Diagnosis Of Drug Reaction With Eosinophilia And Systemic Symptoms Syndrome Research Articles

ATT associated DRESS syndrome in a patient of multidrug resistant tuberculosis diagnosed on lymph node FNAC

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare type of idiosyncratic drug reaction. It is usually associated with antiepileptic drugs. It can also be associated with first line anti-tubercular drugs (ATDs), antibiotics, herbal medicines and many other drugs. We report a case of DRESS syndrome presented with erythematous lesions all over the body following the intake of second line ATDs for multi drug resistant tuberculosis. FNAC was done from the enlarged inguinal lymph node which revealed the presence of atypical lymphocytes. Clinical and other supportive features confirmed the diagnosis of DRESS syndrome.

PSUN62 A Rare Case of Atorvastatin Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome - A Case Report.

Abstract Clinical Case A 77 year-old female presented to emergency department with progressively worsening rash that started one week ago. On physical examination blanching erythema was noted in lower back, buttocks and extremities. There was no desquamation or involvement of oral mucosa. No lymphadenopathy or hepatosplenomegaly was noted. Laboratory investigations showed white blood cell count of 21.2×10^3/uL, with 33.1% eosinophils. Creatinine was elevated at 2.8mg/dL from baseline of 0.8mg/dL. Further lab work revealed alkaline phosphate 2314 IU/L, aspartate transaminase 587 IU/L, and alanine transaminase 620 U/L, total bilirubin 7.3mg/dL with direct bilirubin of 5.1mg/dL, Immunoglobulin E level of 2000 IU/ml and normal Tryptase levels. Serology for viral hepatitis, Epstein-Barr virus, Cytomegalovirus and Human immunodeficiency virus was negative. Autoimmune workup including antinuclear Antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA), mitochondrial antibody, smooth muscle antibody, double stranded DNA, anti-histone antibody, rheumatoid factor, Sjogren's antibody and centromere antibody were negative. Urinalysis, urine protein electrophoresis and serum protein electrophoresis were also normal. Computed tomography (CT) scan of chest showed mild supraclavicular and mediastinal lymphadenopathy. Review of medical records revealed that patient was recently discharged from hospital with a prescription of Atorvastatin following admission for transient ischemic attack 6 weeks ago. Skin biopsy showed superficial perivascular dermatitis with extravasation of red blood cells with no diagnostic evidence of vasculitis, granuloma or malignancy. Based on biopsy findings, recent drug administration followed by appearance of rash, hematological abnormality, lymphadenopathy and multi-system involvement and after exclusion of other possible causes, diagnosis of DRESS syndrome was made. Atorvastatin was held and patient was given Methylprednisolone for three days followed by Prednisone 1mg/kg with taper. Rash as well as kidney and liver functions improved drastically within two days. Discussion Our patient presented with one week of rash associated with deteriorating kidney and liver functions. Atorvastatin was initiated five weeks prior to development of rash. All the possible infectious etiologies and malignancy was ruled out based on the laboratory work mentioned above. Work up for vasculitis was also negative. DRESS syndrome is a late onset drug induced hypersensitivity reaction which usually manifests 3 weeks to months after the offending drug is started. It is very rare with an incidence of 0.9-2 per 100,000 patients per year and accounts for 10-20% of all cutaneous adverse drug reactions. DRESS syndrome if untreated carries significant risk of mortality, between 10-20%. RegiSCAR (European Registry of Severe Cutaneous Adverse Reaction) scoring system can be used to help diagnose DRESS syndrome. It takes into account multiple factors including fever, lymphadenopathy, eosinophilia, rash, number of organs involved, disease duration, skin biopsy findings and negative results of investigations to rule out alternate causes of patient's symptoms. Patient responded well to systemic steroids followed by oral steroids with taper. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome Associated with Enoxaparin Therapy in a Pediatric Patient

Introduction: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a rare drug hypersensitivity reaction characterized by diffuse skin eruption with systemic symptoms (fever, lymphadenopathy, elevated transaminases, leukocytosis with eosinophilia and atypical lymphocytes) which develops 2-6 weeks after exposure to inciting medications. Clinical presentation is variable and nonspecific. DRESS syndrome is more common in adults, can be life threatening, and is most commonly seen with antibiotics, antiepileptic drugs, and allopurinol. An inciting drug is identified in the majority of cases. DRESS syndrome has been described rarely in association with Vitamin K antagonists and direct oral anticoagulants. In an in-depth examination of existing literature, there are only two reported cases of DRESS syndrome associated with enoxaparin therapy, both in adult patients and no reports of pediatric DRESS syndrome secondary to anticoagulants. We present a case of a pediatric patient with DRESS syndrome associated with enoxaparin therapy.Case Report: A previously healthy 11-year-old female was admitted with sepsis secondary to osteomyelitis and periosteal abscess of the left lower extremity, as well as MRSA bacteremia. The patient was initiated on clindamycin and vancomycin for treatment of underlying infections. A left lower extremity ultrasound with doppler was obtained due to lower extremity swelling and demonstrated an acute deep venous thrombus of the left popliteal vein. She was initiated on a heparin drip and subsequently transitioned to enoxaparin one week later. Several weeks into her hospital course (two weeks after initiation of enoxaparin), she developed facial swelling, a generalized morbilliform rash, and diffuse lymphadenopathy both on exam and abdominal imaging. She continued to have persistent fevers despite multiple washouts of the extremity, appropriate antimicrobial coverage, and negative blood cultures. Liver enzymes concurrently increased (AST 362 IU/L (normal 5-60 IU/L), ALT 371IU/L (normal <35 IU/L) at peak) with development of clinical symptoms. Eosinophilia was not present on initial CBC, though she subsequently developed mild eosinophilia (1.1 K/ul at peak). HHV6, CMV, and EBV serologies were all negative. Skin biopsy was performed and was consistent with a drug eruption. Using the RegiSCAR criteria for DRESS syndrome, this constellation of labs and symptoms indicate a definite case of DRESS syndrome with a score of 6 (final score >5 is needed for a definite case). The patient was started on treatment with high-dose steroids. Clindamycin and vancomycin were both discontinued due to their known association with DRESS syndrome. She was transitioned to doxycycline, however, no improvement in rash, fevers, or liver enzymes was seen over the course of five days. Given this, enoxaparin was transitioned to apixaban. The patient improved with resolution of rash, fevers, and improvement of liver enzymes and eosinophilia within a few days of the discontinuation of enoxaparin.Conclusion: The diagnosis of DRESS syndrome can be challenging due to its nonspecific presentation, particularly in pediatric patients where symptoms can overlap with common viral syndromes and Kawasaki disease, and therefore requires a high index of suspicion. Though children with DRESS syndrome have a better prognosis than adults, prompt recognition and treatment is required to limit morbidity and mortality. In pediatric patients receiving treatment with enoxaparin, DRESS syndrome should be included on the differential for those who develop persistent fevers, lymphadenopathy, rash, transaminitis and/or eosinophilia, and discontinuation of enoxaparin should be considered. DisclosuresWeyand: Takeda: Consultancy; Genentech: Consultancy; Novo Nordisk: Research Funding; Sanofi: Consultancy, Research Funding.

An unusual case of ATT induced DRESS syndrome

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug-induced hypersensitivity reaction characterized by skin rash, fever, blood abnormalities, and multiple organ involvement. The diagnosis of DRESS syndrome is often delayed because of its variable presentation. DRESS syndrome induced by antituberculosis drugs has rarely been reported. A 45-year-old female patient taking anti-tubercular drugs since 2 weeks presented to our hospital with extensive skin lesion with mucosal involvement. The case responded well to treatment with systemic corticosteroids and withdrawal of isoniazid with no recurrence of lesions and further follow-up.

DRESS syndrome: a pediatric case report.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and idiosyncratic hypersensitivity (type-IVb) severe adverse drug reaction, also known as drug induced hypersensitivity syndrome (DIHS). It is usually characterized by the triad of rash, fever and single or multiple organ involvement. DRESS syndrome usually begins within two months from ingestion of the drug, most often two-six weeks after its first use. However, symptoms may occur more rapidly and be more severe upon re-exposure. A six-year-old female child was brought to the hospital with chief complaints of high-grade fever and centrifugal rash; on further investigation, laboratory reports showed organ involvement leading to the diagnosis of DRESS syndrome. The untreated condition may be fatal, so prompt discontinuation of the offending drug and starting the patient on systemic corticosteroids is the mainstay of treatment in DRESS syndrome along with other supportive treatment.

Methicillin resistant staphylococcus aureus（MRSA）多発膿瘍経過中に発症し，ステロイドが著効したDrug reaction with eosinophilia and systemic symptoms（DRESS）の1例(A case report: Corticosteroid effective Drug reaction with eosinophilia and systemic symptoms (DRESS) due to antibiotics drugs)

要旨 症例は83歳の男性。発熱，呼吸困難，血圧低下で救急搬送となり，化膿性椎間板炎および腸腰筋膿瘍，敗血症性ショックの診断で，腸腰筋膿瘍に対して経皮的穿刺ドレナージ後にICU入室となった。血液培養からはMethicillin resistant staphylococcus aureus（MRSA）が検出され，全身に多発膿瘍形成を認めた。バンコマイシンを長期間投与する方針とし，洗浄ドレナージを追加した。第9病日に血液培養は陰性化したが，第18病日に発熱，拡大する紅斑，好酸球増多，腎機能障害，肝機能障害が出現し，循環動態の悪化および炎症所見が増悪した。敗血症の二次感染を疑い加療したが状態は改善せず，RegiSCARスコアよりDrug reaction with eosinophilia and systemic symptoms（DRESS）と診断した。被疑薬である抗菌薬を中止し，ステロイド投与により循環動態は安定し，発熱，紅斑，好酸球増多，腎機能障害，肝機能障害は改善した。本症例は敗血症の二次感染との鑑別に難渋し，敗血症診療のピットフォールであると考えられた。

Drug reaction with eosinophilia and systemic symptom induced by carbamazepine: a case report

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, potentially life-threatening acute adverse drug reaction (ADR), typically characterized by a long latency period (2-6 weeks to 3 months) from drug exposure. DRESS syndrome is defined by the presence of fever, cutaneous eruption, lymphadenopathy, systemic or asymptomatic internal organ involvement (e.g. Hepatitis, carditis, interstitial nephritis, interstitial pneumonitis, etc.) and haematological abnormalities, mainly leucocytosis, eosinophilia and sometimes atypical lymphocytosis. There are around 50 culprit drugs which cause DRESS syndrome e.g. carbamazepine, phenytoin, allopurinol, sulfa derivatives, antidepressants, antiepileptics, non-steroidal anti-inflammatory drugs and antimicrobials. The incidence of DRESS syndrome has been estimated to be between 1 in 1,000 and 1 in 10,000 drug exposures. There are many reported cases of DRESS syndrome due to carbamazepine, phenytoin, vancomycin, levitiracitam, ceftriaxone etc. Author presented a case of DRESS syndrome by carbamazepin. RegiSCAR and Japanese consensus group have developed specific criteria for making the diagnosis of DRESS syndrome. The patient described here met the majority of criteria according to RegiSCAR scoring guidelines for a diagnosis of DRESS syndrome induced by carbamazepine. As per RegiSCAR diagnostic criteria author had concluded that this was a “Definite” case of DRESS (Drug Reaction with Eosinophilia and Systemic Symptom) syndrome induced by carbamazepine. Carbamazepine is most common broad-spectrum antiepileptic drugs so, this case report will raises awareness among physician to suspect DRESS syndrome in patients who present unusual complaints and skin findings after starting antiepileptic drugs.

Dress Syndrome - A Case Report

Abstract The drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an adverse drug-induced reaction that occurs most commonly after exposure to drugs, most frequently anticonvulsants, sulfa derivates, antidepressants, nonsteroidal anti-inflammatory drugs, and antimicrobials. We present a 61-year-old male, with a generalized maculopapular exanthema on the trunk, face, extremities, palms, soles, palate, and fever (38°C). His medical history was notable for generalized epilepsy, treated with carbamazepine during 1 month. The diagnosis of DRESS syndrome was confirmed by specific RegiSCAR criteria. In our case, skin eruptions were successfully treated with oral methylprednisolone, cephalexin, and topical corticosteroid ointment. In conclusion, although the mechanisms of this syndrome are not completely understood, numerous cases were reported in children and adults. This syndrome should be considered in every patient with skin eruption, fever, eosinophilia, liver and hematological abnormalities. Prompt recognition, supportive therapy and initiation of corticosteroids may prevent systemic manifestations.

Comparison of diagnostic criteria and determination of prognostic factors for drug reaction with eosinophilia and systemic symptoms syndrome.

PurposeDrug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is characterized by prolonged clinical symptoms even after the withdrawal of the culprit drug. Different criteria to diagnose DRESS syndrome have been proposed; however, there have been limited studies on prognostic factors. We investigated appropriate criteria for the diagnosis of DRESS syndrome in practice and with associated prognostic factors.MethodsA total of 48 patients with DRESS syndrome that satisfied RegiSCAR possible (or more) criteria were retrospectively recruited. They were also analyzed according to Bocquet's criteria and Japanese drug-induced hypersensitivity syndrome (DIHS) criteria. The duration of clinical manifestations, requirement for steroids, and fatalities determined the severity of DRESS syndrome. Blood tests were performed at initial presentation to our hospital.ResultsA total of 60.4% of patients satisfied RegiSCAR definite criteria and 77.1% satisfied Bocquet's criteria. Only 18.8% satisfied atypical DIHS criteria from the Japanese group. A total of 96.6% patients who fit the RegiSCAR definite criteria, 96.6% also satisfied Bocquet's criteria; reciprocally, 75.7% of patients who met Bocquet's criteria also satisfied RegiSCAR definite criteria. The duration of clinical symptoms positively correlated with leukocyte, lymphocyte, and eosinophil counts in non-fatal cases. Lymphocyte counts were higher in patients who used steroids compared to steroid-naïve patients. Fatal cases showed higher serum creatinine and ferritin levels compared to non-fatal cases.ConclusionsBocquet's criteria is efficient and appropriate to diagnose DRESS syndrome in clinical practice. Lymphocyte and eosinophil counts as well as creatinine and ferritin levels could be useful early prognostic factors.

Levetiracetam-Induced Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome

To describe a case of levetiracetam-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. A 31-year-old white male with a low-grade astrocytoma presenting with tonic-clonic seizures was treated with levetiracetam 1 g twice daily and dexamethasone (initial dosage 12 mg/day, tapered down to 2 mg/day). On day 45 after levetiracetam initiation, dexamethasone was discontinued and levetiracetam continued. The patient developed fever and dyspnea on day 46 and was admitted to the hospital on day 49. A chest X-ray showed bilateral pulmonary interstitial infiltrates, and laboratory tests showed elevated lactate dehydrogenase (LDH; 288 U/L [reference range <204]), ferritin (223 ng/mL [13-178]), and C-reactive protein (CRP; 3.1 mg/dL [<0.5]). Neurologic fever was suspected and the reinitiation of dexamethasone at 6 mg/day was followed by improvement of all symptoms; the patient was discharged on day 55 with dexamethasone 4 mg/day for 2 more days. On day 59, 2 days after the withdrawal of dexamethasone for the second time, the patient presented with a pruritic erythematous maculopapular rash along with recurrence of fever and dyspnea, and was admitted to the hospital. A chest X-ray showed reappearance of the bilateral pulmonary interstitial infiltrates, and laboratory tests showed impaired liver function (alanine aminotransferase 60 U/L [reference range <56], aspartate aminotransferase 53 U/L [<30], LDH 516 U/L, ferritin 419 ng/mL, and CRP 2.6). A diagnosis of DRESS syndrome was suspected and levetiracetam was discontinued. Upon levetiracetam withdrawal, the patient's symptoms resolved by day 66, and radiological images showed resolution of the interstitial infiltrate by day 68. The patient was discharged on day 68. Low-grade fever persisted until day 71, with no other symptoms. During a 2-month follow-up period, liver function test results returned to normal. DRESS is a hypersensitivity reaction to several drugs, mainly antiepileptic drugs (AEDs), characterized by cutaneous, hematologic, and visceral involvement. Levetiracetam is structurally and pharmacologically unrelated to other AEDs. Previously, only one case of levetiracetam-induced DRESS syndrome had been reported, which required corticosteroids to control symptoms. We describe a case of levetiracetam-induced DRESS syndrome presenting with pneumonitis and hepatitis that resolved with levetiracetam withdrawal. Our patient was classified as a definitive DRESS case according to the RegiSCAR scoring system, which grades DRESS cases. According to the Naranjo probability scale, the adverse drug reaction was considered probable. Although levetiracetam is usually well tolerated, clinicians should be aware of the potential for it to cause DRESS syndrome.