Time is skin: what does the emergency physician need to know about DRESS?

Abstract

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome, also known as Drug Induced Hypersensitivity Syndrome (DIHS), is an acute drug-induced hypersensitivity reaction. The pathogenesis of this syndrome, which can develop due to many drugs, especially antiepileptic agents, is not known exactly. This syndrome, which was denominated “hydantoin hypersensitivity” in 1950, was renamed as “DRESS syndrome” by Bocquet and his colleagues in 1996 and the first diagnostic criteria were determined.
Unlike syndromes that may develop due to other drugs, DRESS syndrome customarily commences 2-8 weeks after the commencement of the drug, and symptoms perpetuate to progress after discontinuation of the responsible drug. Symptoms such as fever, lymphadenopathy, hematological disorders, maculopapular rash and internal organ involvement are common in this syndrome.
Diagnosis of DRESS syndrome is often difficult, as the clinical manifestations are varied and the latent period after the initiation of drug use can be up to 3 months. Thus, it is thought that the diagnosis of DRESS should be in the minds of all doctors, especially emergency physicians.

Keywords

• DRESS
• drug rash with eosinophilia systemic symptoms
• ED

Zaman cilttir: Acil servis hekimleri DRESS sendromu hakkında ne bilmeli?

Öz

Drug Rash with Eoshinophilia and Systemic Symptoms (DRESS) sendromu ve ya diğer adıyla da bilinen İlaçla indüklenen hipersensitivite sendromu (Drug Induced Hypersensitivity Syndrome (DIHS), ilaca bağlı akut bir hipersensitivite reaksiyonudur.
Başta antiepileptik ajanlar olmak üzere birçok ilaca bağlı gelişebilen bu sendromun patogenezi tam olarak bilinmemektedir. Bazı ilaçların detoksifikasyonundaki yetersizliğe bağlı artan reaktif metabolitlerin immünolojik reaksiyona neden olduğu tahmin edilmektedir. İlaçların yanısıra herpesvirüs ve Ebstein Barr Virüsü gibi benzer bir reaksyonlar DRESS sendromuna yola açabildiği düşünülmektedir.
DRESS sendromunun diğer ilaçlara bağlı gelişebilen sendromlardan farklı olarak Klinik bulgularının genellikle ilacın kullanılmaya başlanmasından 2-8 hafta sonrasında başlaması ve sorumlu ilacın kesilmesiyle semptomların ilerlemeye devam etmesidir.
Ateş, lenfadenopati, hematolojik bozukluklar, makülopapüler döküntü ve ve iç organ tutulumları gibi bulgular bu sendromda rastlamak sıktır.
Klinik bulguların çeşitli olması ve ilaç kullanımının başlaması sonrasındaki latent periyodun 3 aya kadar uzun olabilmesi nedeniyle DRESS sendromunun tanısı sıklıkla güçtür. Tanısı gözden kaçtığında mortalitesi %10-20 civarında olup oldukça önemli bir klinik tablodur.

Anahtar Kelimeler

• DRESS
• eozinofili ve sistemik semptomlarla seyreden ilaç reaksiyonu
• acil servis

Kaynakça

1. 1. Choudhary S, McLeod M, Torchia D, Romanelli P. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. J Clin Aesthet Dermatol 2013;6:31-37.
2. 2. Criado PR, Criado RFJ, Avancini JM, Santi CG. Drug reaction with Eosinophilia and Systemic Symptoms (DRESS) / Drug-induced Hypersensitivity Syndrome (DIHS): a review of current concepts. An Bras Dermatol 2012;87:435-449. https://doi.org/10.1590/s0365-05962012000300013
3. 3. Cacoub P, Musette P, Descamps V, et al. The DRESS syndrome: a literature review. Am J Med 2011;124:588-597. https://doi.org/10.1016/j.amjmed.2011.01.017
4. 4. Husain Z, Reddy BY, Schwartz RA. DRESS syndrome: part I. clinical perspectives. J Am Acad Dermatol 2013;68:693(e1-14). https://doi.org/10.1016/j.jaad.2013.01.033.
5. 5. Fernando SL. Drug-reaction eosinophilia and systemic symptoms and drug-induced hypersensitivity syndrome. Australas J Dermatol 2014;55:15-23. https://doi.org/10.1111/ajd.12085
6. 6. Bocquet H, Bagot M, Roujeau JC. Drug-induced pseudolymphoma and drug hypersensitivity syndrome (Drug Rash with Eosinophilia and Systemic Symptoms: DRESS). Semin Cutan Med Surg 1996;15:250-257. https://doi.org/10.1016/s1085-5629(96)80038-1
7. 7. Callot V, Roujeau JC, Bagot M, et al. Drug-induced pseudolymphoma and hypersensitivity syndrome. Two different clinical entities. Arch Dermatol 1996;132:1315-1321. https://doi.org/10.1001/archderm.1996.03890350057010
8. 8. Alkhateeb H, Said S, Cooper CJ, Gaur S, Porres Aguilar M. DRESS syndrome following ciprofloxacin exposure: an unusual association. Am J Case Rep 2013;14:526-528. https://doi.org/10.12659/AJCR.889703

9. 9. Shiohara T, Inaoka M, Kano Y. Drug-induced Hypersensitivity Syndrome (DIHS): a reaction ınduced by a complex ınterplay among herpesviruses and antiviral and antidrug ımmune responses. Allergol Int 2006;55:1-8. https://doi.org/10.2332/allergolint.55.1
10. 10. 10. R Cabañas, E Ramírez , E Sendagorta. Spanish Guidelines for Diagnosis, Management, Treatment and Prevention of DRESS Syndrome. J Investig Allergol Clin Immunol. 2020;30(4):229-253. doi: 10.18176/jiaci.0480
11. 11. Chen YC, Chiu HC, Chu CY. Drug reaction with eosinophilia and systemic symptoms: a retrospective study of 60 cases. Arch Dermatol 2010;146:1373-1379. https://doi.org/10.1001/archdermatol.2010.198
12. 12. Chiou CC, Yang LC, Hung SI, et al. Clinicopathological features and prognosis of drug rash with eosinophilia and systemic symptoms: a study of 30 cases in Taiwan. J Eur Acad Dermatol Venereol 2008;22:1044-1049. https://doi.org/10.1111/j.1468-3083.2008.02585.x
13. 13. Yang CY, Dao RL, Lee TJ, et al. Severe cutaneous adverse reactions to antiepileptic drugs in Asians. Neurology 2011;77:2025-2033. https://doi.org/10.1212/WNL.0b013e31823b478c
14. 14. Emre S, Akoglu G, Metin A, Demirseren DD, Kurtoğlu G. Evaluation of clinical features of 11 cases with DRESS syndrome. Türkderm 2013;47:218-222. https://doi.org/10.4274/turkderm.71324
15. 15. Tetsuo Shiohara, Yoshiko Mizukawa. Drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS): An update in 2019. Allergol Int. 2019 Jul;68(3):301-308. doi: 10.1016/j.alit.2019.03.006.
16. 16. Tsyrulnik A, Landman A. Drug rash with eosinophilia and systemic symptoms: two emergency department cases. West J Emerg Med 2011;12:559-562. https://doi.org/10.5811/westjem.2010.11.2077
17. 17. Criado PR, Avancini J, Santi CG, Amoedo Medrado AT, Rodrigues CE, de Carvalho JF. Drug reaction with eosinophilia and systemic symptoms (DRESS): a complex interaction of drugs, viruses and the immune system. Isr Med Assoc J 2012;14:577-582.
18. 18. Kim DH, Koh YI. Comparison of diagnostic criteria and determination of prognostic factors for drug reaction with eosinophilia and systemic symptoms syndrome. Allergy Asthma Immunol Res 2014;6:216-221. https://doi.org/10.4168/aair.2014.6.3.216
19. 19. Abhishek D, Murlidhar R, Aarti S. Drug reaction with eosinophilia and systemic symptoms: an update and review of recent literature. Indian J Dermatol 2018;63:30-40. https://doi.org/ doi: 10.4103/ijd.IJD_582_17