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drug eruption with eosinophilia & systemic symptoms

Etiology: - see morbilliform drug eruption - pharmaceuticals - antibacterial agents - TMP-SMX - minocycline - abacavir - allopurinol - anticonvulsants - carbamazepine - phenytoin - phenobarbital - proton pump inhibitors - sulfasalazine Epidemiology: - rare Pathology: - type B drug reaction - liver, kidney & lungs may be involved - skin biopsy: lymphocytic infiltration, edema Clinical manifestations: - signs/symptoms begin 5-10 days (2-6 weeks [6]) after starting offending drug - morbilliform drug eruption (rash) - fever - facial edema - lymphadenopathy - hepatomegaly * images [5] Laboratory: - complete blood count* - atypical lymphocytosis, eosinophilia - liver function tests* - serum ALT & serum AST frequently elevated - skin biopsy - useful for confirmation of diagnosis - not helpful for assessing severity of systemic involvement - lymph node biopsy is rarely required for diagnosis [1] * essential testing for suspected DRESS syndrome Complications: - hepatotoxicity progressing to liver failure even if rash resolves - mortality 5% [2] Differential diagnosis: - Stevens-Johnson syndrome (lymphadenopathy not a feature) Management: - potentially life-threatening - hospitalize - discontinue offending agent - systemic glucocorticoids may be needed

General

exanthematous drug eruption (morbilliform exanthem) type B drug reaction; drug-induced hypersensitivity syndrome; drug rash with eosinophilia & systemic symptoms (DIHS, DRESS) syndrome

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018.
  2. Cacoub P, Musette P, Descamps V et al The DRESS syndrome: a literature review. Am J Med. 2011 Jul;124(7):588-97 PMID: 21592453
  3. NEJM Knowledge+ - Husain Z, Reddy BY, Schwartz RA. DRESS syndrome: Part I. Clinical perspectives. J Am Acad Dermatol. 2013 May;68(5):693.e1-14 PMID: 23602182 - Husain Z, Reddy BY, Schwartz RA. DRESS syndrome: Part II. Management and therapeutics. J Am Acad Dermatol. 2013 May;68(5):709.e1-9; quiz 718-20. Review. PMID: 23602183
  4. Buck ML Medscape: DRESS Syndrome http://www.medscape.com/viewarticle/776164
  5. DermNet NZ. Drug hypersensitivity syndrome. (images) http://www.dermnetnz.org/reactions/drug-hypersensitivity-syndrome.html
  6. Chen YC, Chiu HC, Chu CY Drug reaction with eosinophilia and systemic symptoms: a retrospective study of 60 cases. Arch Dermatol. 2010 Dec;146(12):1373-9. PMID: 20713773