DRESS – Drug Reaction with Eosinophilia and Systemic Symptoms
THE SHORT VERSION:- Drug-induced hypersensitivity reaction o Antiepileptics and allopurinol- Life threatening- Look for: o Rash (morbiliform) o Diffuse lymphadenopathy o Diffuse facial edema (ask the pt as this may not be obvious on exam and something they forget to mention) o Visceral involvement - Liver (typically mild, can be severe liver failure) - Kidneys (check Cr and BUN) - Lungs (hypoxemia, pneumonitis, pleural effusion)- Typically resolves in weeks after offending agent is removed- Treat supportively (if renal/lung involvement consider corticosteroids)
THE LONG VERSION THAT YOU LIKELY WONT REMEMBER AND WILL HAVE TO LOOK UP WHEN YOU SEE A PATIENT WITH DRESS:
- Drug-induced hypersensitivity reaction
- Life threatening
o 80% drug related
o Occurs 2-8 weeks after initiation of medication
o Antiepileptic agents (eg, carbamazepine, lamotrigine, phenytoin, phenobarbital) and allopurinol are the most frequently reported causes
o 10-20% a drug relationship cannot be established
- Look for:
1. Rash - starts as a morbilliform rash and rapidly (hours – days) progresses to a diffuse, confluent, and infiltrated erythema with follicular accentuation covering ≥50% of the body
a. Associated with ≥2 of the following: facial edema, scaling, purpura
2. Diffuse lymphadenopathy
3. Inflammation and pain of mucous membranes without lesions/erosions
4. Labs
a. Leukocytosis with eosinophils with >700/microL
b. Large activated lymphocytes, lymphoblasts, or mononucleosis-like cells
5. Organ involvement
a. Liver (60-80%) – typically mild transient asymptomatic hepatitis (^LFTs)
i. Severe hepatitis is responsible for the majority of deaths associated with DRESS.
ii. Most important predictors of death: markedly elevated aminotransferase, bilirubin levels and jaundice
b. Kidneys (10-30%) - acute interstitial nephritis (seen with allopurinol)
c. Lungs (5-25%) – hypoxemia secondary to interstitial pneumonitis and/or pleural effusion. On broncho-alveolar lavage: Drug-specific T-lymphocytes and eosinophils may be found
- Clinical course:
o Rash and visceral involvement resolve in 6-9 weeks after withdrawal of offending agent
o 20% of cases symptoms persist for months with remission and relapse
- Diagnosis:
o Pt who received new medication in the last 2-6 weeks with the following:
- Morbilliform rash
- Fever
- Lymphadenopathy
- Facial edema
- Eosinophilia
o Labs: CBC (eosinophilia), BMP (creatinine/BUN), viral hepatitis panel, dermatology referral for skin biopsy
o CT chest if pulmonary symptoms
- Management:
o Drug withdrawal and supportive measures
o If suspected medication is antiepileptic, substitute with valproate
o For pts with hepatic involvement refer to hepatologist
o For pts with severe interstitial nephritis or interstitial pneumonia, consider corticosteroids