DRESS (drug induced hypersensitivity reaction)

Question 1

What % mortality is a/w DRESS:

Answer 1

10%

Question 2

How long after drug initiation does DRESS start?

Answer 2

- 2-6 weeks

• this is later than other drug rashes

Question 3

What are the most common symptoms seen with DRESS?

Answer 3

• fever (85%)

- morbilliform skin eruption (75%)

- multi-organ involvement (liver, kidneys especially)

• lymphadenopathy

- peripheral eos

- mononucleosis like atypical lymphocytes

Question 4

What lab abnormalities to look for with DRESS?

Answer 4

• peripheral eos (dont have to be present though)
• monitor liver and kidney function
• check for atypical lymphocytes

Question 5

Where does rash of DRESS start typically?

Answer 5

starts on face and upper trunk/extremities

Question 6

How does rash of DRESS progress clinically?

Answer 6

• starts as morbilliform eruption, then becomes EDEMATOUS (facial edema is classic clue) with follicular accentuation (sign of edema)
• can also have tense vesicles/bullae, pustules and purpuric lesions

Question 7

What are possible late sequalae of DRESS syndrome that need to be monitored?

Answer 7

- Thyroiditis (at risk of becoming hypothyroid)

- myocarditis

- SIADH

• diabetes

Question 8

When can patients who have had DRESS syndrome develop hypothyroidism?

Answer 8

• typically 4-12 weeks after DRESS

Question 9

What are the genetic risk factors for DRESS?

Answer 9

HLA 3101 (northern eruopeans on carbamazepine)

HLA-B-5801 (Han chinese on allopurinol)

Question 10

Inability to detoxify _____ metabolites is one of the proposed mechanisms for DRESS.

Answer 10

arene oxide (Phenobarbital, phenytoin, and carbamazepine have this structure)

• note: this is why valproic acid and levetiracetam can be used instead, because they dont have the same structure

Question 11

What anticonvulsants are commonly known to cause DRESS, and which can be used in their place?

Answer 11

• Phenytoin, Carbamazepine, and Phenobarbitol (PCP is a bad drug)
• instead can use valproic acid and levetiracetam (these dont have aromatic structure)

Question 12

What virus possibly plays a role in DRESS?

Answer 12

HHV6 > HHV7

Question 13

What are the most common meds a/w DRESS?

Answer 13

aromatic anticonvulsants (phenytoin, carbamazepine, phenobarbital)

• lamotrigine
• sulfonamides
• minocycline
• dapsone
• allopurinol
• abacavir
• nevirapine
• All Llamas suck minos down an awesome nose

Question 14

What anti-seizure meds can you use instead of ones that can cause DRESS?

Answer 14

levetiracetam and valproic acid (because these dont have aromatic structure of the “PCP” drugs

• Valproic acid and Levatiracetam have a Very Low chance to cause DRESS

Question 15

DRESS caused by Dapsone will have what lab abnormalities?

Answer 15

hemolysis and methemoglobinemia

• increased bili–> icterus

- lacks eosinophilia

Question 16

DRESS caused by Minocycline is a/w:

Answer 16

• glutathione S-transferase deficiency

- Interstitial eosinophilic pneumonia

- liver involvement

Question 17

Treatment of DRESS:

Answer 17

STOP OFFENDING MED + Systemic steroids (or superpotent topicals if limited to skin with no systemic organ involvement)

• need very slow taper over weeks to months to avoid relapse