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Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

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Advances in Diagnosis and Management of Cutaneous Adverse Drug Reactions

Abstract

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a delayed, potentially life-threatening, hypersensitivity reaction characterized by a widespread, long-lasting skin eruption, fever, lymphadenopathy, hematological abnormalities, and organ involvement. Time to onset and course are relatively long; relapses may occur. Clinical and biological variability make DRESS a challenging diagnosis. Pathogenesis is not exactly known, but probably reflects a complex interplay of drug and viral-related factors in which genetics and abnormal metabolic pathways of drugs play an important role. Although associated with many drugs, DRESS is mainly observed after a limited number of “high risk” drugs. Early recognition, prompt withdrawal of the culprit, and treatment with corticosteroids are the mainstay of management.

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Abbreviations

AED:

Antiepileptic drugs

cADR:

Cutaneous adverse drug reactions

CBZ:

Carbamazepine

D(I)HS:

Drug (induced) hypersensitivity syndrome

DRESS:

Drug reaction with eosinophilia and systemic symptoms

HHV-6:

Herpes virus type 6

LTA:

Lymphocyte toxicity assay

LTT:

Lymphocyte transformation test

MPE:

Maculopapular exanthema

References

  • Barbaud A, Collet E, Milpied B et al (2013) A multicentre study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions. Br J Dermatol 168:555–562

    Article  CAS  Google Scholar 

  • Barbaud A, Waton J, Herbeth B et al (2014) Comparison of cytokine gene polymorphism in drug-induced maculopapular eruption, urticaria and drug reaction with eosinophilia and systemic symptoms (DRESS). J Eur Acad Dermatol Venereol 28:491–499

    Article  CAS  Google Scholar 

  • Bastuji-Garin S, Rzany B, Stern RS et al (1993) Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme. Arch Dermatol 129:92–96

    Article  CAS  Google Scholar 

  • Bernstein DI, Carney J, Cherry JD (1983) Pseudo-toxic-shock syndrome due to a drug reaction. Clin Pediatr 22:524–525

    Article  CAS  Google Scholar 

  • Bocquet H, Bagot M, Roujeau JC (1996) Drug-induced pseudolymphoma and drug hypersensitivity syndrome (drug rash with eosinophilia and systemic symptoms: DRESS). Semin Cutan Med Surg 15:250–257

    Article  CAS  Google Scholar 

  • Brown M, Schubert T (1986) Phenytoin hypersensitivity hepatitis and mononucleosis syndrome. J Clin Gastroenterol 8:469–477

    Article  CAS  Google Scholar 

  • Cacoub P, Musette P, Descamps V et al (2011) The DRESS syndrome: a literature review. Am J Med 124:588–597

    Article  CAS  Google Scholar 

  • Chaiken BH, Goldberg BI, Segal JP (1950) Dilantin sensitivity; report of a case of hepatitis with jaundice, pyrexia and exfoliative dermatitis. N Engl J Med 242:897–898

    Article  CAS  Google Scholar 

  • Chen YC, Chang CY, Cho YT et al (2013) Long-term sequelae of drug reaction with eosinophilia and systemic symptoms: a retrospective cohort study from Taiwan. J Am Acad Dermatol 68:459–465

    Article  Google Scholar 

  • Chi MH, Hui RC, Yang CH et al (2014) Histopathological analysis and clinical correlation of drug reaction with eosinophilia and systemic symptoms (DRESS). Br J Dermatol 170:866–873

    Article  Google Scholar 

  • Chiou CC, Chung WH, Hung SI et al (2006) Fulminant type 1 diabetes mellitus caused by drug hypersensitivity syndrome with human herpesvirus 6 infection. J Am Acad Dermatol 54(2 Suppl):S14–S17

    Article  Google Scholar 

  • Chiou CC, Yang LC, Hung SI et al (2008) Clinicopathological features and prognosis of drug rash with eosinophilia and systemic symptoms: a study of 30 cases in Taiwan. J Eur Acad Dermatol Venereol 22:1044–1049

    Article  Google Scholar 

  • Chung WH, Chang WC, Lee YS et al (2014) Genetic variants associated with phenytoin-related severe cutaneous adverse reactions. JAMA 312:525–534

    Article  Google Scholar 

  • Chung WH, Chang WC, Stocker SL et al (2015) Insights into the poor prognosis of allopurinol-induced severe cutaneous adverse reactions: the impact of renal insufficiency, high plasma levels of oxypurinol and granulysin. Ann Rheum Dis 74:2157–2164

    Article  CAS  Google Scholar 

  • Descamps V, Ben Saïd B, Sassolas B et al (2010) Management of drug reaction with eosinophilia and systemic symptoms (DRESS). Ann Dermatol Venereol 137:703–708

    Article  CAS  Google Scholar 

  • Elzagallaai AA, Jahedmotlagh Z, Del Pozzo-Magaña BR et al (2010) Predictive value of the lymphocyte toxicity assay in the diagnosis of drug hypersensitivity syndrome. Mol Diagn Ther 14:317–322

    Article  Google Scholar 

  • Eshki M, Allanore L, Musette P et al (2009) Twelve-year analysis of severe cases of drug reaction with eosinophilia and systemic symptoms: a cause of unpredictable multiorgan failure. Arch Dermatol 145:67–72

    Article  Google Scholar 

  • Fruchter L, Laptook A (1981) Diphenylhydantoin hypersensitivity reaction associated with pulmonary infiltrates and hypereosinophilia. Ann Allergy 47:453–454

    CAS  PubMed  Google Scholar 

  • Funck-Brentano E, Duong TA, Bouvresse S (2015) Therapeutic management of DRESS: a retrospective study of 38 cases. J Am Acad Dermatol 72:246–252

    Article  Google Scholar 

  • Ghislain PD, Roujeau JC (2002) Treatment of severe drug reactions: Stevens-Johnson syndrome, toxic epidermal necrolysis and hypersensitivity syndrome. Dermatol Online J 8:5

    PubMed  Google Scholar 

  • Gupta A, Eggo MC, Uetrecht JP et al (1992) Drug-induced hypothyroidism: the thyroid as a target organ in hypersensitivity reactions to anticonvulsants and sulfonamides. Clin Pharmacol Ther 51:56–67

    Article  CAS  Google Scholar 

  • Hicks RA, Murphy JV, Jackson MA (1988) Kawasaki-like syndrome caused by carbamazepine. Pediatr Infect Dis J 7:525–526

    Article  CAS  Google Scholar 

  • Hirsch LJ, Weintraub DB, Buchsbaum R, Spencer HT, Straka T, Hager M, Resor SR Jr (2006) Predictors of Lamotrigine-associated rash. Epilepsia 47:318–322

    Article  CAS  Google Scholar 

  • Houwerzijl J, De Gast GC, Nater JP et al (1977) Lymphocyte-stimulation tests and patch tests to carbamazepine hypersensitivity. Clin Exp Immunol 29:272–277

    CAS  PubMed  PubMed Central  Google Scholar 

  • Hung SI, Chung WH, Liou LB et al (2005) HLA-B*5801 allele as a genetic marker for severe cutaneous adverse reactions caused by allopurinol. Proc Natl Acad Sci U S A 15:4134–4139

    Article  Google Scholar 

  • Ishida T, Kano Y, Mizukawa Y, Shiohara T (2014) The dynamics of herpesvirus reactivations during and after severe drug eruptions: their relation to the clinical phenotype and therapeutic outcome. Allergy 69:798–805

    Article  CAS  Google Scholar 

  • Iwatsuki K, Tsugiki M, Tagami H, Yamada M (1984) Infectious mononucleosis-like manifestations. An adverse reaction to sulfasalazine. Arch Dermatol 120:964–965

    Article  CAS  Google Scholar 

  • Kano Y, Shiohara T (2004) Sequential reactivation of herpesvirus in drug-induced hypersensitivity syndrome. Acta Derm Venereol 84:484–485

    PubMed  Google Scholar 

  • Kano Y, Inaoka M, Shiohara T (2004) Association between anticonvulsant hypersensitivity syndrome and human herpesvirus 6 reactivation and hypogammaglobulinemia. Arch Dermatol 140:183–188

    Article  Google Scholar 

  • Kano Y, Hiraharas K, Sakuma K, Shiohara T (2006) Several herpesviruses can reactivate in a severe drug-induced multiorgan reaction in the same sequential order as in graft-versus-host disease. Br J Dermatol 155:301–306

    Article  CAS  Google Scholar 

  • Kano Y, Hirahara K, Mitsuyama Y et al (2007) Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. Allergy 62:1439–1444

    Article  CAS  Google Scholar 

  • Kano Y, Hirahara K, Asano Y, Shiohara T (2008) HLA-B allele associations with certain drugs are not confirmed in japanese patients with severe cutaneous drug reactions. Acta Derm Venereol 88:616–618

    PubMed  Google Scholar 

  • Kano Y, Ishida T, Hirahara K, Shiohara T (2010) Visceral involvements and long-term sequelae in drug-induced hypersensitivity syndrome. Med Clin North Am 94:743–759

    Article  Google Scholar 

  • Kardaun SH, Scheffer E, Vermeer BJ (1988) Drug induced pseudolymphomatous skin reactions. Br J Dermatol 118:545–552

    Article  CAS  Google Scholar 

  • Kardaun SH, Sidoroff A, Valeyrie-Allanore L et al (2007) Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol 156:609–611

    Article  CAS  Google Scholar 

  • Kardaun SH, Sekula P, Valeyrie-Allanore L et al (2013) Drug reaction with eosinophilia and systemic symptoms (DRESS): an original multisystem adverse drug reaction. Results from the prospective RegiSCAR study. Br J Dermatol 169:1071–1080

    Article  CAS  Google Scholar 

  • Kardaun SH, Mockenhaupt M, Roujeau JC (2014) Comments on: DRESS syndrome. J Am Acad Dermatol 71:1000–1000.e2

    Article  Google Scholar 

  • Kleier RS, Breneman DL, Boiko S (1991) Generalized pustulation as a manifestation of the anticonvulsant hypersensitivity syndrome. Arch Dermatol 127:1361–1364

    Article  CAS  Google Scholar 

  • Knowles S, Shapiro L, Shear N (1996) Serious adverse reactions induced by minocycline: a report of 13 patients and review of the literature. Arch Dermatol 132:934–939

    Article  CAS  Google Scholar 

  • Knowles SR, Uetrecht J, Shear NH (2000) Idiosyncratic drug reactions: the reactive metabolite syndromes. Lancet 356:1587–1591

    Article  CAS  Google Scholar 

  • Lau G, Kwan C, Chong SM (2001) The 3-week sulphasalazine syndrome strikes again. Forensic Sci Int 122:79–84

    Article  CAS  Google Scholar 

  • Leeder JS, Cannon M, Nakhooda A, Spielberg SP (1988) Drug metabolite toxicity assessed in human lymphocytes with a purified, reconstituted cytochrome P-450 system. J Pharmacol Exp Ther 245:956–962

    CAS  PubMed  Google Scholar 

  • Mahatma M, Haponik EK, Nelson S, Lopez A, Summer WR (1989) Phenytoin-induced acute respiratory failure with pulmonary eosinophilia. Am J Med 87:93–94

    Article  CAS  Google Scholar 

  • Manns MP, Obermayer-Straub P (1997) Cytochromes P450 and uridine triphosphate-glucuronosyltransferases: model autoantigens to study drug-induced, virus-induced, and autoimmune liver disease. Hepatology 26:1054–1066

    Article  CAS  Google Scholar 

  • Martel P, Laroche L, Courville P et al (2000) Cutaneous involvement in patients with angioimmunoblastic lymphadenopathy with dysproteinemia. Arch Dermatol 136:881–886

    Article  CAS  Google Scholar 

  • Martin M, Wurpts G, Ott H et al (2010) In vitro detection and characterization of drug hypersensitivity using flow cytometry. Allergy 65:32–39

    Article  CAS  Google Scholar 

  • McCormack M, Alfirevic A, Bourgeois S et al (2011) HLA-A*3101 and carbamazepine-induced hypersensitivity reactions in Europeans. N Engl J Med 364:1134–1143

    Article  CAS  Google Scholar 

  • McMenamin RA, Davies LM, Craswell PW (1976) Drug induced interstitial nephritis, hepatitis and exfoliative dermatitis. Aust NZ J Med 6:583–587

    Article  CAS  Google Scholar 

  • Mennicke M, Zawodniak A, Keller M et al (2009) Fulminant liver failure after vancomycin in a sulfasalazine-induced DRESS syndrome: fatal recurrence after liver transplantation. Am J Transplant 9:2197–2202

    Article  CAS  Google Scholar 

  • Michael JR, Mitch WE (1976) Reversible renal failure and myositis caused by phenytoin hypersensitivity. J Am Med Assoc 236:2773–2775

    Article  CAS  Google Scholar 

  • Nyfeler B, Pichler WJ (1997) The lymphocyte transformation test for the diagnosis of drug allergy: sensitivity and specificity. Clin Exp Allergy 27:175–181

    Article  CAS  Google Scholar 

  • Ohtani T, Hiroi A, Sakurane M, Furukawa F (2003) Slow acetylator genotypes as a possible risk factor for infectious mononucleosis-like syndrome induced by salazosulfapyridine. Br J Dermatol 148:1035–1039

    Article  CAS  Google Scholar 

  • Ortonne N, Valeyrie-Allanore L, Bastuji-Garin S et al (2015) Histopathology of drug rash with eosinophilia and systemic symptoms syndrome: a morphological and phenotypical study. Br J Dermatol 173:50–58

    Article  CAS  Google Scholar 

  • Peyrière H, Dereure O, Breton H et al (2006) Network of the French pharmacovigilance centers. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol 155:422–428

    Article  Google Scholar 

  • Phillips EJ, Chung WH, Mockenhaupt M et al (2011) Drug hypersensitivity: pharmacogenetics and clinical syndromes. J Allergy Clin Immunol 127:S60–S66

    Article  CAS  Google Scholar 

  • Picard D, Janela B, Descamps V et al (2010) Drug reaction with eosinophilia and systemic symptoms (DRESS): a multiorgan antiviral T cell response. Sci Transl Med 2:46ra62

    Article  Google Scholar 

  • Pichler WJ, Tilch J (2004) The lymphocyte transformation test in the diagnosis of drug hypersensitivity. Allergy 59:809–820

    Article  CAS  Google Scholar 

  • Potter T, DiGregorio F, Stiff M, Hashimoto K (1994) Dilantin hypersensitivity syndrome imitating staphylococcal toxic shock. Arch Dermatol 130:856–858

    Article  CAS  Google Scholar 

  • Prussick R, Shear NH (1996) Dapsone hypersensitivity syndrome. J Am Acad Dermatol 35:346–349

    Article  CAS  Google Scholar 

  • Rieder MJ, Uetrecht J, Shear N et al (1989) Diagnosis of sulfonamide hypersensitivity reactions by in-vitro “rechallenge” with hydroxylamine metabolites. Ann Intern Med 110:286–289

    Article  CAS  Google Scholar 

  • Roujeau JC, Dupin N (2017) Virus reactivation in drug reaction with eosinophilia and systemic symptoms (DRESS) results from a strong drug-specific immune response. J Allergy Clin Immunol Pract 5:811–812

    Article  Google Scholar 

  • Roujeau JC, Stern RS (1994) Severe adverse cutaneous reactions to drugs. N Engl J Med 331:1272–1285

    Article  CAS  Google Scholar 

  • Sachs B, Erdmann S, Malte Baron J et al (2002) Determination of interleukin-5 secretion from drug-specific activated ex vivo peripheral blood mononuclear cells as a test system for the in vitro detection of drug sensitisation. Clin Exp Allergy 32:736–744

    Article  CAS  Google Scholar 

  • Sakuma K, Kano Y, Fukuhara M, Shiohara T (2008) Syndrome of inappropriate secretion of antidiuretic hormone associated with limbic encephalitis in a patient with drug-induced hypersensitivity syndrome. Clin Exp Dermatol 33:287–290

    Article  CAS  Google Scholar 

  • Santiago F, Gonçalo M, Vieira R et al (2010) Epicutaneous patch testing in drug hypersensitivity syndrome (DRESS). Contact Dermatitis 62:47–53

    Article  CAS  Google Scholar 

  • Seishima M, Yamanaka S, Fujisawa T et al (2006) Reactivation of human herpesvirus (HHV) family members other than HHV-6 in drug-induced hypersensitivity syndrome. Br J Dermatol 155:344–349

    Article  CAS  Google Scholar 

  • Shaughnessy KK, Bouchard SM, Mohr MR et al (2010) Minocycline-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome with persistent myocarditis. J Am Acad Dermatol 62:315–318

    Article  CAS  Google Scholar 

  • Shear NH, Spielberg SP (1988) Anticonvulsant hypersensitivity syndrome. In vitro assessment of risk. J Clin Invest 82:1826–1832

    Article  CAS  Google Scholar 

  • Shear N, Spielberg S, Grant D et al (1986) Differences in metabolism of sulfonamides predisposing to idiosyncratic toxicity. Ann Intern Med 105:179–184

    Article  CAS  Google Scholar 

  • Shiohara T, Kano Y (2017) Drug reaction with eosinophilia and systemic symptoms (DRESS): incidence, pathogenesis and management. Expert Opin Drug Saf 16:139–147

    CAS  PubMed  Google Scholar 

  • Shiohara T, Inaoka M, Kano Y (2006) Drug-induced hypersensitivity syndrome (DIHS): a reaction induced by a complex interplay among herpesviruses and antiviral and antidrug immune responses. Allergol Int 55:1–8

    Article  Google Scholar 

  • Shiohara T, Iijima M, Ikezawa Z, Hashimoto K (2007) The diagnosis of a DRESS syndrome has been sufficiently established on the basis of typical clinical features and viral reactivations. Br J Dermatol 156:1083–1084

    Article  CAS  Google Scholar 

  • Shiohara T, Kano Y, Takahashi R et al (2012) Drug-induced hypersensitivity syndrome: recent advances in the diagnosis, pathogenesis and management. Chem Immunol Allergy 97:122–138

    Article  Google Scholar 

  • Skowron F, Bensaid B, Balme B et al (2015) Drug reaction with eosinophilia and systemic symptoms (DRESS): clinicopathological study of 45 cases. J Eur Acad Dermatol Venereol 29:2199–2205

    Article  CAS  Google Scholar 

  • Skowron F, Bensaid B, Balme B et al (2016) Comparative histological analysis of drug-induced maculopapular exanthema and DRESS. J Eur Acad Dermatol Venereol 30:2085–2090

    Article  CAS  Google Scholar 

  • Spielberg S, Gordon G, Blake D et al (1981) Anticonvulsant toxicity in vitro: possible role of arene oxides. J Pharmacol Exp Ther 217:386–389

    CAS  PubMed  Google Scholar 

  • Sullivan JR, Shear NH (2000) What are some of the lessons learnt from in vitro studies of severe unpredictable drug reactions? Br J Dermatol 142:205–207

    Article  CAS  Google Scholar 

  • Takahashi R, Kano Y, Yamazaki Y et al (2009) Defective regulatory T cells in patients with severe drug eruptions: timing of the dysfunction is associated with the pathological phenotype and outcome. J Immunol 182:8071–8079

    Article  CAS  Google Scholar 

  • Tas S, Simonart T (2003) Management of drug rash with eosinophilia and systemic symptoms (DRESS syndrome): an update. Dermatology 206:353–356

    Article  CAS  Google Scholar 

  • Tassaneeyakul W, Jantararoungtong T, Chen P et al (2009) Strong association between HLA-B*5801 and allopurinol-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in a Thai population. Pharmacogenet Genomics 19:704–709

    Article  CAS  Google Scholar 

  • Tennis P, Stern R (1997) Risk of serious cutaneous disorders after initiation of use of phenytoin, carbamazepine, or sodium valproate: a record linkage study. Neurology 49:542–546

    Article  CAS  Google Scholar 

  • Teraki Y, Shibuya M, Izaki S (2010) Stevens-Johnson syndrome and toxic epidermal necrolysis due to anticonvulsants share certain clinical and laboratory features with drug-induced hypersensitivity syndrome, despite differences in cutaneous presentations. Clin Exp Dermatol 35:723–728

    Article  CAS  Google Scholar 

  • Tohyama M, Hashimoto K (2011) New aspects of drug-induced hypersensitivity syndrome. J Dermatol 38:222–228

    Article  CAS  Google Scholar 

  • Tohyama M, Hashimoto K, Yasukawa M et al (2007) Association of human herpesvirus 6 reactivation with the flaring and severity of drug-induced hypersensitivity syndrome. Br J Dermatol 157:934–940

    Article  CAS  Google Scholar 

  • Ushigome Y, Kano Y, Ishida T et al (2013) Short- and long-term outcomes of 34 patients with drug-induced hypersensitivity syndrome in a single institution. J Am Acad Dermatol 68:721–728

    Article  Google Scholar 

  • Vittorio CC, Muglia JJ (1995) Anticonvulsant hypersensitivity syndrome. Arch Intern Med 155:2285–2290

    Article  CAS  Google Scholar 

  • Wade AW, McDonald AT, Acott PD et al (1998) Human herpes virus-6 or Epstein-Barr virus infection and acute allograft rejection in pediatric kidney transplant recipients: greater risk for immunologically naive recipients. Transplant Proc 30:2091–2093

    Article  CAS  Google Scholar 

  • Walsh S, Diaz-Cano S, Higgins E et al (2013) Drug reaction with eosinophilia and systemic symptoms: is cutaneous phenotype a prognostic marker for outcome? A review of clinicopathological features of 27 cases. Br J Dermatol 168:391–401

    Article  CAS  Google Scholar 

  • Wei CH, Chung-Yee Hui R, Chang CJ et al (2011) Identifying prognostic factors for drug rash with eosinophilia and systemic symptoms (DRESS). Eur J Dermatol 21:930–937

    CAS  PubMed  Google Scholar 

  • Zuliani E, Zwahlen H, Gilliet F, Marone C (2005) Vancomycin-induced hypersensitivity reaction with acute renal failure: resolution following cyclosporine treatment. Clin Nephrol 64:155–158

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

    Sylvia H. Kardaun

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  1. Sylvia H. Kardaun
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Editors and Affiliations

  1. University of Toronto Medical School, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Neil H. Shear

  2. Department of Dermatology, Emek Medical Center, Afula, Israel

    Roni P. Dodiuk-Gad

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Kardaun, S.H. (2019). Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). In: Shear, N., Dodiuk-Gad, R. (eds) Advances in Diagnosis and Management of Cutaneous Adverse Drug Reactions. Adis, Singapore. https://doi.org/10.1007/978-981-13-1489-6_7

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