidemiology and Preventive Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Slave Petrovski
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Pak C Sham
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Kheng-Seang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wei-Ping Liao
- Institute of Neuroscience and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, China
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Alfred Hospital, Monash University, Melbourne, Victoria, Australia.,Institute of Neuroscience and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, China.,Departments of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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23
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Rastogi S, Pandey P. Idiosyncratic adversity reported after oral consumption of an ayurvedic formulation containing bhallataka (Semecarpus anacardium): A case report. J Ayurveda Integr Med 2022; 13:100635. [PMID: 36462347 PMCID: PMC9713265 DOI: 10.1016/j.jaim.2022.100635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 12/05/2022] Open
Abstract
Drugs associated adversities are common in health care practice. These adversities are often associated with the dose-related, time-related and methods of drug intake and their rationality in a given condition but can also be unrelated to either of these causes. Such unpredictable drug reactions are highly important from the perspective of safe use of a drug and to prevent complications from any such adversity which is relatively uncommon. The case reported here is a likely case of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) like idiosyncratic adversity after oral consumption of an ayurvedic formulation containing Bhallataka (Semecarpus anacardium). DRESS is found associated with many other classes of drugs but its association with ayurvedic drug has not yet been reported. Upon Naranjo probability scale the event scored 6, putting it into the category of probable drug related adversity. This report widens our understanding towards the possibility of delayed and idiosyncratic drug adversities upon the consumption of certain ayurvedic drugs.
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Govindaraj V, Bai M, Kottaisamy R, Vijayarangam N. Drug reaction with eosinophilia and systemic symptoms syndrome related to piperacillin-tazobactam use. J Postgrad Med 2022; 68:102-105. [PMID: 35466662 PMCID: PMC9196285 DOI: 10.4103/jpgm.jpgm_1226_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, idiosyncratic reaction to a drug which presents after a prolonged latency period. Although it most commonly occurs with aromatic anticonvulsants, antibiotics are also occasionally implicated. A 50-year-old male was admitted for left pyopneumothorax. He was started on intravenous piperacillin-tazobactam (Pip/Taz) and clindamycin. After 10 days of treatment, he developed high grade fever with maculopapular rashes with areas of scaling. He had elevated WBC counts with eosinophils of 21% and raised serum transaminases. After excluding other possible etiologies for febrile illness, a possibility of DRESS was considered. Naranjo scale, used for causality assessment, yielded a total score of 6, pointing toward probable adverse drug reaction. Also, the patient had 6 out of the 7 inclusion criteria for DRESS as per European Registry of Severe Cutaneous Adverse Reaction (RegiScar) scoring. Pip/Taz was found to be causative drug and was discontinued. He was conservatively managed with antipyretics and topical steroids. Fever subsided the day after stopping Pip/Taz and his rashes resolved gradually. In conclusion the possibility of antibiotics-induced DRESS should be considered and high index of vigilance is advised.
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25
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Maloney NJ, Rana J, Yang JJ, Zaba LC, Kwong BY. Clinical features of drug-induced hypersensitivity syndrome to BRAF inhibitors with and without previous immune checkpoint inhibition: a review. Support Care Cancer 2021; 30:2839-2851. [PMID: 34546454 DOI: 10.1007/s00520-021-06543-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 09/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Cutaneous reactions to BRAF inhibitors are common, but severe reactions resembling or consistent with drug-induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) are relatively rare. Several reports suggest that cutaneous reactions including DRESS/DIHS to BRAF inhibitors are more frequent and severe in the setting of previous immune checkpoint inhibition (ICI). METHODS To characterize existing literature on these reports, we queried the PubMed/MEDLINE database for cases of DIHS/DRESS to BRAF inhibitors. RESULTS We identified 23 cases of DIHS to BRAF inhibitors following checkpoint inhibition and 14 cases without prior checkpoint inhibitor therapy. In both cohorts, DIHS occurred relatively early, with median time to onset from drug exposure of 8-10 days. Patients who received prior ICI were less likely to have peripheral eosinophilia (26% vs 71%), atypical lymphocytes (9% vs 50%), renal involvement (61% vs 79%), hepatic involvement (52% vs 86%), and lymphadenopathy (9% vs 43%) compared to patients who did not receive prior ICI. Thrombocytopenia was more common with prior ICI (17% vs 7%). Only patients who received prior ICI experienced hypotension (26%) during the course of their DIHS. All cases of BRAF-induced DIHS generally improved on systemic steroids/supportive care, and no cases of death were identified. CONCLUSION Dermatologists should consider a diagnosis of DIHS following BRAF inhibitor initiation, particularly in the setting of past checkpoint inhibition, with atypical features including relatively rapid onset and steroid responsiveness, lack of peripheral eosinophilia, lymphocytosis, or lymphadenopathy, and increased risk of thrombocytopenia and hypotension.
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Affiliation(s)
- Nolan J Maloney
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Jasmine Rana
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Jason J Yang
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
| | - Lisa C Zaba
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA.
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Naveed S, Urrutia V, Kaur L, Marshall J, Malik S. Systemic Adverse Reactions to Psychotropic Medications: What Do We Need to Know? Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210803-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Zereshkian A, Waserman S. Liver enzyme elevation and eosinophilia with atorvastatin: a case of probable DRESS without cutaneous symptoms. Allergy Asthma Clin Immunol 2021; 17:81. [PMID: 34330325 PMCID: PMC8322645 DOI: 10.1186/s13223-021-00581-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/18/2021] [Indexed: 12/18/2022] Open
Abstract
Background Drug reaction with eosinophilia and systemic symptoms (DRESS) is a potentially life-threatening hypersensitivity reaction to medication. While a relatively rare phenomenon, early identification and discontinuation of the offending agent is pivotal to patient management. To our knowledge this is the first reported case of probable atorvastatin induced DRESS syndrome without rash. Case presentation An adult female presented with 4 days of persistent fevers, abdominal and flank pain, malaise, and generalized muscle weakness without any cutaneous reaction following 20 days of therapy with atorvastatin. She was febrile (38.5 °C), at presentation with a heart rate of 72, and blood pressure of 93/51 mmHg. Her laboratory investigations at their peak demonstrated an Alkaline Phosphatase (ALP) of 792 U/L, Alanine aminotransferase (ALT) of 265 U/L, gamma glutamyl transferase (GGT) of 236 U/L, total bilirubin at 21 mg/dL, eosinophils 3100 cells/µL, leukocytes 20.2 K/µL, hemoglobin of 12.5 gm/dL. During her admission she had normal creatinine and troponin. Her serology for Hepatitis A, B and C were negative. Cytomegalovirus, Epstein-Barr viral serologies were negative. Antinuclear Antibody (ANA), rheumatoid factor, anti-neutrophil cytoplasmic antibody (ANCA), mitochondrial antibody, and smooth muscle antibody were negative. The patient was initially diagnosed as having pyelonephritis due to nonspecific bilateral flank pain but given ongoing fevers and lack of clinical and laboratory improvement with antibiotics, a diagnosis of atorvastatin induced DRESS syndrome was considered probable, and atorvastatin was discontinued. The patients’ clinical status improved gradually without any further therapy and her liver enzymes and eosinophils normalized over the course of a month. Conclusion In patients who present with systemic organ involvement and eosinophilia, even without cutaneous manifestations, clinicians should apply the RegiSCAR criteria for DRESS syndrome. This can then help guide treatment with discontinuation of offending agent, or treatment with systemic corticosteroids.
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Truong K, Kelly S, Bayly A, Smith A. Successful mepolizumab treatment for DRESS-induced refractory eosinophilic myocarditis and concurrent thyroiditis. BMJ Case Rep 2021; 14:14/7/e242240. [PMID: 34266818 DOI: 10.1136/bcr-2021-242240] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a potentially life-threatening adverse drug reaction with a mortality rate of 10%. Interstitial nephritis, pneumonitis, myocarditis, meningitis, thyroiditis and pancreatitis are major causes of morbidity and mortality in this syndrome. Cessation of offending medication is paramount. There is paucity in high quality prospective studies guiding the treatment of DRESS, and there are no published therapeutic clinical trials in the treatment of corticosteroid refractory hypersensitivity myocarditis. The authors present a unique case of ciprofloxacin-induced DRESS with concurrent thyroiditis and refractory eosinophilic myocarditis that required mepolizumab and multiple immunosuppressants for successful treatment.
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Affiliation(s)
- Kelvin Truong
- Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia .,Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Shane Kelly
- Department of Clinical Immunology, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Angela Bayly
- Department of Tissue Pathology and Diagnostic Oncology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Annika Smith
- Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia.,Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Role of Multiple Comorbidities and Therapies in Conditioning the Clinical Severity of DRESS: A Mono-Center Retrospective Study of 25 Cases. Int J Mol Sci 2021; 22:ijms22137072. [PMID: 34209467 PMCID: PMC8268599 DOI: 10.3390/ijms22137072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 12/14/2022] Open
Abstract
DRESS/DiHS is a complex and potentially fatal drug reaction. Little is known about risk factors and elements that can help to identify patients with a severe reaction early. The aim of the study was to investigate those factors favoring the disease and its severity by analyzing the clinical conditions and therapies preceding the reaction. We conducted a retrospective analysis on patients admitted to our center between 2010 and 2020 who were discharged with a diagnosis of DRESS. We used the RegiSCAR diagnostic criteria. We defined the severity of DRESS using the criteria of Mizukawa et al. We included 25 patients (15 females) with a median age of 66 years. Skin involvement, eosinophilia, and liver injury were the most important aspects. Allopurinol was found to be the most involved drug. Reaction severity was significantly associated with the number of daily medications (p = 0.0067) and an age of at least 68 years (p = 0.013). In addition, 75% of severe cases had at least three comorbidities in history, and most of the severe cases were female. In our study the advanced age, the high number of comorbidities and home therapies, and the inflammatory state were found to be predisposing elements to the development of the disease and its severity.
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Mifsud NA, Illing PT, Lai JW, Fettke H, Hensen L, Huang Z, Rossjohn J, Vivian JP, Kwan P, Purcell AW. Carbamazepine Induces Focused T Cell Responses in Resolved Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Cases But Does Not Perturb the Immunopeptidome for T Cell Recognition. Front Immunol 2021; 12:653710. [PMID: 33912179 PMCID: PMC8071863 DOI: 10.3389/fimmu.2021.653710] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Antiseizure medications (ASMs) are frequently implicated in T cell-mediated drug hypersensitivity reactions and cause skin tropic pathologies that range in severity from mild rashes to life-threatening systemic syndromes. During the acute stages of the more severe manifestations of these reactions, drug responsive proinflammatory CD8+ T cells display classical features of Th1 cytokine production (e.g. IFNγ) and cytolysis (e.g. granzyme B, perforin). These T cells may be found locally at the site of pathology (e.g. blister cells/fluid), as well as systemically (e.g. blood, organs). What is less understood are the long-lived immunological effects of the memory T cell pool following T cell-mediated drug hypersensitivity reactions. In this study, we examine the ASM carbamazepine (CBZ) and the CBZ-reactive memory T cell pool in patients who have a history of either Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) from 3-to-20 years following their initial adverse reaction. We show that in vitro drug restimulation of CBZ-reactive CD8+ T cells results in a proinflammatory profile and produces a mainly focused, yet private, T cell receptor (TCR) usage amongst human leukocyte antigen (HLA)-B*15:02-positive SJS or TEN patients. Additionally, we show that expression of these CBZ-reactive TCRs in a reporter cell line, lacking endogenous αβTCR, recapitulates the features of TCR activation reported for ASM-treated T cell lines/clones, providing a useful tool for further functional validations. Finally, we conduct a comprehensive evaluation of the HLA-B*15:02 immunopeptidome following ASM (or a metabolite) treatment of a HLA-B*15:02-positive B-lymphoblastoid cell line (C1R.B*15:02) and minor perturbation of the peptide repertoire. Collectively, this study shows that the CBZ-reactive T cells characterized require both the drug and HLA-B*15:02 for activation and that reactivation of memory T cells from blood results in a focused private TCR profile in patients with resolved disease.
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Affiliation(s)
- Nicole A Mifsud
- Infection and Immunity Program, Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Patricia T Illing
- Infection and Immunity Program, Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Jeffrey W Lai
- Infection and Immunity Program, Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Heidi Fettke
- Infection and Immunity Program, Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Luca Hensen
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, VIC, Australia
| | - Ziyi Huang
- Infection and Immunity Program, Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Jamie Rossjohn
- Infection and Immunity Program, Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia.,Australian Research Council Centre of Excellence for Advanced Molecular Imaging, Monash University, Clayton, VIC, Australia.,Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Julian P Vivian
- Infection and Immunity Program, Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia.,Australian Research Council Centre of Excellence for Advanced Molecular Imaging, Monash University, Clayton, VIC, Australia
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Alfred Hospital, Monash University, Melbourne, VIC, Australia.,Departments of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.,Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Anthony W Purcell
- Infection and Immunity Program, Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
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31
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Drug Rash With Eosinophilia and Systemic Symptoms: Diagnosis and Management. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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32
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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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33
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Ramaswamy S, Sah S, Shakya B, Shariff A, Babu MS, Ramesh M, Niharika P, Dhurappanavar S. Aceclofenac-induced drug reaction with eosinophilia and systemic symptoms syndrome. J Pharmacol Pharmacother 2021. [DOI: 10.4103/jpp.jpp_80_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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34
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Sandhu S, Neema S, Vashisht D, Venugopal R, Sengupta P, Radhakrishnan S. Drug reaction with eosinophilia and systemic symptoms: A single center descriptive observational study. Dermatol Ther 2020; 34:e14670. [PMID: 33314590 DOI: 10.1111/dth.14670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 12/17/2022]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse cutaneous drug reaction with mortality up to 10%. It is a rare condition with risk varying between 1 in 1000 and 1 in 10 000 drug exposures. The aim of the study was to describe clinical features, management and drugs responsible for causing DRESS. The study was retrospective, observational study. The data of patients admitted to hospital with diagnosis of DRESS during study period (March 2018 to February 2020), were retrieved and analyzed. The descriptive data of patients were summarized. The continuous variables were summarized as mean ± SD and/or median, depending on the skewness of the data. The categorical variables were expressed as absolute numbers, frequency, and proportions (%). The data was tabulated and analyzed in Microsoft Excel 2019 version. A total of 20 patients who met inclusion criteria (probable or definite DRESS as per RegiSCAR criteria) were included in the study. The mean age of the patients was 41.2 ± 15.7 years. The average latency period was 26.45 ± 5.65 days (range: 7-60). The commonest culprit drugs were dapsone and phenytoin, each in five (25%) patients. Commonest morphology of rash was morbilliform in 13 (65%) patients. One patient with targetoid rash had multi-organ involvement. Facial edema, periorbital edema, and conjunctival injection were seen in 17 (85%), seven (35%), and six (30%) cases, respectively. Eosinophilia was present in 18 (90%) patients with mean (±SD) value of 1976 ± 840 cells/μl. Liver was the commonest internal organ involved in 14 (70%) patients and kidney in three (15%) patients. The initial dose of prednisolone for treatment varied from 0.75 to 2 mg/kg/day. The mean duration of steroid treatment was 64 ± 21 days. Two patients were treated with intravenous methylprednisolone and one with intravenous immunoglobulin. Two patients (10%) had recurrence of adverse drug reaction >6 months after completion of initial treatment and two (10%) developed autoimmune thyroiditis during follow-up. Small sample size and retrospective nature of the study were main limitations. Selection bias is a possibility as study was carried out in tertiary care center. Tests for incriminating culprit drugs such as patch test, intradermal test, and lymphocyte transformation test were not performed. DRESS is a rare disease that can be diagnosed early with high index of suspicion and treated successfully with steroids. The internal organ involvement is common in DRESS and requires a thorough evaluation.
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Affiliation(s)
- Sunmeet Sandhu
- Department of Dermatology, Command Hospital Airforce Bangalore, India
| | - Shekhar Neema
- Department of Dermatology, Armed Forces Medical College, Pune, India
| | - Deepak Vashisht
- Department of Dermatology, Armed Forces Medical College, Pune, India
| | - Ruby Venugopal
- Department of Dermatology, Armed Forces Medical College, Pune, India
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Drug reaction with eosinophilia and systemic symptoms (DRESS) with severe and atypical lung involvement. Radiol Case Rep 2020; 15:2178-2182. [PMID: 32944113 PMCID: PMC7481882 DOI: 10.1016/j.radcr.2020.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 12/17/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms is a rare and potentially fatal drug hypersensitivity reaction. Reactions include skin eruption, fever, hematologic abnormalities (eosinophilia or atypical lymphocytosis), enlarged lymph nodes, and/or organic involvement. The liver is the most commonly compromised organ. We present a case of drug reaction with eosinophilia and systemic symptoms associated with Naproxen intake in a young female patient with severe lung involvement. The patient's chest tomography highlights the presence of adenomegalies, pericardial and pleural effusion, peribroncovascular consolidations, and centrilobular nodules. After reviewing the literature few similar cases were found. The main radiological alterations in those cases included interstitial opacities attributed to pneumonitis. Therefore, this case study is considered an unusual case with atypical presentation of drug-induced eosinophilic lung disease.
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Prejean R, Haas C. Recalcitrant
minocycline‐induced DRESS
mimicking
HLH. Dermatol Ther 2020; 33:e14104. [DOI: 10.1111/dth.14104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/13/2020] [Accepted: 07/26/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Rosemary Prejean
- Louisiana State University School of Medicine—Shreveport Shreveport Louisiana USA
| | - Christopher Haas
- Department of Dermatology LSUHSC New Orleans New Orleans Louisiana USA
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Sanabria-Cabrera J, Medina-Cáliz I, Stankevičiūtė S, Rodríguez-Nicolás A, Almarza-Torres M, Lucena MI, Andrade RJ. Drug-Induced liver Injury Associated with Severe Cutaneous Hypersensitivity Reactions: A Complex Entity in Need of a Multidisciplinary Approach. Curr Pharm Des 2020; 25:3855-3871. [PMID: 31696806 DOI: 10.2174/1381612825666191107161912] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/06/2019] [Indexed: 12/12/2022]
Abstract
Idiosyncratic drug-induced liver injury (DILI) occasionally occurs in the setting of severe cutaneous adverse reactions (SCARs), including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and drug reaction with eosinophilia and systemic symptoms (DRESS). This strengthens the proposed immunologic mechanism associated with this adverse reaction. DRESS exhibits the most common association with DILI. SCARs have a wide spectrum of heterogeneous clinical presentations and severity, and genetic predisposition has been identified. In the context of SCARs, DILI present a different clinical picture, ranging from mild injury to acute liver failure. Elucidating the role of DILI in the clinical presentation and outcome of SCARs represents a challenge due to limited information from published studies and the lack of consensus on definitions. The cholestatic and mixed pattern of liver damage typically predominates in the case of DILI associated with SCARs, which is different from DILI without SCARs where hepatocellular is the most common injury pattern. Only a few drugs have been associated with both DILI and SCARs. Is this article, the criteria used for DILI recognition among SCARS have been revised and discussed, along with the drugs most commonly involved in these syndromes as well as the outcome, prognostic factors and the need for a multidisciplinary approach to improve the management of DILI in the context of SCARs.
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Affiliation(s)
- Judith Sanabria-Cabrera
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain.,UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Madrid, Spain
| | - Inmaculada Medina-Cáliz
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | - Marina Almarza-Torres
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain
| | - M Isabel Lucena
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain.,UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Raúl J Andrade
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
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Patocka J, Wu Q, Nepovimova E, Kuca K. Phenytoin - An anti-seizure drug: Overview of its chemistry, pharmacology and toxicology. Food Chem Toxicol 2020; 142:111393. [PMID: 32376339 DOI: 10.1016/j.fct.2020.111393] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/16/2020] [Accepted: 04/24/2020] [Indexed: 12/22/2022]
Abstract
Phenytoin is a long-standing, anti-seizure drug widely used in clinical practice. It has also been evaluated in the context of many other illnesses in addition to its original epilepsy indication. The narrow therapeutic index of phenytoin and its ubiquitous daily use pose a high risk of poisoning. This review article focuses on the chemistry, pharmacokinetics, and toxicology of phenytoin, with a special focus on its mutagenicity, carcinogenicity, and teratogenicity. The side effects on human health associated with phenytoin use are thoroughly described. In particular, DRESS syndrome and cerebellar atrophy are addressed. This review will help in further understanding the benefits phenytoin use in the treatment of epilepsy.
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Affiliation(s)
- Jiri Patocka
- Faculty of Health and Social Studies, Department of Radiology and Toxicology, University of South Bohemia Ceske Budejovice, Ceske Budejovice, Czech Republic; Biomedical Research Centre, University Hospital, Hradec Kralove, Czech Republic
| | - Qinghua Wu
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove, Czech Republic; College of Life Science, Yangtze University, Jingzhou, 434025, China
| | - Eugenie Nepovimova
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Kamil Kuca
- Biomedical Research Centre, University Hospital, Hradec Kralove, Czech Republic; Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove, Czech Republic.
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Mukit W, Cooper R, Moudgil H, Ahmad N. DRESS syndrome: an important differential for eosinophilia with systemic organ dysfunction. BMJ Case Rep 2020; 13:13/5/e234251. [DOI: 10.1136/bcr-2020-234251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Drug rash occurring with eosinophilia and systemic symptoms syndrome is a potentially fatal adverse drug reaction that requires immediate action in order to minimise patient harm. Initially implicated with the use of anticonvulsants, it has also been shown to be caused by many other medications but less frequently with vancomycin. Patients typically present with fever, lymphadenopathy, eosinophilia and systemic organ dysfunction. Diagnosis is aided using probability calculators such as RegiSCAR (Registry of Severe Cutaneous Adverse Reaction), as well as clinical response on removing the responsible medication. Here, we present a case without any systemic organ dysfunction that improved with withdrawal of the offending drug vancomycin.
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Gowda SM, Vijay Kumar KG, Shilpa K. Chlorpromazine-induced Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome. Indian J Psychol Med 2020; 42:99-101. [PMID: 31997872 PMCID: PMC6970299 DOI: 10.4103/ijpsym.ijpsym_364_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/30/2019] [Accepted: 12/13/2019] [Indexed: 11/18/2022] Open
Affiliation(s)
- Shayanth Manche Gowda
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - K G Vijay Kumar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - K Shilpa
- Department of Dermatology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
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Sohn SJ, Jeung SY, Chae HK, Cho HS, An JH, Li Q, Song WJ, Youn HY. Phenobarbital-induced anticonvulsant hypersensitivity syndrome in a cat. J Vet Med Sci 2019; 81:1850-1852. [PMID: 31685729 PMCID: PMC6943318 DOI: 10.1292/jvms.19-0388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In this study, we document a case of phenobarbital-induced anticonvulsant
hypersensitivity syndrome (AHS), which has been rarely reported in veterinary medicine. A
2-year-old, 5.4 kg, neutered male Russian Blue cat was diagnosed with idiopathic epilepsy
and started on phenobarbital treatment. Eight days after initiation of phenobarbital
treatment, the cat showed tachypnea and hyperthermia. CBC and serum biochemistry were
unremarkable. However, the patient showed high serum amyloid A (SAA). On abdominal
ultrasonography, generalized enlargement of abdominal lymph nodes and splenic multiple
hypo-echoic nodules, which were consistent with reactive lymphadenopathy were found. The
cat was diagnosed with AHS, and phenobarbital was discontinued. After 10 days of
cessation, the patient had normal SAA, and clinical signs were resolved.
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Affiliation(s)
- Sang-June Sohn
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - So-Young Jeung
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - Hyung-Kyu Chae
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - Hee-Seon Cho
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - Ju-Hyun An
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - Qiang Li
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - Woo-Jin Song
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - Hwa-Young Youn
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
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Phenytoin-associated necrotising lymphadenitis mimicking Kikuchi disease. Pathology 2019; 51:650-653. [DOI: 10.1016/j.pathol.2019.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 03/25/2019] [Accepted: 04/07/2019] [Indexed: 11/20/2022]
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Zafar S, Decastro A, Pal S, Pandav J, Kanaparthy N. Vancomycin-induced DRESS syndrome. Ann Allergy Asthma Immunol 2019; 124:107-108. [PMID: 31513907 DOI: 10.1016/j.anai.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/16/2019] [Accepted: 09/03/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Saira Zafar
- Department of Internal Medicine, Westchester Medical Center Valhalla, New York.
| | - Alicia Decastro
- Department of Internal Medicine, Westchester Medical Center Valhalla, New York
| | - Suman Pal
- Department of Internal Medicine, Westchester Medical Center Valhalla, New York
| | - Jay Pandav
- Department of Internal Medicine, Westchester Medical Center Valhalla, New York
| | - Naga Kanaparthy
- Department of Internal Medicine, Westchester Medical Center Valhalla, New York
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Rhyou HI, Nam YH. Procalcitonin as a diagnostic marker for differentiating DRESS syndrome from bacterial infection. Ann Allergy Asthma Immunol 2019; 123:307-309.e1. [PMID: 31238099 DOI: 10.1016/j.anai.2019.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Hyo-In Rhyou
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Young-Hee Nam
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea.
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Mullan KA, Anderson A, Illing PT, Kwan P, Purcell AW, Mifsud NA. HLA-associated antiepileptic drug-induced cutaneous adverse reactions. HLA 2019; 93:417-435. [PMID: 30895730 DOI: 10.1111/tan.13530] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 02/20/2019] [Accepted: 03/18/2019] [Indexed: 12/31/2022]
Abstract
Adverse drug reactions (ADRs) are a common cause of hospital admissions (up to 19%), with the majority of cases due to off-target predictable drug effects (type A reactions). However, idiosyncratic drug-induced immune activated (type B) reactions contribute to a range of hypersensitivity reactions, with T-cell-mediated type IV hypersensitivity reactions mainly manifesting as cutaneous ADRs (cADRs). Aromatic antiepileptic drugs (AEDs), used in the treatment of epilepsy as well as bipolar disorder or neuropathic pain, have been implicated as culprit drugs in a spectrum of pathologies ranging from mild maculopapular exanthema (MPE) to severe and life-threatening conditions including drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). These AED-induced cADRs are unpredictable based on pharmacological and clinical factors alone, thereby prompting investigations into genomic contributors mediating risk of pathology. The most strongly associated risk genes identified are from the human leukocyte antigen (HLA) class I alleles, which play a critical role in adaptive immunity by flagging either infected or aberrant cells for recognition by surveying T-cells. In the setting of drug hypersensitivity, the immunogenicity of HLA molecules and their peptide cargo can be modulated by interactions with small drug molecules that drive inappropriate T-cell responses. This review discusses the current understanding of HLA class I molecules in modifying risk of AED-induced cADRs.
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Affiliation(s)
- Kerry A Mullan
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Alison Anderson
- Department of Neuroscience, Central Clinical School, Monash University, Clayton, Victoria, Australia
| | - Patricia T Illing
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Clayton, Victoria, Australia.,Department of Neuroscience, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Anthony W Purcell
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Nicole A Mifsud
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
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Abstract
CASE SUMMARY A 3-year-old spayed female domestic shorthair cat developed a fever 1 week after starting the anticonvulsant phenobarbital. A diagnostic work-up for seizures and subsequent onset of fever of unknown origin, consisting of MRI of the brain, cerebrospinal fluid analysis and infectious disease testing, was unremarkable. The cat was switched from phenobarbital onto pregabalin with complete resolution of the fever within 24 h, consistent with a drug-induced fever following phenobarbital administration. RELEVANCE AND NOVEL INFORMATION While anticonvulsant hypersensitivities have been reported and studied in veterinary medicine, phenobarbital-induced fever outside of the context of systemic clinical signs has not been documented in the veterinary scientific literature. Drug-induced fever secondary to anticonvulsants should be considered in patients that develop a fever after starting anticonvulsant therapy with an unrewarding diagnostic work-up for fever of unknown origin.
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Affiliation(s)
- Dylan M Djani
- VCA Animal Specialty Center of South Carolina,
Columbia, SC, USA
| | - William E Draper
- VCA Animal Specialty Center of South Carolina,
Columbia, SC, USA
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Gauckler P, Shin JI, Mayer G, Kronbichler A. Eosinophilia and Kidney Disease: More than Just an Incidental Finding? J Clin Med 2018; 7:E529. [PMID: 30544782 PMCID: PMC6306805 DOI: 10.3390/jcm7120529] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 11/29/2018] [Accepted: 12/05/2018] [Indexed: 02/07/2023] Open
Abstract
Peripheral blood eosinophilia (PBE), defined as 500 eosinophils or above per microliter (µL) blood, is a condition that is not uncommon but often neglected in the management of patients with chronic kidney disease (CKD), acute kidney injury (AKI), or patients on renal replacement therapy (RRT). The nature of PBE in the context of kidney diseases is predominantly secondary or reactive and has to be distinguished from primary eosinophilic disorders. Nonetheless, the finding of persistent PBE can be a useful clue for the differential diagnosis of underdiagnosed entities and overlapping syndromes, such as eosinophilic granulomatosis with polyangiitis (EGPA), IgG4-related disease (IgG4-RD), acute interstitial nephritis (AIN), or the hypereosinophilic syndrome (HES). For patients on RRT, PBE may be an indicator for bio-incompatibility of the dialysis material, acute allograft rejection, or Strongyloides hyperinfection. In a subset of patients with EGPA, eosinophils might even be the driving force in disease pathogenesis. This improved understanding is already being used to facilitate novel therapeutic options. Mepolizumab has been licensed for the management of EGPA and is applied with the aim to abrogate the underlying immunologic process by blocking interleukin-5. The current article provides an overview of different renal pathologies that are associated with PBE. Further scientific effort is required to understand the exact role and function of eosinophils in these disorders which may pave the way to improved interdisciplinary management of such patients.
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Affiliation(s)
- Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
- Department of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea.
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
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Drug-Induced Hypersensitivity Syndrome: A Clinical, Radiologic, and Histologic Mimic of Lymphoma. Case Rep Hematol 2018; 2018:7037352. [PMID: 30420928 PMCID: PMC6215581 DOI: 10.1155/2018/7037352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/06/2018] [Indexed: 12/17/2022] Open
Abstract
Drug-induced hypersensitivity syndrome (DIHS; also known as drug reaction with eosinophilia and systemic symptoms, or DRESS) is a rare, potentially life-threatening condition that typically presents 2–8 weeks after drug exposure with fever, rash, organ dysfunction, and lymphadenopathy. Here, we describe the case of an 18-year-old African American female who presented with cervical lymphadenopathy, fevers, and a macular rash. A PET scan showed diffuse hypermetabolic lymphadenopathy suggestive of lymphoma, with involvement of the spleen and kidneys. The clinical history, imaging, and biopsy findings initially raised concern for a malignant process, with a differential diagnosis including classic Hodgkin's lymphoma and T-cell lymphoma. However, the morphologic and immunophenotypic features were not entirely typical for those diagnoses. The patient was ultimately diagnosed with DIHS after it was learned that she recently had been treated with minocycline, a medication previously implicated in causing DIHS.
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