2. Drug-induced liver injury with hypersensitivity features/drug reaction with eosinophilia and systemic symptoms (DRESS): a single center experience of 38 cases

Abstract

Background and Aims: Liver involvement is the most common visceral involvement in Drug Reaction with Eosinophilia and Systemic symptoms (DRESS), which may complicate the prognosis. However, due to concomitant involvement of skin, drug induced liver injury (DILI) in them may have different picture. So this study was conducted to determine clinical characteristics, course and outcome of DRESS cases associated with liver injury. Methods: This data is collected from prospective DILI cohort from 2015 and rest of cases were collected retrospectively from the department of Gastroenterology and Dermatology, Medical college, Kozhikode, India over a period of 4 1/2 years from January 2014 till April 2018. Causality assessment was done by RUCAM scoring for DILI and by RegiSCAR for DRESS. Results: There were a total of 38 cases with DRESS and liver involvement with a mean age of 40.7 +/− 19.3 years (9–83 years) and female predominance (n = 25). Skin rash (71%) was the major symptom followed by anorexia (44.7%), fever (34.2%), vomiting (23.6%) and jaundice (15.7%). Based on R factor, 15 had hepatocellular, 17 with mixed and 6 patients had cholestatic pattern of injury. Drugs implicated were Phenytoin (31.5%), sulpha drugs (21%), carbamazepine (10.5%), valproate (7.8%), Amoxicillin-clavulanate (7.8%) and others. Stevens-Johnson syndrome was seen in 7 patients, out of which 1 patient died. When compared with the DILI cohort without DRESS (137 cases), DILI patients had significantly higher no. of severe cases (59.8% vs. 39.4%), MELD score (14.5 vs. 9.6), mean INR (1.71 vs. 1.05), albumin (3.44 g/dl vs. 3.64 g/dl), normalization of liver biochemistry (29.8 vs. 14.5 days) and mortality (13.1 vs. 2.6%). Conclusions: Although DILI has significant morbidity and mortality, patients who present with DRESS have relatively mild form of liver injury and better prognosis due to early presentation and specific treatment with steroids. The authors have none to declare.